Fully uniportal robotic-assisted lobectomy using da Vinci Xi system: surgical technique for a fifth intercostal approach with the cross-arm technique

Introduction

Minimally invasive thoracic surgery has evolved from conventional open thoracotomy to video-assisted thoracic surgery (VATS) and, more recently, to robotic-assisted thoracic surgery (RATS). RATS provides several advantages, including a three-dimensional high-definition view and wristed instruments, enabling precise hilar dissection and systematic lymph node dissection with enhanced safety and dexterity (1). Meanwhile, continuous advancements in VATS techniques and instruments have led to progressive reductions in incision size, and uniportal VATS (U-VATS), performed through a single incision of approximately 4 cm, has become an established and feasible approach in clinical practice (2).

Against this background, uniportal RATS (U-RATS) has emerged as an approach that integrates the minimal invasiveness of U-VATS with the technical advantages of robotic systems. U-RATS was initially introduced as a hybrid approach in which stapling was performed by an assistant, and subsequently evolved into pure U-RATS, allowing the primary surgeon to independently perform robotic stapling (3,4). More recently, its application has expanded to advanced procedures, including bronchoplasty and vascular reconstruction (5).

However, the da Vinci Xi system, currently the most widely used robotic platform, was originally designed for multi-port approaches. When applied through a single intercostal incision, several technical challenges arise, including robotic arm interference, limited range of motion, and difficulty in robotic stapler manipulation. Various modifications, such as assistant-controlled stapling or the use of additional ports, have been reported (6); however, these approaches do not fully meet the principles of a completely uniportal and fully surgeon-controlled procedure.

Although robotic platforms specifically designed for single-port surgery have recently been introduced, their clinical adoption remains limited due to high implementation costs and challenges in establishing dedicated training systems. Therefore, developing a practical and reproducible pure U-RATS technique using the existing da Vinci Xi system is of considerable importance for broader dissemination.

At our institution, we established a fully surgeon-controlled U-RATS technique using the da Vinci Xi system by incorporating the cross-arm technique, which minimizes robotic arm interference and enables safe, independent robotic stapling by the primary surgeon (7). This approach does not require additional ports, specialized instruments, or a highly experienced assistant, and thus represents a practical and versatile strategy using a widely available robotic platform.

This technique is primarily applied to lobectomy for lung cancer and is suitable for standard indications of pulmonary resection. However, its application in advanced disease or procedures requiring bronchial or vascular reconstruction warrants further investigation.

In this article, we describe in detail a completely uniportal robotic-assisted lobectomy using the da Vinci Xi system via a fifth intercostal approach, focusing on the cross-arm technique, operative setup, port placement, and robotic stapler manipulation. The accompanying video demonstrates the key procedural steps and highlights the reproducibility and practical applicability of this technique.

This technique is applicable to surgical treatment of pulmonary malignancies, including lobectomy and segmentectomy. In selected cases, it has also been applied to patients after induction chemotherapy and to those requiring bronchoplastic procedures. We present this article in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0008/rc).

Preoperative preparations and requirements

This study was approved by the Ethics Committee of Toyohashi Municipal Hospital (No. 304) and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images, and the videos. A copy of the written consent is available for review by the editorial office of this journal.

This technique was applied to patients undergoing lobectomy or segmentectomy for malignant pulmonary diseases, including primary lung cancer and metastatic lung tumors. The patient population included a wide range of demographics, with ages ranging from 44 to 89 years and body mass index (BMI) values from 14.9 to 38.6 kg/m², representing diverse body habitus. Although the majority of patients had clinical stage I lung cancer, cases with advanced disease and those who had received preoperative neoadjuvant therapy were also included.

Preoperative evaluation was performed in accordance with established guidelines and institutional clinical practice. Pulmonary function was assessed using spirometry and diffusing capacity of the lungs for carbon monoxide (DLCO). Predicted postoperative values [predicted postoperative forced expiratory volume in 1 second (ppoFEV1) and predicted postoperative DLCO (ppoDLCO)] were calculated based on the number of functional lung segments. Patients were considered eligible for lobectomy if ppoFEV1 and/or ppoDLCO were ≥60%, or between 40% and 60% when exercise tolerance was deemed clinically acceptable. In patients with intermediate functional impairment (predicted postoperative values between 40% and 60%), further risk stratification was performed based on functional assessment, such as stair climbing, in addition to a comprehensive evaluation of respiratory function, general condition, and surgical tolerability.

