Total-port vs. utility-incision robotic pulmonary segmentectomy: a propensity score–based analysis of 418 patients

The optimal robotic approach for pulmonary segmentectomy remains debated, and objective standards to verify anatomical precision are lacking. We compared the effectiveness of total-port (TP) versus utility-incision (UI) robotic segmentectomy and validated a 3D-CT metric for assessing surgical completeness. A retrospective propensity score-matched and inverse probability of treatment weighting (IPTW) analysis was performed on 418 patients undergoing robotic segmentectomy (January 2020–December 2024). Surgical completeness was objectively assessed using postoperative 3D-CT airway reconstruction, blindly reviewed by independent radiologists, to confirm exact transection of the target bronchus. Secondary outcomes included perioperative complications and blood loss. Of 418 patients, 203 underwent TP and 215 underwent UI. The TP approach was more frequently utilized for complex segmentectomies (59.6% vs. 38.6%; p < 0.001) and required less preoperative localization (1.0% vs. 17.7%; p < 0.001). Interobserver agreement for the 3D-CT completeness metric was substantial (κ = 0.65). In the IPTW-adjusted analysis, the TP group demonstrated significantly higher verified surgical completeness (95.8% vs. 80.0%; adjusted OR, 5.72; p < 0.001). Additionally, the TP group had lower intraoperative blood loss (45.0 vs. 58.3 mL; adjusted mean difference, -13.28 mL; p < 0.001) and fewer 30-day early complications (3.6% vs. 10.3%; adjusted OR, 0.33; p = 0.01). The TP robotic approach offers superior surgical precision and improved perioperative outcomes compared with the UI approach, particularly for complex segments. Postoperative 3D-CT airway reconstruction serves as a highly reproducible metric for auditing surgical quality in thoracic oncology. Central Message: Total-port robotic segmentectomy provides superior precision and fewer complications than utility-incision, objectively verified by postoperative 3D-CT as a reproducible quality metric. Perspective Statement: Objective quality control for anatomical precision in robotic segmentectomy is lacking. This propensity-matched study validates postoperative 3D-CT airway reconstruction to audit surgical completeness. Using this, the total-port approach showed superior precision and safety over the utility-incision approach, offering evidence to refine port strategies and standardize quality control. Abbreviated legend for the Central Picture: TP improves completeness and complications, reduces localizations; 3D-CT–verified.