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Page 4 of 13 Gharagozloo et al. Mini-invasive Surg 2020;4:55 I http://dx.doi.org/10.20517/2574-1225.2020.42

injects a 10 mL subpleural bubble of 0.25% bupivacaine with epinephrine near the intercostal nerve. Next,
Port #3 is placed 10 cm posterior to Port #2 in the 7th intercostal space just medial to the spine. This port
accommodates da Vinci arm #3. Port #4 is placed 9 cm anterior to Port #1 in the 7th intercostal space at
the anterior scapular line. This port accommodates da Vinci arm #1. The Assistant Port #5 uses a 10-12
Versiport (Medtronic Inc., Norwalk, Conn, USA) trocar and is placed in the 9th intercostal space and is
triangulated between Port #1 and #4. It should be two or three ribs lower than and as distant to the da
Vinci ports as possible to maximize the assistant workspace. Keeping this port off the trajectory lines for
the other ports will facilitate the patient-side assistant’s access for the retraction and other maneuvers.
In all, including the vitally important Assistant Port, lobectomy is performed with five ports. The use of
additional ports should be tailored to the specific situation and the experience of the surgeon. Surgeons are
encouraged to use as many ports as are necessary to perform a safe and oncologically efficacious lobectomy.

Port placement and intercostal sites are the same for every lobe. All efforts should be made to keep the
distance between the ports as close to what has been described above. In smaller patients, care must be
taken to keep the trocar sites as far as possible and within the parameters that have been outlined. This
strategy prevents interference in arm function with the present robotic platforms. Port placement may be
modified in the future with the development of new platforms and robot arms which may have a smaller
“footprint” on the chest.

Port Placement with Si Robot: Robotic arm #3 is located two cm lateral from the spinous process of the
vertebral body, robotic arm #2 is 10 cm medial to robotic arm #3, the camera port (we prefer the 12 mm
camera) is 9 cm medial to robotic arm 2, and robotic arm #1 is placed right above the diaphragm anteriorly.

Port Placement with Xi Robot: For the Xi system, the ports are placed in slightly different locations. They
are also numbered differently due to the system. Robotic arm #1 is placed 4 cm away from the spinous
process. Robotic arm #2 is placed 8 cm from arm #1 and robotic arm #3 is placed 8 cm from arm #2.
Robotic arm #4 is placed right above the diaphragm anteriorly. The assistant port is triangulated behind the
camera arm and robotic arm #4 in a similar fashion. The camera is carried by arm #3. Arms #1 through #4
are all placed in the 7th intercostal space.

Instruments: 0° and/or 30° down viewing endoscope, 5 mm Thoracic Grasper (left ③), Cadiere Forceps (left
② ) and Curved Bipolar Dissector (right ① ).

Begin by dividing the inferior pulmonary ligament and remove station #9, and #8 nodes [Figures 2 and 3].
Next, the most posterior arm is used to retract the lower lobe medially and anteriorly to remove lymph
nodes from station #7. Next, open the pleura anterior to the vagus nerve and divide the anterior branch of
the nerve which traverses the subcarinal space. At the beginning of the case, a nasogastric tube should be
inserted to decompress the stomach. After decompression of the stomach, some surgeons may prefer to
remove the nasogastric tube to aid in the retraction of the esophagus during the subcarinal dissection. This
opens the subcarinal space and allows for better access to the Station #7 nodes. Identify the right mainstem
bronchus and stay posterior to the edge of the cartilage. Remove the station #7 nodes and control the
subcarinal artery at the carina. At the end of the dissection, the right and left mainstem bronchi should be
visible, and the posterior aspect of the pericardium should be cleaned and visible [Figure 4]. Next, the most
posterior arm is used to retract the upper lobe inferiorly during dissection of stations 2R and 4R, clearing
the space between the superior vena cava (SVC) anteriorly, the trachea posteriorly, and the azygos vein
inferiorly [Figure 5].

Completion of the lymph node dissection opens the mediastinal space and facilitates the dissection of
the artery and the bronchus. The key to the safe dissection of the posterior aspect of the artery, vein, and