Surgical technical aspects of uniportal hybrid RATS and biportal pure RATS using a subcostal port

Since 2021, multiportal robotic-assisted thoracic surgery (RATS) has developed into a more minimally invasive approach, uniportal RATS, as conventional multiportal video-assisted thoracic surgery (VATS) has developed into uniportal VATS. The uniportal pure RATS allows surgeons to perform a minimally invasive approach in which all procedures are robotically controlled. Although uniportal pure RATS seems to be the ultimate surgical approach, this approach is not applicable to every patient owing to the following technical issues. The handling difficulties of the robotic stapler in uniportal pure RATS due to the insufficient distance from the trocar to the hilar structure seem to limit the surgical indications in some patients, such as patients with short stature and those undergoing middle lobectomy, complex segmentectomies in the lower lobe, and dissection of the inferior pulmonary vein. Alternative approaches are useful for overcoming the limitations of uniportal pure RATS. In this report, we present our surgical methods for uniportal hybrid RATS and biportal pure RATS with a subcostal port as alternatives to uniportal pure RATS. In uniportal hybrid RATS, we describe the placement of standard 8-mm trocars in a triangular configuration and the manipulation of forceps in head-to-tail positioning to avoid collisions between the trocars and robotic arms. In biportal pure RATS, we describe the insertion of an additional port placed under the costal arch to reduce pain at the port site and to provide sufficient distance from the hilar structure.