Chest computed tomography (CT) was used for imaging evaluation, including assessment of tumor location, size, and its relationship to surrounding structures. A representative preoperative CT image from the case presented in the surgical video is shown (Figure 1).

Figure 1 Preoperative chest CT of a 75-year-old man with right upper lobe lung cancer. The patient was diagnosed with adenocarcinoma (cT2aN0M0, stage IB) and underwent U-RATS right upper lobectomy with ND2a-1 lymph node dissection. (A) Axial view; (B) coronal view. CT, computed tomography; U-RATS, uniportal robotic-assisted thoracic surgery.

Although no strict absolute contraindications were defined, in patients with a small body habitus (e.g., height <150 cm), the uniportal robotic approach was considered with caution due to narrow intercostal spaces and the potential risk of increased postoperative pain, and conventional VATS tended to be selected in such cases.

All procedures were performed at a tertiary referral center equipped with robotic surgical facilities.

Step-by-step description

Operating room setup and patient positioning

Surgery was performed under general anesthesia. Endotracheal intubation was achieved using a double-lumen tube to establish one-lung ventilation. The patient was positioned in the lateral decubitus position, and the operative lung was deflated to provide adequate surgical exposure. In addition, no intrathoracic insufflation system (e.g., AirSeal^®), which is sometimes used in robotic thoracic surgery, was employed. The procedure was performed under conventional one-lung ventilation without the use of CO₂ insufflation.

The flexion point of the operating table is aligned just below the intended intercostal space to maximize intercostal widening. The ipsilateral upper extremity is positioned either extended or flexed and secured carefully to avoid brachial plexus compression (Figure 2).

Figure 2 Left lateral decubitus position. The operation table is flexed below the target intercostal space, and the ipsilateral upper extremity is positioned to prevent brachial plexus compression.

For both right- and left-sided procedures, the robotic patient cart is docked from the patient’s left cranial side. Any obstacles within the arm working envelope are removed, and adequate space is ensured to allow an emergency roll-out if required (Figure 3).

Figure 3 Docking of the da Vinci system. The robotic system is rolled in from the patient’s left cranial side for both right and left side procedures.

Robotic docking and setting

A single incision of approximately 4 cm is created on the mid-axillary line at the fifth intercostal space, similar to U-VATS (the sixth intercostal space is used for lower lobectomy), and an Alexis XS^® wound retractor is applied. The da Vinci Xi^® system is docked from the patient’s left cranial side, and the intersection point of the laser targeting lines is aligned with the dorsal edge of the incision. The boom is rotated while confirming the laser lines so that it runs parallel to the rib orientation. The targeting function and AirSeal^® system are not used. Video 1 demonstrates the docking procedure and robotic arm configuration of the da Vinci system. The procedure shown is a right upper lobectomy. The patient is positioned in the left lateral decubitus position, and the robotic system is docked from the left cranial side of the patient.

Ports mounted on the robotic arms are slimmed by removing the electrode component of flare ports; however, standard 8- or 12-mm ports commonly used in thoracic surgery also provide sufficient operability (Figure 4).

Figure 4 Modified flare port used in this procedure. The electrode component of a flare port originally designed for oral and maxillofacial surgery was removed to create a slimmer profile. The left port is designated for robotic stapler insertion, while the other ports are used for the camera and working instruments.

A 30-degree endoscope is positioned at the dorsal edge of the incision to obtain a so-called “look-up view”. The robotic arms are arranged compactly in a fan-shaped configuration along the ribs (Figure 5). To prevent arm interference, it is important not to excessively separate the arms but rather to align them closely in a compact manner. When using the cross-arm technique, the instrument of the dominant hand is assigned to the contralateral robotic arm.

Figure 5 Port configuration. Port configuration with a dorsal 30° endoscope and bilateral working arms arranged in a compact fan shape, with the inferior port edges aligned at the level of the parietal pleura.

