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

Introduction

Background

Anatomical segmentectomy is an established parenchyma-sparing option for selected early-stage non-small cell lung cancer (NSCLC) and small peripheral pulmonary nodules, supported by randomized evidence (1,2). As its use expands, surgeons increasingly require techniques that ensure reproducible bronchovascular identification and reliable intersegmental plane (ISP) control. These technical requirements become more stringent in complex segmentectomy, where bronchial misidentification and suboptimal parenchymal division can compromise procedural safety.

Robotic-assisted thoracic surgery (RATS) provides stable three-dimensional visualization and articulated instrumentation, yet conventional multiport configurations may not fully address the desire to reduce access trauma.

Reduced-port RATS has therefore attracted interest, although decreasing the number of ports can introduce new constraints, including restricted stapling trajectories and a higher risk of external arm collision, particularly around the posterior hilum. In dual-portal robotic-assisted thoracic surgery (DRATS), right-hand stapling through the dedicated port is usually feasible; however, left-hand stapling can be constrained because the left-hand instrument shares the utility incision with the camera, leading to camera-instrument interference. Importantly, this limitation has not prevented completion of segmentectomy in our experience, and when patient-side stapling is required, it can be performed after temporary undocking of the arms to avoid external interference. DRATS has been proposed as a reduced-port configuration intended to preserve robotic visualization and dexterity while maintaining patient-side operability for stapling, instrument exchange, and troubleshooting within a standardized two-incision setup, and early multi-institutional experience has demonstrated feasibility for anatomical lung resection (3). In addition, a propensity score-matched comparison reported comparable short-term outcomes between DRATS and multiport RATS, with a lower incidence of post-thoracotomy pain syndrome after DRATS (4).

For anatomical segmentectomy performed in a reduced-port geometry, “reproducibility” refers to the ability to perform the key operative steps with consistency comparable to multiport RATS across different segmental anatomies, supported by protocolized intraoperative confirmation steps rather than ad hoc decision-making. Two elements are particularly important for achieving reproducibility in reduced-port segmentectomy: (I) consistent delineation of the ISP, commonly supported by intravenous indocyanine green (IV-ICG) fluorescence imaging (5); (II) selective bronchial verification to reduce the risk of bronchial misidentification when anatomy is complex. Several fluorescence-based approaches to bronchial identification have been described, including endobronchial ICG bronchial marking techniques, highlighting the clinical need for robust verification steps (6). We present a standardized DRATS setup and a step-by-step workflow that integrates protocolized confirmation steps (ISP delineation and selective bronchial verification when indicated) to reduce avoidable errors. In this article, we address the challenge of maintaining reproducibility in reduced-port segmentectomy. We present a standardized DRATS setup and a step-by-step workflow that integrates protocolized confirmation steps, including ISP delineation and selective bronchial verification when indicated, to reduce avoidable errors.

Two representative videos (right S6 and left S1+2) demonstrate the application of this standardized workflow under different hilar geometries.

Rationale

Conventional multiport RATS provides stable three-dimensional visualization and articulated instrumentation for anatomical segmentectomy, but its multi-incision access may not fully satisfy the goal of minimizing access-related trauma. Reduced-port robotic approaches aim to decrease the number of intercostal entries; however, port reduction can introduce constraints in assistant workflow and stapling access, potentially affecting reproducibility across different segmental anatomies. DRATS represents a modified reduced-port configuration that uses two incisions (a utility incision plus a caudal access port) to preserve key robotic advantages while maintaining patient-side operability. Early multi-institutional experience has demonstrated the feasibility of DRATS for anatomical lung resection (3), and a propensity score-matched comparison reported comparable short-term outcomes between DRATS and multiport RATS, with a lower incidence of post-thoracotomy pain syndrome after DRATS (4).

For segmentectomy, procedural safety and oncologic adequacy depend not only on meticulous hilar dissection but also on reliable control of the ISP and robust verification steps when bronchial anatomy is complex. IV-ICG fluorescence imaging offers a reproducible method for ISP delineation (5), and fluorescence-assisted bronchial identification strategies, including endobronchial ICG bronchial marking, can strengthen bronchial verification in selected cases (6). Therefore, a protocolized, step-by-step description that integrates these elements within a standardized DRATS setup may improve reproducibility and reduce avoidable pitfalls during the adoption of DRATS anatomical segmentectomy.

