Dual-portal robotic-assisted thoracic surgery for anatomical segmentectomy: standardized setup and a step-by-step...

Dual-portal robotic-assisted thoracic surgery (DRATS) is a reduced-port robotic approach intended to preserve the core advantages of robotic surgery while limiting the number of intercostal entries. Anatomical segmentectomy requires precise bronchovascular identification, reliable intersegmental plane (ISP) control, and appropriate patient selection, particularly in complex segmentectomy where bronchial misidentification or suboptimal parenchymal division can compromise procedural safety. This article provides a step-by-step, multimedia guide to a standardized DRATS workflow for anatomical segmentectomy. The workflow includes patient-specific preoperative three-dimensional planning, laterality-specific port placement and arm assignment, coordinated console-patient-side teamwork, and protocolized confirmation steps. Intravenous indocyanine green (IV-ICG) fluorescence imaging is used for ISP delineation, while bronchial verification is applied selectively when anatomy is complex or bronchial misidentification is a concern. Two representative videos, right S6 and left S1+2 segmentectomy, demonstrate how the same standardized operative sequence can be adapted to different segmental anatomies. We also summarize perioperative outcomes from a consecutive institutional cohort, including operative time, blood loss, chest tube duration, length of hospital stay, complications, and R0 resection, to provide context for feasibility and safety. DRATS may be a useful reduced-port option for parenchyma-sparing robotic segmentectomy in appropriately selected patients, without implying superiority over multiport or uniportal robotic approaches. Standardized setup, careful planning, coordinated patient-side workflow, and selective verification steps may improve reproducibility and reduce avoidable technical errors during adoption.