For right-sided procedures, Arm 1 is not used. Arm 2 is inserted at the dorsal edge of the incision and assigned to the camera. Arm 3 is equipped with a SynchroSeal™ for right-hand manipulation, and Arm 4 is equipped with a Force Bipolar™ for left-hand manipulation. The console arm assignment is set as Arm 1: right; Arm 2: left; Arm 3: right; and Arm 4: left, regardless of the operative side (Figure 6).

Figure 6 Setting for the cross-arm technique. The same configuration is used for both sides. This configuration facilitates effective use of the cross-arm technique.

With this configuration, the look-up view camera is angled cranially, while the two working arms are directed slightly caudally, thereby reducing arm interference. In addition, the use of the cross-arm technique allows the working arms to achieve a wide range of motion in the ventral-dorsal direction (Figure 7). The assistant performs lung retraction and field exposure using lung graspers and suction devices through the inter-arm space. The assistant’s instruments are identical to those used in U-VATS, and no specialized instruments dedicated to U-RATS are required.

Figure 7 3D arm configuration. This arm configuration demonstrates reduced arm interference and an expanded working range with the cross-arm technique. 3D, three-dimensional.

U-RATs right upper lobectomy: intraoperative technique

Video 2 demonstrates the intrathoracic procedure for a patient with early-stage right upper lobe lung cancer. It highlights tissue dissection using the SynchroSeal device, exposure techniques with gauze assistance, safe insertion of the stapler using vessel loop guidance, and extracorporeal maneuvers performed during the procedure.

At the beginning of the procedure, the thoracic cavity is thoroughly inspected to assess the presence of pleural adhesions. When adhesions are present near the incision site, they are carefully dissected manually. In contrast, adhesions located distant from the incision are dissected after robotic roll-in using robotic instruments. With a uniportal approach through the fifth intercostal space, adhesiolysis can be safely performed from the lung apex to the subdiaphragmatic region. Throughout the procedure, the operative field is adjusted so that both working instruments are consistently positioned in the lower portion of the endoscopic view. When the instruments cross over the camera placed dorsocranially and move cranially, interference between the camera and instruments may occur; therefore, appropriate adjustments are made as needed. This configuration provides an operative view that closely resembles that of open thoracotomy.

Hilar dissection

Hilar dissection is initiated by approaching the pulmonary artery either from the ventral hilum or through the interlobar fissure. In most cases, the pulmonary artery, bronchus, and pulmonary vein are divided sequentially; however, the order of dissection may be modified according to disease characteristics and individual anatomical variations. Surgical exposure is achieved either by the assistant using suction instruments or by the surgeon performing dissection primarily with the right hand while using the left hand for lung retraction. To minimize lung injury during retraction, surgical gauze is used for gentle compression of the lung parenchyma. Dissection is performed using fenestrated bipolar forceps in the left hand and SynchroSeal™ in the right hand. With the cross-arm technique, precise vascular dissection comparable to that achieved in multi-port RATS (m-RATS) can be performed.

Identification of interlobar or intersegmental planes in incomplete fissure cases

In cases with incomplete fissures, interlobar or intersegmental planes are identified using indocyanine green (ICG) fluorescence imaging after division of the pulmonary vessels. Diluted ICG (2.5 mg/10 mL) is administered intravenously at a dose of 5 mL as a bolus through a peripheral vein, followed by a saline flush. Upon switching to Firefly™ mode, fluorescence appears in perfused lung regions. The non-perfused lung surface is marked using bipolar forceps. After marking is completed, Firefly™ mode is discontinued, and the demarcation line is divided. In the case presented in the accompanying video, ICG fluorescence was used to delineate the fissure because the right upper and middle lobes exhibited complete fissure absence.

Robotic stapler manipulation

When using the robotic stapler SureForm™ 45, the port is exchanged for a 12-mm port, and the stapler is inserted while elevating the inferior edge of the cannula extracorporeally. Elevation of the cannula tip allows sufficient articulation of the stapler near the incision edge. Even when the distance between the incision and the target vessel or tissue is short, tunneling and division can be safely performed using the robotic stapler. When using SureForm™ 30, an 8-mm port is typically sufficient, and stapling can often be performed without lifting the port.

