Non-assistant help operation in dual-portal RATS (neoDRATS): a surgical technique

Robot-assisted thoracic surgery (RATS) has evolved toward reduced-port approaches to further minimize surgical invasiveness. However, current uniportal RATS techniques are associated with technical challenges, including limited working space and instrument interference, particularly in patients with smaller physiques. To overcome these limitations, we developed a non-assistant help operation in dual-portal RATS (neoDRATS), which fully utilizes all four arms of the da Vinci Xi system without canceling any arm. This technique enables console-surgeon-driven lung retraction and robotic stapling through a dual-portal configuration consisting of a 4-cm main incision and a single auxiliary port. In this article, we describe the step-by-step surgical technique of neoDRATS, including patient positioning, port placement, robotic arm configuration, use of the third arm, and robotic stapling strategies. Representative operative videos of right upper and left lower lobectomy are provided to illustrate key technical aspects and demonstrate the feasibility of this approach in clinical practice. neoDRATS offers a practical reduced-port RATS approach that balances minimal access with operative safety and maneuverability, while preserving familiar surgical views and workflows from conventional video-assisted thoracic surgery (VATS) and thoracotomy. This technique may facilitate the safe and reproducible adoption of reduced-port robotic thoracic surgery in a wide range of clinical settings, particularly for anatomical pulmonary resections. Furthermore, this approach may help bridge the gap between conventional multiport RATS and uniportal techniques by combining technical stability with reduced invasiveness.