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Gharagozloo et al. Mini-invasive Surg 2020;4:66 I http://dx.doi.org/10.20517/2574-1225.2020.53 Page 5 of 22

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 anatomic
segmentectomy.

Port placement and intercostal sites are the same for all segments. All effort should be made to keep the
distance between the ports as close as possible as to what is described above. In smaller patients, care must
be taken to keep the trocar sites as far as possible and within the parameters that are outlined. This strategy
prevents interference in arm function with the present robotic platforms. It is possible that 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. 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-#4 are all placed in the 7th
intercostal space. The Xi robot has the advantage of providing the robotic stapler, which gives the surgeon
control of the stapling and the use of indocyanine green dye for identification of the intersegmental plane.

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

Mediastinal nodal dissection
Complete nodal dissection is performed with all anatomic segmentectomy procedures. Begin by dividing
the inferior pulmonary ligament and remove Station #9 and #8 nodes [Figure 4]. 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 clearly visible [Figure 5]. 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 anteriorly, the trachea posteriorly, and the azygos vein inferiorly [Figure 6].

Completion of the lymph node dissection opens the mediastinal space and facilitates the dissection of
the artery and the bronchus. After identifying the right mainstem bronchus, it is followed up to the level
of Station #10R lymph node [Figure 7]. This node is superior to the right mainstem bronchus. It should
be dissected and swept towards the lung, thereby exposing the bronchus and the truncus branch of the
pulmonary artery.

Dissection is continued and the crotch between the right upper lobe bronchus and bronchus intermedius
is defined. All Station #7 and #11 nodes and the sump node are removed. This maneuver facilitates later