Specimen retrieval and lymph node dissection

After completion of lobectomy or segmentectomy, the ports and wound retractor are temporarily removed. A specimen retrieval bag is inserted into the thoracic cavity through the 4-cm incision, and the specimen is enclosed and extracted. The wound retractor and ports are then reinserted, followed by standard hilar and mediastinal lymph node dissection. The assistant supports surgical exposure using suction instruments as needed. Systematic lymph node dissection was feasible with this technique, and in our previously reported series, the median number of retrieved lymph nodes was 12–13, which was comparable to that achieved with multiportal approaches (5).

Completion of the procedure

After completion of lymph node dissection, a sealing test is performed to assess for air leakage from the bronchial stump and fissure division surfaces. Additional sutures are placed if air leakage is detected. After confirming the absence of intrathoracic bleeding, the robotic system is rolled out. Following confirmation of hemostasis at the incision site, a 20-Fr thoracic drain is placed through the same incision, and the procedure is concluded.

Institutional experience

Between 2023 and 2025, a total of 120 U-RATS procedures were performed at our institution. The median operative time was 152.1 minutes, and the median blood loss was 50 g. R0 resection was achieved in all patients, corresponding to an R0 resection rate of 100%.

Conversion to VATS or thoracotomy was required in six cases, primarily due to pulmonary artery bleeding caused by nodal adhesion, bleeding during vascular handling, and vascular injury resulting from poor visualization.

Conversion strategy

When conversion to m-RATS is required, an additional port can be created on the dorsal side of the same intercostal space, allowing utilization of Arm 1, which is not used during the uniportal procedure. For conversion to U-VATS, the robotic system is rolled out and the operation can be continued through the same incision. Conversion to open thoracotomy is achieved by extending the existing incision, without the need to create an additional incision at a different site.

In emergency situations, such as uncontrolled intraoperative bleeding, the robotic camera is manually controlled by an assistant to maintain visualization of the operative field, while a second assistant performs robotic roll-out and initiates thoracotomy simultaneously.

Postoperative considerations and tasks

After completion of surgery, patients are transferred to a monitored setting for assessment of pain control, respiratory status, and hemodynamic stability. Postoperative management is conducted in accordance with the institutional enhanced recovery after surgery (ERAS) protocol.

Pain control is primarily achieved with intraoperative intercostal nerve block, with additional analgesics administered as needed. Given the single incision at the fifth intercostal space, early mobilization is feasible on the day of surgery or the first postoperative day, and the mean postoperative hospital stay was 4 days. In most cases, pain was adequately managed with oral analgesics from postoperative day 1.

Chest tube management is routinely assessed from the first postoperative day onward. The chest drain is removed when there is no air leakage, drainage volume is minimal, and adequate lung re-expansion is confirmed on imaging. In most cases, chest tube removal is feasible within 1–3 postoperative days.

The overall postoperative complication rate was 10.8%, with the main complications including prolonged air leak, pneumonia, arrhythmia, bronchopleural fistula, and chylothorax. Prolonged air leak was managed with chest drainage, and pleurodesis was considered when it persisted beyond 7 days. Bronchopleural fistula was managed with reoperation. The 30-day postoperative mortality rate was 0%.

For the assessment of short-term safety, patients were followed up in the outpatient setting every 2 weeks for the first 2 months postoperatively to screen for postoperative complications and to manage pain. Chest radiography and blood tests were performed at each visit. The frequency of follow-up was adjusted as appropriate based on the individual patient’s clinical course.

For oncological follow-up, patients were monitored for recurrence with chest CT and tumor marker measurements every 6 months for 5 years after surgery.

Tips and pearls

• Optimization of port position: a fifth intercostal approach is essential for establishing an effective three-dimensional arrangement of the camera and working arms, allowing sufficient range of motion while minimizing robotic arm interference.
• Look-up configuration with a 30° endoscope: dorsal placement of the camera provides a caudal-to-cranial view of the hilar structures, facilitating clear identification of the pulmonary vessels and bronchus.
• Effective use of the cross-arm technique: assigning the dominant hand to the contralateral robotic arm increases the distance between instruments, enabling precise dissection even in a uniportal setting.
• Technical refinements for robotic stapler insertion: during stapler insertion, avoiding use of the remote center and slightly elevating the cannula extracorporeally helps secure adequate stapler articulation near the incision.
• Preparation for rapid roll-out: the single incision can be readily extended for thoracotomy if required, facilitating prompt management in emergency situations. Preoperative simulation and clear team communication are essential.

