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Page 2 of 18 Ninomiya et al. Mini-invasive Surg 2022;6:33 https://dx.doi.org/10.20517/2574-1225.2022.12

esophagectomy (RATE) has become a widely adopted esophageal surgery. We introduced RATE in the
lateral decubitus position (LDP) with the four-arm da Vinci Xi robotic system (Intuitive Surgical Inc.,
Sunnyvale, CA) as a curative operative procedure in 2018. The videoscopic images and hand control
manipulation in the previously reported RATE in LDP [4-17] are the same as those in RATE in the prone
position (PP) [18-24] , where the arms for the right and left hands are introduced into the thoracic cavity from
the cranial and caudal directions, respectively. We performed thoracoscopic esophagectomy (TE) in the
LDP under the image rotated by 180°, where the left side was cranial and the upper side was ventral; this
[25]
image is similar to the view under open thoracotomy . We successfully reproduced the same endoscopic
view and hand manipulation in RATE in the LDP as in our TE via inversion of the image with camera
[26]
rotation and manual hand control assignment .

In this technical note, we present our surgical techniques of mediastinal dissection by RATE in LDP.

OPERATIVE PROCEDURE
As a radical surgical procedure for esophageal cancer, esophagectomy with three-field lymphatic dissection
consisting of cervical, mediastinal, and abdominal dissections was performed. The operation was started
from the thoracic procedure with RATE in LDP. After RATE, abdominal and supraclavicular cervical
lymph node dissections were done simultaneously by two teams in the supine position. The abdominal
lymphatic dissection was done by hand-assisted laparoscopic surgery. The gastric tube was selected as the
primary reconstruction conduit and pulled up through the posterior mediastinum. The operation was
finished with cervical anastomosis. In cases of non-curative resection, the retrosternal route was selected for
elevation of the gastric tube to allow subsequent chemoradiotherapy of the residual tumor.

Preparation of RATE in LDP
For the thoracic procedure, patients were placed in the left LDP after intubation with a left-side
double-lumen tube. The patient body was titled 30°-45° ventrally to prevent visual disturbance by the right
lung. RATE was performed using the da Vinci Xi Surgical System (Intuitive Surgical Inc.). The patient cart
was positioned on the dorsal side, with two assistants on the ventral side. An assistant retracted the lung and
trachea with a tracheal retractor and dried the surgical field using suction. Another assistant exchanged the
EndoWrist instruments (Intuitive Surgical Inc.). Four 8 mm robotic ports were placed; one in the 9th
intercostal space (ICS) at the middle axillary line (AL) (Arm 1), one in the 8th ICS behind the posterior AL
(Arm 2), one in the 6th ICS between the anterior and middle AL (Arm 3), and one in the 4th ICS at the
middle AL (Arm 4). Two 12 mm assistant ports were placed in the 3rd ICS at anterior AL and the 4th ICS at
anterior AL [Figure 1]. Ports 1-4 were connected to the corresponding robot arm [Figure 2]. The endoscope
was held by Arm 3. The camera image for the operator was vertically and horizontally inverted by camera
rotation to create an operative view similar to that achieved under open thoracotomy. We used a forward-
oblique viewing endoscope with a 30° down-facing orientation. The right and left hands were assigned to
Arms 1 and 4, Arms 2 and 4, or Arms 1 and 2, respectively, by manual hand control assignment depending
on the situation. The remaining arm was used as an assistant arm. One of the assistant ports was connected
to the valveless insufflation system (AirSeal; ConMed, Utica, NY) and used to achieve artificial
pneumothorax with carbon dioxide insufflation at a pressure of 8 mmHg through an assistant port. The
operator mainly used monopolar curved scissors in the right hand and a large bipolar grasper in the left
hand. Organ retraction was done using Cadiere forceps held in the assistant arm. The assistant performed
tracheal rotation using a narrow tracheal retractor inserted through the assistant port [Figure 3]. Dissection
was done mainly using monopolar curved scissors, especially around the trachea and bronchus. A Vessel
Sealer Extend (Intuitive Surgical Inc.) was used around the aorta, and it was occasionally used by the left
hand during dissection at the left side of the middle and lower mediastinum. The image for the assistants