Objective

The objective of this manuscript is to provide a detailed, step-by-step, multimedia guide to a standardized DRATS workflow for anatomical segmentectomy. We aim to describe a reproducible setup and operative sequence, with IV-ICG fluorescence used as a standardized tool for ISP delineation rather than the primary novelty of the report. Two representative videos (right S6 and left S1+2) accompany the text to illustrate the application of the same workflow under different hilar geometries. We present this article in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0018/rc).

Preoperative preparations and requirements

Patient selection criteria and contraindications

Patient selection should be guided primarily by oncologic suitability rather than by the surgical approach. DRATS segmentectomy is considered for patients with early-stage clinical N0 NSCLC or small peripheral pulmonary nodules when anatomical segmentectomy can achieve adequate parenchymal margins and appropriate nodal evaluation, consistent with randomized evidence supporting sublobar resection in selected patients (1,2).

Several scenarios require careful consideration. Centrally located tumors, hypermetabolic tumors on positron emission tomography/computed tomography (PET/CT), and cases in which an adequate parenchymal margin or reliable nodal assessment cannot be ensured may be better treated with lobectomy (7,8). In our practice, the planned parenchymal margin should be at least equal to the preoperative tumor diameter (margin/tumor ≥1.0). When this criterion cannot be met, lobectomy or another oncologically appropriate strategy should be selected.

Contraindications and cautionary scenarios include:

• Centrally located tumors: centrally located clinical stage I NSCLCs tend to be hypermetabolic and may carry a higher risk of lymph node metastasis; lobectomy is often preferred to ensure oncologic clearance and comprehensive nodal assessment (8).
• Hypermetabolic tumors: high preoperative PET/CT uptake [e.g., maximum standardized uptake value (SUVmax) ≥3.0] is associated with worse prognosis after sublobar resection compared with lobectomy in propensity score-matched analyses (7).
• Inability to secure a parenchymal margin at least equal to the tumor diameter (margin/tumor ≥1.0): when the anticipated margin is insufficient, an alternative resection strategy should be selected.
• Known or suspected nodal involvement (cN1 or cN2): these patients fall outside the randomized evidence base supporting sublobar resection and are not candidates for segmentectomy within this framework (1,2).

Oncologic indications and choice of surgical approach

Once these oncologic criteria are fulfilled, anatomical segmentectomy can be performed via several minimally invasive approaches, including multiport video-assisted thoracoscopic surgery (VATS), RATS, and reduced-port robotic configurations. DRATS has been proposed as a reduced-port approach using two incisions, and early multi-institutional experience has demonstrated feasibility for anatomical pulmonary resection (3). Comparative short-term outcomes between dual-portal and multi-portal RATS have also been reported, showing similar perioperative outcomes and a lower incidence of post-thoracotomy pain syndrome after DRATS (4). Within these appropriate oncologic indications, this manuscript describes a standardized DRATS setup and a step-by-step workflow for anatomical segmentectomy.

Surgical team composition

A typical DRATS team includes a console surgeon experienced in robotic anatomical lung resection, a patient-side (bedside) surgeon/assistant proficient in exposure and stapling, and a scrub nurse familiar with robotic instrumentation and reduced-port workflows. The patient-side surgeon functions as the primary bedside operator, maintaining safe stapling trajectories and managing external arm interference in reduced-port geometry, while performing robot-related tasks including port/trocar troubleshooting, robotic instrument exchange, camera cleaning/exchange, suction/irrigation, specimen retrieval, and preparation for emergency undocking and conversion when indicated. Because robotic instrument exchange is frequent, instruments should be removed and reinserted under direct vision with clear communication to the console surgeon to minimize inadvertent tissue injury. A standardized emergency undocking and conversion protocol with predefined trigger words and role assignments for the console surgeon, bedside surgeon, anesthesia team, and nursing staff should be established and rehearsed before DRATS adoption.