Discussion

Current status of RATS in Japan

In recent years, RATS has rapidly expanded, with increasing diversity in port configurations and surgical approaches. In Japan, m-RATS has been widely adopted, as it provides sufficient working space and minimizes robotic arm interference. This approach allows stable surgeon-controlled manipulation and facilitates collaboration with the assistant, making it relatively easy to introduce (8).

However, multi-port procedures are associated with several drawbacks, including increased postoperative pain, reduced cosmetic outcomes, higher costs, and the risk of inadvertent injury due to extracorporeal instrument manipulation (9,10). Reduced-port RATS has been introduced as an intermediate strategy to maintain minimal invasiveness while transitioning toward U-RATS, although it requires a high level of expertise from the assistant.

Furthermore, the da Vinci single-port system, designed specifically for single-port surgery, offers advantages in reducing arm interference and improving cosmetic outcomes. However, it requires assistant-controlled stapling due to the lack of robotic staplers and is associated with limitations related to patient body habitus and difficulty in conversion (11-13).

Institutional background and development of surgeon-controlled U-RATS

At our institution, U-VATS was introduced in 2019 and has since been widely adopted. When robotic surgery was introduced in 2021, m-RATS was initially employed; however, in order to maintain our established minimally invasive philosophy, we sought to achieve a completely uniportal approach in robotic surgery as well. Through stepwise reduction of port numbers and iterative refinements, the current technique was established.

During the early phase of robotic program implementation, the number of thoracic surgeons sufficiently experienced in robotic procedures was limited, making it challenging to rely on assistants for critical tasks such as stapling. Therefore, establishing a technique that allows the primary surgeon to independently perform key procedures—including vascular and bronchial division—was a crucial objective. The present technique was developed in response to this institutional background, aiming to achieve a safe, reproducible, and fully surgeon-controlled U-RATS procedure. Prior experience with U-VATS may facilitate the safe introduction of U-RATS. A stepwise transition from VATS to U-VATS and then to U-RATS may improve safety and reproducibility.

Significance and advantages of uniportal surgery using a multi-port robotic platform

The U-RATS technique using the da Vinci Xi system at our institution is characterized by the completion of surgery through a single incision using a multi-port robotic platform, while incorporating the advantages of various surgical approaches. Importantly, this technique does not require the introduction of a dedicated single-port robotic system and can be implemented at relatively low cost. The procedure is performed without AirSeal^®, uses only three robotic arms, and allows the assistant to utilize conventional U-VATS instruments, resulting in a procedural burden comparable to or lower than that of m-RATS.

Because all instruments are inserted through a single incision, inadvertent injuries caused by extracorporeal instrument manipulation outside the visual field are minimized. Moreover, surgeon-controlled robotic stapling ensures consistent and stable stapling performance independent of assistant experience. By optimizing arm configuration and stapler insertion techniques, operability comparable to that of multi-port robotic surgery can be achieved.

Another major advantage of this technique is its flexibility in conversion strategies. Conversion from U-RATS to m-RATS can be achieved by activating an unused robotic arm, while conversion to U-VATS can be performed without adding an incision. Even when conversion to open thoracotomy is required, the procedure can be accomplished by extending the existing incision, allowing rapid roll-out and minimizing surgical delay. From both a risk management perspective and in institutions with limited assistant expertise, this reproducible and minimally invasive approach represents a significant advantage.

Comparison with other surgical approaches

To clarify the positioning of the present technique, comparison with m-RATS, the da Vinci single-port system, and other uniportal approaches is essential. From the perspective of the learning curve, m-RATS allows relatively rapid acquisition of proficiency due to its superior operability and ease of collaboration with the assistant. In contrast, U-RATS requires manipulation of multiple robotic arms through a single incision, making it technically more demanding and associated with a longer learning curve. The single-port system requires assistant-controlled stapling, and thus its performance is partly dependent on the assistant’s level of experience.

Regarding indications, m-RATS is applicable to a wide range of patients and procedures and is currently considered the most versatile approach. The single-port system, which utilizes a subxiphoid or subcostal approach, may be subject to limitations in operability depending on patient body habitus, particularly in larger patients. In contrast, U-RATS employs an intercostal approach, and therefore may be less suitable for patients with narrow intercostal spaces. Furthermore, the optimal indications for each approach in advanced disease or in procedures requiring bronchial or vascular reconstruction remain to be established.

