To retrospectively evaluate the perioperative outcomes and safety of port-only four-arm robotic-assisted precision pulmonary segmentectomy performed under artificial pneumothorax in a single-center cohort, and to explore the technical value of this approach in improving exposure of the deep operative field and facilitating complex segmental resections.

Clinical data were retrospectively collected from patients who underwent totally portal four-arm robotic-assisted pulmonary segmentectomy at our center between May 2022 and December 2025. All procedures were performed using the da Vinci Xi robotic system under a fully closed artificial pneumothorax. Preoperative individualized planning was based on thin-section computed tomography (CT) and three-dimensional CT bronchography and angiography (3D-CTBA). Intraoperatively, coordinated four-arm traction, meticulous dissection using Maryland bipolar forceps, and indocyanine green (ICG) near-infrared fluorescence imaging were applied to assist in identifying the intersegmental plane. Primary outcomes included operative time, estimated blood loss, conversion to thoracotomy, postoperative drainage parameters, chest tube duration, length of postoperative hospital stay, and postoperative complications.

A total of 271 patients were included. The mean age was (58.3±10.3) years; 186 patients (68.6%) were female, and 69 (25.5%) had a history of smoking. Postoperative pathology revealed invasive adenocarcinoma as the predominant histological type (65.3%), followed by minimally invasive adenocarcinoma (21.4%). The mean operative time was (117.8±31.0) min, and the median estimated blood loss was 40 mL (range, 0–200 mL). One patient (0.4%) required conversion to thoracotomy. The mean postoperative drainage volume was (485.2±440.2) mL, the mean chest tube duration was (2.9±1.3) days, and the mean postoperative hospital stay was (4.3±1.5) days. Chest tube drainage lasting >7 days occurred in 4 patients (1.5%). The mean number of dissected lymph node stations was 4.34±2.03, with a mean of 7.07±4.92 lymph nodes retrieved. R0 resection was achieved in all patients (271/271, 100%). 244 (90.0%) experienced no postoperative complications. Clavien-Dindo grade Ⅰ and grade Ⅱ complications occurred in 23 (8.5%) and 3 (1.1%) patients, respectively, while persistent postoperative air leak was observed in 1 patient (0.4%).

Port-only four-arm robotic-assisted precision pulmonary segmentectomy under artificial pneumothorax is feasible and demonstrates favorable perioperative outcomes and safety in a single-center retrospective cohort. Beyond minimizing surgical incisions, this approach enables centralized control of the camera and traction by the primary surgeon, thereby reducing exposure-related variability associated with assistant-dependent maneuvers. Coupled with wristed robotic instruments, it may improve the precision of deep small-vessel dissection and intersegmental plane management, providing a practical technical strategy for complex precision pulmonary segmentectomy.