ObjectiveTo compare the surgical effects of totally thoracoscopic and thoracoscopic-assisted small incision for left atrial appendage clipping. Methods The clinical data of patients who underwent left atrial appendage clipping surgery via totally thoracoscopy or thoracoscopic-assisted minimally invasive small incision from November 2018 to March 2022 in Beijing Tiantan Hospital were retrospectively analyzed. According to the surgical approach, they were divided into a totally thoracoscopic group and a small incision group. The clinical results were compared between the two groups. ResultsA totoal of 41 patients were enrolled, including 30 males and 11 females, with an average age of 66.6±6.1 years. There were 23 patients in the totally thoracoscopic group and 18 patients in the small incision group. The CHA2DS2-VASc score was 4.5±1.1 points, and HAS-BLED score was 3.7±1.5 points. No death occured in the whole group. There was no statistical difference between the two groups in terms of operation time, chest complications, successful rate of closure of the left atrial appendage, residual length of the left atrial appendage, or displacement of the atrial appendage clip (P>0.05). The total drainage volume in the totally thoracoscopic group was less than that in the small incision group, and the difference was statistically significant (P=0.031). The median follow-up time was 10 (1-30) months, during which there was 1 patient of stroke and 1 patient of left atrial thrombus in both groups. ConclusionTotally thoracoscopic left atrial appendage clipping is less invasive than thoracoscopic-assisted minimally invasive small incision surgery and does not increase the risk of surgical complications.