Biportal robotic-assisted surgery for lung segmentectomies: a surgical technique overview

Minimally invasive thoracic surgery has evolved significantly over the past two decades, with robotic-assisted thoracic surgery (RATS) emerging as a leading approach due to its enhanced visualization, wristed instrumentation, and improved ergonomics. Traditional multiport RATS relies on three or four incisions, while uniportal RATS (U-RATS) offers a less invasive approach but presents technical challenges, including instrument crowding and limited stapler manoeuvrability. The development of biportal RATS (Bi-RATS) represents a balance between these techniques, offering improved ergonomics while reducing access-related trauma. This approach has been employed for diverse pulmonary resections-ranging from wedge resections in peripheral nodules to complex anatomic segmentectomies and lobectomies. This manuscript provides a comprehensive overview of Bi-RATS for lung segmentectomies, detailing patient positioning, port placement, intraoperative technique, and the role of advanced imaging adjuncts such as near-infrared fluorescence [indocyanine green (ICG)] and three-dimensional computed tomography (3D CT) reconstruction. By leveraging these advancements, thoracic surgeons can achieve improved outcomes and enhanced decision-making during complex resections. Compared to multiport RATS, U-RATS, and video-assisted thoracoscopic surgery (VATS), Bi-RATS offers improved instrument manoeuvrability, a more ergonomic stapler trajectory, and utilizes anterior port placement in such a way as to reducing intercostal nerve compression, which may lead to lower postoperative pain. It allows for a fully robotic stapling process, minimizing the need for manual staplers and excessive lung manipulation. The integration of ICG fluorescence further refines segmental plane identification, ensuring precise and safe parenchymal division. Postoperative management includes adherence to enhanced recovery after surgery (ERAS) protocols, early chest tube removal, and effective pain control, which contribute to shorter hospital stays and faster patient recovery. Despite a steep learning curve, Bi-RATS optimizes robotic thoracic surgery by enhancing surgical efficiency while minimizing access trauma. Future research should focus on long-term oncological outcomes, cost-effectiveness, and training standardization to establish Bi-RATS as a widely adopted technique in modern thoracic surgery.