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Kikuchi et al. Mini-invasive Surg 2024;8:8 https://dx.doi.org/10.20517/2574-1225.2023.88 Page 5 of 11

Figure 4. Intraoperative views of lower mediastinal lymphadenectomy in robot-assisted minimally invasive esophagectomy in the semi-
prone position. (A) Parietal pleura on the dorsal side of the esophagus was incised using Maryland bipolar forceps; (B) Lymph node no.
112 was dissected from the descending aorta and the left pleura using a vessel sealer; (C) Coarse connective tissues between the lower
esophagus and the pericardium were dissected using Maryland bipolar forceps. The pericardium was gently pressed and ventrally
retracted by an assistant surgeon using a flexible suction retractor with a Lapaclear D cover (Hakujuji Co., Ltd); (D) Lymph node no. 111
was dissected using a vessel sealer. A: Assistant; DAo: descending aorta; Eso: esophagus; LH: left hand; RH: right hand; Ver: vertebra.

Dissection of the middle mediastinum
The mediastinal pleura was dissected cranially to the upper mediastinum, and the azygos vein arch was
excised using a linear stapler with a closed staple height of 1.0 mm inserted from the assistant port
[Figure 5A]. The dorsal end of the azygos vein arch was ligated using an Endoloop PDS II (ETHICON,
Cincinnati, OH, USA) and retracted dorsally to the nearby ICS. At our institute, the right bronchial artery
was generally excised to prevent blind injury with the pulled-up gastric conduit within the posterior
mediastinal reconstruction route following esophagectomy. The esophagus was retracted using a Teflon
tape below the tracheal bifurcation [Figure 5B]. The right vagus nerve was dissected below the right
bronchus, and lymph node no. 109R was dissected using Maryland bipolar forceps or a vessel sealer
[Figure 5C]. After dissecting the upper mediastinum and cutting the upper thoracic esophagus, lymph node
nos. 107 and 109L were dissected using Maryland bipolar forceps or a vessel sealer [Figure 5D].

Dissection of the upper mediastinum
The parietal pleura on the ventral side of the upper thoracic esophagus was incised along the right vagus
nerve using Maryland bipolar forceps, and the right vagus nerve was taped and gently retracted with vessel
loops. Fatty tissues containing lymph node no. 106recR were dissected from the right side of the tracheal
cartilage and the right subclavian artery using Maryland bipolar forceps. Subsequently, no. 106recR
lymphadenectomy was performed using Maryland bipolar forceps or Potts scissors on the right hand
[Figure 6A]. Fatty tissues containing lymph node no. 106recL were dissected from the left side of the