Chief surgeon’s experience and training

Before adopting DRATS anatomical segmentectomy, the chief surgeon should be proficient in multiport robotic lobectomy and segmentectomy (or advanced multiport VATS anatomical resection) and should have an established strategy for pulmonary arterial bleeding control and timely conversion. Reduced-port geometry requires deliberate training in standardized port placement and docking, patient-side coordination, and safe stapler handling within a limited working space. Early DRATS reports support feasibility for anatomical lung resection and comparable short-term outcomes to multiport RATS, supporting staged adoption under a standardized setup (3,4). During the initial phase, case selection should favor anatomically straightforward segmentectomies and avoid variants-rich anatomy until the setup and team coordination become reproducible. Adequate margins and systematic nodal assessment should remain the primary determinants of procedural suitability.

All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board of Yamagata University Hospital (IRB No. 2025-179; dated October 24, 2025) and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for publication of this study, including accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal upon request.

Step-by-step description

Imaging and pathway planning

Preoperative planning is based on thin-slice CT and patient-specific 3D reconstruction. We obtain 0.5–1 mm CT images and generate 3D models using SYNAPSE VINCENT (Fujifilm Medical, Tokyo, Japan). The target segmental artery, vein, and bronchus are reviewed to identify anatomical variants, define the ISP, and assess the planned resection margin. Because 3D models may miss small branches or obscure arterial-venous relationships, key findings are confirmed on the original axial CT images.

Anesthesia and patient positioning

The procedure is performed under general anesthesia with differential lung ventilation using a double-lumen endotracheal tube. All procedures were performed using the da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). The patient is positioned in the full lateral decubitus position, and the operating table is flexed to widen the intercostal spaces as needed. All pressure points are padded, and the ipsilateral arm is securely supported to avoid traction injury. The anesthetic management and positioning are otherwise identical to those used for conventional minimally invasive anatomical lung resection. We perform DRATS without an insufflation system (e.g., AirSeal).

When preoperative endobronchial ICG bronchial marking is planned, we perform bronchoscopic ICG marking after induction of anesthesia and after the patient has been positioned in the lateral decubitus position, before robotic docking (6).

Port placement and initial exploration (Figure 1)

Figure 1 Standard port configuration for right- and left-sided RATS anatomical segmentectomy. (A) Right sided segmentectomy. The main access incision is positioned from the midaxillary to the posterior axillary line and accommodates the arm-2 camera and the arm-3 left-hand instrument. The main port is placed in the 5th intercostal space for upper-lobe segmentectomy and in the 6th intercostal space for lower-lobe segmentectomy. A separate 1.5-cm port is placed ventral to the main access incision, usually at the anterior axillary line in the 7th–8th intercostal space and is used for the arm-4 right-hand instrument. (B) Left-sided segmentectomy. The main access incision is positioned from the anterior axillary to the midaxillary line and accommodates the arm-2 left-hand instrument and the arm-3 camera. The main port is placed in the 5th intercostal space for upper-lobe segmentectomy and in the 6th intercostal space for lower-lobe segmentectomy. A separate 1.5-cm port is placed dorsal to the main access incision in the 7th–8th intercostal space and is used for the right-hand instrument. Port levels may be adjusted by one intercostal space cranially or caudally depending on patient habitus and intrathoracic working distance. RATS, robotic-assisted thoracic surgery.

Two incisions are used for DRATS anatomical segmentectomy: a main access incision for the camera and one working arm, and a second smaller port for the contralateral working arm. The main incision is typically placed in the 5th intercostal space for upper-lobe segmentectomy and in the 6th intercostal space for lower-lobe segmentectomy, while the second port is placed more caudally. Port levels may be adjusted by one intercostal space depending on patient habitus and intrathoracic working distance.

The arm assignment and relative port position are determined by laterality. For right-sided segmentectomy, the utility incision accommodates the camera and left-hand instrument, and the right-hand port is consistently placed ventral to the utility incision. This arrangement positions the hilum between the utility incision and the right-hand port, allowing bimanual access around the hilar target.

