How I do it: The Hi-UP approach-single-port da Vinci SP-assisted mediastinoscopic subtotal esophagectomy with a transhiatal-dominant strategy in the abdominal and cervical phases.

Mediastinoscopic esophagectomy for thoracic esophageal cancer may reduce pulmonary morbidity; however, upper mediastinal lymphadenectomy, particularly along the left recurrent laryngeal nerve (station 106recL), remains technically challenging. We developed a transhiatal-dominant mediastinoscopic subtotal esophagectomy using the da Vinci SP system for both the abdominal and cervical phases. After completing lower and mid-mediastinal lymphadenectomy while preserving the mediastinal pleura, transhiatal dissection is advanced beyond the carina into the upper mediastinum to perform 106recL lymphadenectomy along the left recurrent laryngeal nerve from its turning point beneath the aortic arch. The cervical phase is limited to confirming and completing the cranial 106recL dissection. Two patients had no postoperative morbidity, and bilateral vocal fold mobility was confirmed by laryngoscopy on postoperative day 3. Transhiatal/cervical console times were 180/71 and 200/45 min, respectively, and postoperative hospital stay was 13 days in both cases. This transhiatal-dominant, dual-phase da Vinci SP approach appears feasible for thoracic esophageal cancer.