Unilateral Biportal Endoscopy (UBE): Right-sided approach for right-handed surgeons

“Sir, why are you standing on this side?”

My fellow once asked me this during a right-sided surgery. I smiled, because this was precisely the nuance we miss when we teach Unilateral Biportal Endoscopy (UBE): the right-sided approach, to a right-sided pathology, by a right-handed surgeon. He told me that he had previously attempted UBE for the right-sided pathology standing on the left side (routine approach) and tried to go over-the-top to the right sided pathology.

He said, “I just couldn’t navigate and overcome the meshwork of the meningo-vertebral ligaments, epidural fat the inner point (akin to contralateral spino-laminar junction), and I had to convert the surgery to a microscope assisted open decompression.” This triggered my own thinking and how I faced similar challenges while starting UBE in my practice. In my teaching experience both nationally and internationally I realized that tackling the right-sided pathology is a major pain point faced by all the beginners of UBE.

Hence, I decided to write this article to help unravel the mysteries of the right-sided approach for the right-sided pathology by a right-handed surgeon standing on the right-side of the patient. Let’s unpack what that actually means.

This article is in conjunction with our previously published article on Unilateral Biportal Endoscopy (UBE): why spine surgeons should make the leap and master the skills in the AO Spine Guest Blog collection.

The conventional assumption: left-side is the default

Most UBE surgeons begin their journey operating from the left side. It’s easier for a right-handed surgeon to triangulate, the saline flows well, and the view is relatively familiar as with open or microscopic tubular surgeries. The trajectory achieved by the right hand through the caudally placed working portal in this default approach with the Kerrison punch helps in cranial laminectomy and other steps.

But in the real world, pathology doesn’t respect default positions and are equally distributed on either the right or the left side. Right-sided disc herniations, lateral recess stenosis, foraminal decompressions—they demand just as much expertise and finesse.

That’s where the true artistry of UBE shows up.

Standing on the right: the psychological hurdle

For a right-handed surgeon, standing on the right side of the patient initially feels like writing with your non-dominant hand. It’s not that the skills are missing—it’s the mental model that needs remapping.

The truth is: once you master the orientation, the ergonomics actually favor you specially to perform the caudal laminectomy and decompressing the lateral recess and the J-point (Junction of the medial part of superior articular process and the caudal lamina).

Let’s talk portals: the key to success

Here’s the golden formula:

Working Portal: Created just cranial to the pathology — usually a mirror image or slightly cranial compared to the left-sided approach.

Viewing Portal (Arthroscope): Always from the caudal end, about 2.5 to 3 cm below the working portal.

This setup gives you excellent triangulation, natural scope navigation, and enough room for saline egress—provided you maintain clean tissue planes.

Why right-sided UBE is a superpower

1. You operate what you see: No need to mentally flip anatomy.

2. Perfect for foraminal + extraforaminal lesions on the right and to perform UBE guided transforaminal lumbar interbody fusion (TLIF) in right sided pathologies or in patients with a high lordotic angle

3. Surgeon comfort increases with time, as caudal laminectomy is easier and straight-forward

4. Decompressing the right sided lateral recess, Intra-discal discectomy in contained herniations, right sided revision disc herniations and cage insertion becomes easier for the surgeon