With respect to clinical outcomes, although comparative data among these approaches have been reported, the available evidence—particularly for U-RATS and the single-port system—remains limited in terms of case volume and long-term outcomes, precluding definitive conclusions regarding superiority.

From a cost perspective, robotic surgery is generally associated with higher costs compared with VATS, largely due to the increased number of ports and specialized instruments in m-RATS. The single-port system may further increase costs because it requires a dedicated platform and instruments. In contrast, the present technique may reduce the economic burden by minimizing the number of ports and robotic arms, avoiding the use of AirSeal^®, and allowing the use of conventional U-VATS instruments.

Finally, in comparison with U-VATS, the latter is widely adopted as a cost-effective and minimally invasive approach that does not require specialized robotic systems. However, U-RATS may offer advantages in terms of instrument articulation and stability of the operative view. Clinically, U-VATS may be well suited for relatively straightforward procedures, such as early-stage lung cancer, whereas U-RATS may be advantageous in more complex procedures requiring bronchial or vascular reconstruction. Nevertheless, clear criteria for selecting between these approaches have not yet been established and warrant further investigation.

Limitations and challenges

Several limitations of this technique should be acknowledged. First, although operability comparable to m-RATS can be achieved through optimized port placement and arm manipulation, a learning curve is inevitable. Similar to the introduction of U-VATS, which requires an initial learning phase (14), proficiency in uniportal robotic surgery also necessitates stepwise accumulation of experience. At our institution, the introduction of U-RATS was performed in a stepwise manner, based on prior proficiency in U-VATS lobectomy. In our single-center experience of 120 U-RATS cases, procedural stabilization was achieved after approximately 50–60 cases from the initial introduction.

Regarding training, we implemented a structured program that combines simulation using thoracic models and porcine lungs, familiarization with console operation, and stepwise participation in clinical cases (assistant → partial operator → primary surgeon). In addition, to ensure stable exposure within the limited operative field, we consider a dedicated team—particularly an assistant experienced in uniportal techniques—to be essential.

Second, uniportal robotic surgery frequently requires non-grasping techniques similar to those used in VATS, with the surgeon’s left hand often playing a major role in exposure. Because the assistant’s working range is more restricted compared with multi-port procedures, the surgeon must compensate through active left-hand manipulation.

Third, current robotic staplers have inherent physical limitations, requiring careful consideration of insertion angle and tunneling techniques. When adequate stapler articulation cannot be achieved, additional strategies—such as mobilizing the lung or adjusting target structure positioning using vessel loops—are necessary.

Finally, in patients with very narrow intercostal spaces, insertion of robotic ports may be technically challenging. As the currently available 8-mm port represents the smallest option, careful patient selection is required, and VATS should be considered in cases where intercostal access is extremely limited.

Future development of more compact, high-performance robotic instruments and staplers is expected to improve operability, shorten the learning curve, and further reduce surgical invasiveness.

Future perspectives

RATS is expected to continue diversifying, with an expanding range of procedural options. No single technique is universally applicable to all institutions or clinical scenarios; therefore, flexible surgical strategies tailored to institutional resources, surgeon experience, and established surgical culture are essential. The present technique may serve not only as a transitional step toward U-RATS but also as a completed form of minimally invasive surgery suited to specific institutional environments. We anticipate that this approach will contribute to expanding the spectrum of options in robotic thoracic surgery.

Conclusions

Although the da Vinci Xi system was not originally designed for uniportal surgery, the present technique enables a fifth intercostal, fully surgeon-controlled U-RATS lobectomy. This approach represents a practical and reproducible technique that can be performed using the existing Xi system without the need for a dedicated single-port robotic platform and may facilitate broader adoption of U-RATS in clinical practice.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Hideki Ujiie) for the series “Reduced Port Robotic-assisted Thoracic Surgery” published in Journal of Visualized Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0008/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0008/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0008/coif). The series “Reduced Port Robotic-assisted Thoracic Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Ethics Committee of Toyohashi Municipal Hospital (No. 304) and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this study, accompanying images, and the videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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