For left-sided segmentectomy, the utility incision is placed more anteriorly. Therefore, the right-hand port is generally positioned dorsal to the utility incision to create a symmetrical working geometry around the hilum. We previously attempted ventral placement of the right-hand port in selected left-sided cases because the anterior intercostal space was wider than the posterior space. However, this configuration resulted in less favorable instrument maneuverability, and dorsal placement is now our standard left-sided configuration.

After standardized docking, the thoracic cavity is explored to assess pleural adhesions, fissure development, and the feasibility of the planned segmentectomy, and the operative plan is reconfirmed against the preoperative three-dimensional simulation.

Standardized DRATS workflow: setup-driven reproducibility

DRATS segmentectomy is performed using a standardized two-incision configuration consisting of a utility incision for the robotic camera and working instruments and an additional caudal port used for stapler access and assistant tasks. A consistent patient-side workflow (exposure, suction/irrigation, robotic instrument exchange, and stapler handling) is integral to maintaining a stable operative field in reduced-port geometry. After docking, we follow a stepwise segmentectomy sequence that prioritizes reproducible identification of bronchovascular structures and reliable ISP control.

Hilar dissection: stepwise identification of segmental structures

We perform an initial thoracoscopic survey to assess adhesions and fissure development and to confirm the feasibility of the planned resection. Based on the preoperative 3D plan, segmental pulmonary vein(s), artery(ies), and bronchus are identified and managed in a stepwise manner. The order of division (vein/artery/bronchus) is adapted to segmental anatomy and fissure status rather than fixed to a single strategy; however, we aim to preserve intersegmental veins that serve as landmarks for the ISP whenever feasible. Throughout hilar dissection, the patient-side surgeon provides stable countertraction, suction, and prompt instrument exchange to maintain a clear dissection plane.

Bronchial confirmation, preoperative endobronchial ICG bronchial marking (Figure 2)

Figure 2 Illustrative intraoperative images of endobronchial ICG bronchial marking. (A) Conventional white-light view of the target segmental bronchus in the operative field. (B) Firefly™ near-infrared fluorescence view of the same field, demonstrating clear fluorescence of the ICG-marked bronchus and facilitating confident identification of the target bronchus before bronchial division. ICG, indocyanine green.

When bronchial anatomy is complex or bronchial misidentification is a concern (e.g., variants-rich anatomy or subsegment-level planning), we incorporate a bronchial verification step. In our practice, when planned, endobronchial ICG bronchial marking is performed bronchoscopically after induction of anesthesia and after positioning in the lateral decubitus position, before robotic docking (6). This verification step is used selectively and is distinct from ISP delineation.

ISP delineation and parenchymal division

After completing key hilar divisions, the ISP is delineated using IV-ICG fluorescence imaging (5). Preserved segments fluoresce, whereas the target segment remains non-fluorescent, providing a clear demarcation of the planned parenchymal transection line. Parenchymal division is then performed along the confirmed ISP using sequential stapler firings. During stapling, the console and patient-side teams coordinate to maintain stable exposure and prevent inadvertent tissue injury during stapler insertion and reinsertion.

Specimen retrieval, nodal assessment, and closure

The specimen is placed in a retrieval bag and removed through the utility incision. Systematic hilar and mediastinal nodal evaluation is performed according to oncologic requirements and institutional standards, consistent with evidence supporting sublobar resection in selected early-stage NSCLC (1,2).

After hemostasis and air-leak assessment, a chest tube is placed (typically via the caudal port), and the incisions are closed in layers.

Representative videos

Two representative videos accompany the manuscript to illustrate the application of the standardized DRATS workflow under different hilar geometries: right S6 segmentectomy (Video 1) and left S1+2 segmentectomy (Video 2).

Postoperative considerations and tasks (apply to DRATS)

Postoperative management after DRATS segmentectomy follows the same institutional enhanced recovery after surgery (ERAS) pathway used for VATS anatomical lung resection, as the postoperative care elements do not differ by approach.

