ObjectiveTo investigate the clinical efficacy of a posterior approach for robot-assisted thoracoscopic anatomical right upper lobectomy. MethodsA retrospective analysis was conducted on the clinical data of patients who underwent da Vinci robot-assisted thoracoscopic anatomical right upper lobectomy at the Department of Thoracic Surgery, Gansu Provincial People's Hospital, from October 2023 to October 2025. Patients were divided into an anterior approach group and a posterior approach group based on the surgical approach. Perioperative outcomes, pain indicators, postoperative complications, inflammatory markers, protein metabolism indicators, and pulmonary function parameters were compared between the two groups. ResultsA total of 80 patients were included. There were 40 patients in the anterior approach group, including 23 males and 17 females with a median age of 64 (60, 65) years; 40 in the posterior approach group, including 22 males and 18 females with a median age of 63 (60, 65) years. The posterior approach group demonstrated significantly shorter operative time, less intraoperative blood loss, lower chest tube drainage volume, and a shorter length of hospital stay compared to the anterior approach group (P＜0.05). Regarding inflammatory indicators, preoperative levels of procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) were comparable between the groups. Postoperatively, they exhibited a trend of an initial increase followed by a decrease, and the magnitude of this postoperative increase was significantly lower in the posterior approach group (P＜0.05). For protein metabolism indicators, preoperative levels of prealbumin, albumin, and transferrin were similar. Postoperatively, they showed a trend of an initial decrease followed by a recovery, with a significantly smaller decrease observed in the posterior approach group (P＜0.05). There were no significant differences in preoperative pulmonary function parameters, including forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and diffusing capacity for carbon monoxide (DLCO), but the postoperative decline in these parameters was less pronounced in the posterior approach group (P＜0.05). Furthermore, there were no statistically significant differences between the two groups in the total number of dissected lymph nodes, postoperative visual analogue scale (VAS) pain scores, or the incidence of complications (P＞0.05). ConclusionThe posterior approach for robot-assisted thoracoscopic anatomical right upper lobectomy is safe and feasible. Its perioperative outcomes are comparable to the traditional anterior approach. This approach may reduce surgical difficulty while lessening the impairment of pulmonary function and maintaining the stability of the patient's internal physiological environment.