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Page 12 of 19 Ackerman et al. Mini-invasive Surg 2021;5:14 https://dx.doi.org/10.20517/2574-1225.2021.02

Figure 12. Port location for the thorax. The dashed line represents the standard thoracotomy incision. This figure is quoted with
permission from Ekeke et al. [27] .

Figure 13. The subcarinal lymphadenectomy includes all nodal tissue between the bronchi, left pleura, and pericardium. Note the
dissected lymph node packet swept up with the esophagus. LMS: Left mainstem bronchus; BI: bronchus intermedius; P: pericardium; E:
esophagus.

extending to the hiatus. The pleura overlying the right diaphragmatic crural pillar is incised to meet the
prior dissection along the pericardium, and the low paraesophageal lymph nodes along the diaphragm are
reflected with the specimen. The pleura overlying the esophagus is grasped with the robotic assist arm and
the esophagus is reflected anteriorly. The posterior esophagus is mobilized along the spine and aorta from
the hiatus to the azygous with the bedside assistant placing clips on any tissue potentially containing
branches of the thoracic duct, or the duct itself [Figure 14]. The pleura overlying the azygous vein is incised,
and the vein divided with a robotic vascular staple load.

Proximal esophageal dissection
Above the level of the azygous vein, the dissection shifts to “hug” the esophagus [Figure 15]. The right vagus
nerve is divided at the level of the azygous to avoid traction injury to the recurrent laryngeal nerve during
the remaining dissection. The esophagus is circumferentially mobilized to the level of the thoracic inlet (if
needed) to provide adequate mobility for the esophagogastric anastomosis.