Pain management

Postoperative pain is managed using multimodal, opioid-sparing analgesia. We combine intraoperative local wound infiltration and/or intercostal nerve block with early oral analgesics to enable effective coughing, deep breathing, and ambulation. A combination of oral NSAIDs (e.g., loxoprofen) and acetaminophen is administered on a scheduled basis unless contraindicated.

Early mobilization and oral intake

Unless contraindicated, patients begin oral intake and mobilization on the day of surgery, with progressive ambulation from postoperative day 0–1.

Chest tube management

A single chest tube is placed at the end of surgery and is managed with close monitoring for air leak and lung re-expansion. The tube is removed promptly once no clinically significant air leak is confirmed and satisfactory lung expansion is verified on chest radiography, in accordance with our ERAS pathway.

Discharge criteria

Patients are discharged when pain is controlled with oral medication, oxygen supplementation is not required, oral intake and ambulation are adequate, and activities of daily living can be performed safely. Early discharge (including postoperative day 1 in selected patients) is feasible within an ERAS pathway.

Tips and pearls

Preventing bronchial misidentification (verification step when indicated)

When bronchial anatomy is complex, incorporate a verification step before bronchial division rather than relying solely on preoperative 3D simulation. In robotic surgery, intraoperative bronchoscopy combined with Firefly™ near-infrared imaging allows visualization of the bronchoscope tip through the bronchial tree as a green dot, providing a simple confirmation of the target bronchus before stapling.

Planned preoperative endobronchial ICG bronchial marking can further support bronchial identification in variant-rich anatomy.

Gentle and anatomical dissection around vessels and bronchus

Maintain a bloodless field and preserve thin tissue planes by using precise bipolar dissection and controlled traction-countertraction. When the target bronchus lies deep to divided vascular structures, careful stepwise hilar dissection and patient-side retraction help maintain orientation and avoid unnecessary injury.

ISP control: mark early, then staple

After completing key hilar divisions, delineate the ISP using IV-ICG fluorescence. Once the boundary becomes clear, mark the transition line on the lung surface (e.g., spot coagulation with bipolar forceps) before parenchymal division to prevent loss of the demarcation during manipulation and stapling.

Safe stapling and patient-side coordination in reduced-port geometry

Because stapling and instrument exchange are patient-side–dependent steps, establish clear console-bedside communication and reinsert instruments under direct vision to avoid inadvertent tissue injury.

When stapler angulation is suboptimal, adjust exposure and insertion axis first. If the axis remains unsafe, consider alternative handling strategies according to institutional practice (e.g., patient-side stapling through the caudal port).

Avoiding internal camera-instrument collision

When the camera and one working instrument are introduced through the same utility incision, internal collision can occur if the shafts are advanced in parallel or if the robotic arm is moved excessively. To minimize this risk, the console surgeon should avoid large arm movements and use the wristed articulation of the instrument whenever possible. At the utility incision, the camera and working instrument should be positioned to widen the incision and maintain adequate separation between the two shafts. During instrument exchange or reinsertion, the instrument tip should always be advanced under direct vision, with clear communication between the console surgeon and patient-side surgeon.

Perioperative outcomes of the anatomical segmentectomy cohort

From May 1, 2023 to December 31, 2025, perioperative outcomes of consecutive dual-portal RATS anatomical segmentectomy cases (n=50), including operative time, console time, blood loss, chest tube duration, length of hospital stay, stapler use, tumor location, and lymph node dissection categories, are summarized in Supplementary Table S1. These data are descriptive and no statistical comparisons were performed.

Discussion

DRATS is a reduced-port robotic approach for anatomical lung resection that aims to limit access-related trauma while preserving the principal advantages of robotic surgery. Early multi-institutional experience has demonstrated its feasibility and safety for anatomical pulmonary resection (3). We do not claim universal superiority over multiport RATS; rather, we present DRATS as a reduced-port option for teams aiming to reduce access points while maintaining reproducibility and safety. This approach preserves stable three-dimensional visualization and wristed instrumentation while decreasing the number of intercostal entries. Because anatomical segmentectomy entails extensive peripheral and intraparenchymal work with meticulous bronchovascular identification and ISP management, the enhanced dexterity and depth perception of robotics may be particularly advantageous in this setting. Segmentectomy also removes a smaller volume of lung parenchyma than lobectomy and is supported by randomized evidence for selected small, peripheral early-stage NSCLC. DRATS may represent a rational approach for parenchyma-sparing resection in appropriately selected patients (1,2).

