 Hi, today we will see how to perform a robotic left recurrent arrangial lymph node dissection for CA esophagus This is the anatomy of the esophagus in the prone position and the left and the right recurrent arrangial lymph node packets as shown in the green. The first step is to perform the suprazygous and the infrazygous mobilization of the azygous vein We cut the parietal pleura both above and below the azygous vein with the left and the help of the right hand monopolar scissors The first step of performing an effective recurrent arrangial lymph node dissection is to ligate and cut the azygous vein as is shown The next step is to ask the assistant to hold up the azygous vein so as to expose the pre-vascular fascia as is being shown by the right black arrow Right now we are dissecting in the pre-vascular fascia as is being shown behind is the iota and the arch of the iota The left recurrent arrangial dissection starts with identification of the pre-vascular fascia as been shown in the PIP mode The thoracic duct is in close vicinity with the left border of the esophagus and all the care should be taken to avoid any injury to the thoracic duct As we go further along the pre-vascular fascia we expose the iota in totality Right the ascending as well as the arch of the iota The dissection is being performed Now you can see the thoracic duct all along the iota and the adventitio of the iota The glistening white of the iota is completely exposed and the whole of the pre-vascular fascia Is being exposed completely All up to the arch of the iota where the left recurrent arrangial nerve hooks underneath The iotic arch The left vagus is now identified and cut in the infra bronchial part now the left vagus nerve is cut The second step is to identify the visceral fascia which runs between the esophagus and the trachea The trachea is been retracted with the cherry forceps the cherry retractor And the fan retractor This maneuver is called the tracheal dip or the tracheal dive One has to be careful to go all along the left border of the trachea And dip right along or parallel to the left border of the trachea as being done Now in the video We are staying very close to the left lateral border of the trachea And we are going all along the visceral fascia As is being marked in the pip mode by the white arrow So the plane of dissection is parallel to the left border of the trachea This maneuver is called the tracheal dive or the tracheal dip We go all along the visceral Plura all along the left recurrent laryngeal lymph nodal packet As being shaded in green color In the pip mode The visceral plura As is cut is completely an avascular zone The trachea is retracted towards the surgeon And the visceral fascia Is cut The whole idea is to follow the visceral plura And meet the visceral fascia and meet the pre-vascular fascia Which is behind the esophagus all along the iota In doing so the whole of the left recurrent laryngeal lymph node packet Is lifted up along with the left recurrent laryngeal nerve With the esophagus As you can see The whole dissection is performed with the help of a monopolar cotree And no energy source is used because this is a complete avascular zone Now you can see the left left recurrent laryngeal nerve coming up from within the packet As is being shown in the pip mode By the right black arrow The arrow is Showing the recurrent laryngeal nerve within the left recurrent laryngeal lymph node packet And the dissection is performed both above and below this left recurrent laryngeal nerve So that all the lymph nodal tissue and the lymphatics Are brought along with into the specimen Above along the esophagus The fan retracted is very important To retract the left main bronchus as well as the trachea Towards the surgeon to expose the left recurrent laryngeal lymph nodal packet area All the packet the lymph nodal tissue and the lymph nodes are lifted along the esophagus The lift the esophagus is lifted up And the assistant helps in exposing this area By lifting the esophagus up and retracting the trachea down and towards the surgeon on the right side Now the dissection is being performed into the Lymph nodal packet And the nerve which was lifted up from behind is now Pushed down And the dissection is done all along the recurrent laryngeal nerve Making sure that one uses does not use the energy source Close to the nerve as it may cause nerve palsy So most of the dissection in this area Is done with bare scissors Hence the robotic right arm which is which comprises of the monopolar scissor Is very instrumental In pushing down the recurrent laryngeal nerve The use of energy source has to be minimum In this region and you can see The tracheoesophageal groove completely devoid of all the fibrofactic tissue of all the lymph nodal tissue Now the visceral fascia meets the pre-vascular fascia Now what we are cutting is the pre-vascular fascia and you can see the thoracic duct in the background Once you are assured that the visceral fascia is completely cut You again go behind the esophagus Towards the iota and the left pleura To completely excise The pre-vascular fascia which is marked by the white arrow in the pipi mode So the visceral fascia and the pre-vascular fascia is now joined As is being cut now to expose the iota from underneath and behind the esophagus The same visceral fascia and the Pre-vascular fascia is run Down up to the infracurinal part The last part of the procedure is to do the infracurinal dissection You can see the right main bronchus And the infracurinal or the subcarinal lymph nodal packet completely exposed One must remember to stay as close to the recurrent to the Right main bronchus and the left main bronchus inferior border and not In the membranous part of the bronchus of the trachea The whole of the carina is exposed In this region the left main bronchus completely exposed And the subcarinal dissection being performed And a small twig of tissue Is now cut and whole of the subcarinal lymph nodes is lifted up from the pericardium And now the whole of the subcarinal area is completely devoid of any fibrofatic tissue and all the lymphatic tissue You can see this whole unedited video Relatively bloodless because we follow all the planes of dissection The mobilization of the esophagus is done as usual done for any other case So this was the whole video and we would like to thanks Ahana Pandit for her diagrammatic representation Of the hand-tron diagram Thank you very much