Fig. 1

Schematic illustrations of port placement in robotic surgery for mediastinal tumors

(a) Upper mediastinal tumor (MT). Patients are positioned lateral decubitus with the affected side up. The patient cart is docked on the patient’s left side. An approximately 12-mm port is inserted anterior to the fourth intercostal space (ICS) as the assist port (orange circle) for carbon dioxide (CO2) infusion. Three 8-mm robotic trocars are inserted into the seventh ICS along the midaxillary line as port 2 (black circle) for the robotic camera, the seventh ICS posteriorly along the posterior axillary line as port 1 (yellow-green circle), and the fifth ICS along the anterior axillary line as port 3 (yellow-green circle)

(b–d) Anterior MT. (b) The lateral approach. Patients are positioned 30° lateral decubitus position with the affected side up at a 30° angle, and the ipsilateral arm is placed low. The camera trocar (black circle) is initially inserted at the fifth ICS along the anterior axillary line. The robotic arms (yellow-green circle) are placed in the second (8 mm) and fifth (12 mm) ICSs along the anterior axillary line, and the fifth (8 mm) ICS along the midclavicular line. An assist port (orange circle) is inserted into the fourth ICS (12 mm) along the midaxillary line. The patient cart is docked from the left side of the patient. (c) The subxiphoid approach. Patients are positioned supine, a 4-cm skin incision is created above the subxiphoid, and a wound protector (Gel POINT Mini Advanced Access Platform; Applied Medical, Rancho Santa Margarita, CA, USA) is affixed to an 8-mm rigid 30° oblique viewing robotic endoscope (black circle). The robotic endoscope is inserted with CO2 gas injection at a pressure of 5–8 mmHg using an AirSeal® Intelligent Flow System (ConMed, Largo, FL, USA). Two 8-mm ports (yellow-green circle) for the da Vinci robotic arm are bilaterally inserted into the sixth ICS along the midclavicular line. The da Vinci camera scope is mounted through the subxiphoid port. (d) Single incision. Patients are positioned lateral decubitus. A 5-cm skin incision is created at the fifth ICS along the anterior axillary line, and a wound protector (Gel POINT Mini Advanced Access Platform; Applied Medical, Rancho Santa Margarita, CA, USA) is placed at the subcutaneous muscular layer. Through the wound protector, an 8-mm camera port (black circle) is placed at the fifth ICS along the anterior axillary line as the second arm. Two 8-mm assisted ports (yellow-green circle) are inserted at the fourth and sixth ICSs on the anterior side as the first and third arms, respectively. The distance between each port is approximately 3 cm

(e) Middle MT. Patients are positioned lateral decubitus. Three trocars are inserted posterior (yellow-green circle) to the eighth ICS, at the posterior axillary line (black circle), and at the midaxillary line (yellow-green circle), and the remaining trocar (yellow-green circle) is inserted anterior to the seventh ICS. An 8-mm 30° robotic camera is inserted through a trocar (black circle) on the posterior axillary line at the eighth ICS

(f) Posterior MT. Patients are positioned lateral decubitus. Port placements are variable, with the robotic camera placed in the sixth or seventh ICS along the midaxillary line. The robotic instruments are placed on either side of the robotic camera (black circle), with the left hand placed dorsal to the posterior axillary line at the seventh ICS (yellow-green circle), and the right hand placed anterior to the anterior axillary line at the sixth or seventh ICS (yellow-green circle)