Uniportal robotic-assisted thoracic surgery has also been reported as an alternative reduced-port strategy for anatomical lung resection (9). However, a single-incision robotic geometry may increase instrument crowding at the access site and can constrain stapling access and patient-side workflow in selected situations. In contrast, DRATS uses two incisions, a utility incision plus a caudal access port to reduce access points while preserving patient-side operability for stapling, instrument exchange, and troubleshooting. We therefore position DRATS as an intermediate reduced-port configuration, without claiming superiority over uniportal or multiport approaches; the optimal approach should be selected according to institutional experience and procedural requirements. A central message of this Surgical Technique article is that reproducibility in segmentectomy depends on standardizing not only dissection steps but also explicit verification steps that help prevent avoidable errors. When bronchial anatomy is variants-rich or the target bronchus is ambiguous, incorporation of a bronchial confirmation pathway before bronchial division may improve procedural safety. Endobronchial ICG bronchial marking has been reported as a safe and feasible adjunct for intraoperative identification of the target segmental bronchus, supporting its selective use in challenging anatomy (6).

ISP control also benefits from having more than one dependable option. Even when fluorescence guidance is available on robotic platforms, any single method can be suboptimal in selected situations. In severely anthracotic lungs (“black lung”), for example, careful identification of intersegmental veins guided by preoperative imaging can provide a reliable anatomic roadmap to complete segmentectomy safely (10). In addition, a selected segmental insufflation technique using direct bronchial insufflation can rapidly generate a clear inflation-deflation boundary without special equipment such as jet ventilation or ICG and has been reported to be applicable even in robotic-assisted segmentectomy (11). Because DRATS is performed without CO₂ insufflation in our practice, this technique can serve as a fallback when fluorescence is inconclusive or unavailable; when using direct bronchial insufflation, excessive pressure should be avoided and inflation of preserved segments should be carefully monitored (11).

In addition to technical standardization, segmentectomy requires indication-driven decision-making. Although randomized evidence supports segmentectomy for carefully selected small, peripheral clinical stage IA NSCLC with node-negative status, these indications are not universal (1,2). Accordingly, DRATS segmentectomy should be applied in appropriately selected patients in whom adequate margins and systematic nodal assessment can be ensured; when these oncologic requirements cannot be met, lobectomy should be considered.

Conclusions

DRATS enables anatomical segmentectomy in a reduced-port configuration while preserving core robotic advantages, including stable three-dimensional visualization and wristed instrumentation. Because anatomical segmentectomy involves extensive peripheral and intraparenchymal work, DRATS may be a suitable approach for parenchyma-sparing resection in appropriately selected patients.

The keys to safe and reproducible DRATS segmentectomy are threefold: meticulous preoperative planning with thin-slice CT and patient-specific 3D-CT simulation; a standardized DRATS setup with coordinated console-patient-side workflow; and protocolized verification steps when anatomy is complex. Finally, rigorous, evidence-based patient selection and systematic nodal evaluation remain essential, and segmentectomy should be chosen only when adequate margins and oncologic nodal assessment can be ensured.

Acknowledgments

We are grateful to Takayuki Sasage, MD; Kohei Abe, MD; Kazumasa Hoshijima, MD; and Yuji Masaki, MD for their assistance and critical feedback. They provided permission to be acknowledged and received no financial compensation.

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-2026-0018/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0018/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-2026-0018/coif). The series “Reduced Port Robotic-assisted Thoracic Surgery” was commissioned by the editorial office without any funding or sponsorship. J.S. serves as an unpaid editorial board member in Journal of Visualized Surgery from September 2025 to December 2027. 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.All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board of Yamagata University Hospital (IRB No. 2025-179; dated October 24, 2025) and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients 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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