Technical nuances and early outcomes of uniportal subxiphoid video-assisted thoracoscopic surgery (VATS) for anterior mediastinal tumor resection without artificial pneumothorax: a retrospective analysis

Introduction

Surgical resection remains the cornerstone of treatment for anterior mediastinal tumors. Currently, the lateral transthoracic approach is the most commonly used surgical route (1). However, this approach requires traversing the intercostal muscles and nerves, leading to significant postoperative incision pain and, frequently, chronic neuralgia that diminishes patient quality of life (2,3).

Thymic tumors are the most prevalent tumors of the adult anterior mediastinum (4), and frequently require extended thymectomy (5). However, when performed through the lateral thoracic approach, visualization of the superior thymic poles is suboptimal, and the surgical view of the contralateral pleural cavity is limited, making complete resection of contralateral thymic and perithymic adipose tissue technically challenging. Furthermore, there is a risk of contralateral phrenic nerve injury, thus compromising treatment outcome.

Minimally invasive subxiphoid video-assisted thoracoscopic surgery (VATS) or extended thymectomy for anterior mediastinal tumor has become increasingly popular in recent years. Currently, the commonly used clinical methods rely on CO₂ artificial pneumothorax (6-9) or the sternal elevation method with multiple retractors (10-15) to maintain the operative space, and most scholars have reported that the operation needs to be performed through multiple incisions. Reports of uniportal subxiphoid approaches without CO₂ artificial pneumothorax are scarce. Since January 2003, we have utilized this technique in 52 consecutive cases, all performed by the same Associate Chief Physician. In this study, we retrospectively analyzed the 52 consecutive cases treated with uniportal subxiphoid VATS without CO₂ insufflation, aiming to summarize the technical nuances and evaluate the feasibility, safety, and early clinical outcomes of this approach. We present this article in accordance with the STROBE and SUPER reporting checklists (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0870/rc).

Methods

Study patients

Clinical data of 52 patients with anterior mediastinal tumors who were admitted to West District of The First Affiliated Hospital of University of Science and Technology of China from January 2023 to August 2025 were analyzed. This study was carried out in accordance with the Declaration of Helsinki and its subsequent amendments, and was approved by Medical Research Ethics Committee of The First Affiliated Hospital of University of Science and Technology of China (No. XJS2022-2-37(WK)). Written informed consent was obtained from all patients.

All patients underwent uniportal video-assisted thoracoscopic anterior mediastinal tumor resection or extended thymectomy via the subxiphoid approach without artificial pneumothorax. Among them, 17 were male and 35 were female. The age ranged from 16 to 79 years (mean, 53.15±13.88 years). The body mass index (BMI) of the patients ranged from 18.4 to 33.2 kg/m², with 32 patients exceeding 23.9 kg/m². 42 patients were incidentally discovered during health check-ups or when undergoing chest computed tomography (CT) examinations for other diseases, without obvious clinical symptoms. Symptomatic patients presented with chest pain (n=5), intermittent chest tightness (n=3), or ptosis of the upper eyelid (n=2). The maximum diameter of the anterior mediastinal tumors ranged from 1.3 to 8.2 cm, with an average of (3.2±1.8) cm (Table 1).

Inclusion criteria: (I) chest enhanced CT or magnetic resonance imaging (MRI) indicating an anterior mediastinal tumor, with a relatively clear boundary and no obvious signs of invasion; (II) the maximum tumor diameter is ≤5.0 cm (threshold relaxed during the later stage of the learning curve).

Exclusion criteria: (I) invasion of major vessels (such as the brachiocephalic vein, superior vena cava, main pulmonary artery) or phrenic nerve, etc.; (II) history of mediastinal surgery or radiotherapy; (III) severe heart diseases; (IV) severe pulmonary dysfunction; (V) other serious diseases that cannot tolerate surgical treatment.

Surgical procedure

Anesthesia: general anesthesia was achieved through combined intravenous and tracheal double-lumen catheter insertion.

Position: the patient was placed in a supine position with legs not spread apart, and the back were slightly elevated. The surgeon stood on the patient’s right side, while the assistant holding the mirror and assisting stood on the left side (Figure 1).

Figure 1 Surgical scene.

Incision: a anterior midline incision 5-10 mm below the xiphoid process was made, approximately 4.0 cm in length (Figure 2).

Figure 2 The surgical incision one month after the operation.

Create the surgical cavity: the skin, subcutaneous tissue, and linea alba were incised, and the xiphoid process was removed. The gap between the posterior part of the sternum and the pericardium was bluntly separated. A sternum retractor (Suzhou Weinuoyikang Medical Devices Co., Ltd., Suzhou, China) was inserted, and the sternum was elevated (Figure 3). Then, an incision protection sleeve (Shiaide Medical Equipment Co., Ltd., Xiamen, China) was placed (Figure 1).

Figure 3 Sternum retractor.

Thymic tumor (Figures 4,5) (as shown in the Video 1: https://amepc.wistia.com/medias/60gwe4hajl): the surgical approach followed the standards set by the International Thymic Malignancy Interest Group (ITMIG) (16). The surgery will be carried out in four steps. Firstly, the surgical field and the operating space were fully exposed: The ultrasonic knife (Johnson & Johnson (Suzhou) Medical Devices Co., Ltd., Suzhou, China) was inserted to cut the dense tissue between the sternum and the pericardium, and open the bilateral pleural cavities. The mediastinal pleura was gradually cut towards the head side along the posterior sternum, until the right thoracic internal vein can be clearly seen merging into the right brachiocephalic vein, which is the optimal height. Second, the right phrenic nerve was exposed and the adjacent adipose tissue along the nerve was removed. Subsequently, the superior vena cava, the proximal ends of the left and right brachiocephalic veins were exposed. Thirdly, the left phrenic nerve was exposed and the adjacent adipose tissue along the nerve was removed until the distal end of the left brachiocephalic vein is revealed. Fourth, the thymus and adipose tissue on the surface of the pericardium between the bilateral phrenic nerves were removed: We dissected towards the head side, exposed and ossified the left brachiocephalic vein (Figure 6), exposed and protected the brachiocephalic trunk artery, trachea, etc. (Figure 6). If the tumor invades the pericardium, a partial pericardectomy will be performed. If it invades a lung lobe, a wedge resection of the lung tissue will be carried out. The entire thoracic gland and adipose tissue (including the tumor) on the surface of the pericardium between the bilateral phrenic nerves were completely removed. The specimen (Figure 5) was taken out, and a drainage tube was left and led out through the incision below the xiphoid process.

Figure 4 Preoperative CT presentation of thymic tumor. CT, computed tomography.

Figure 5 Thymic tumor specimen.

Figure 6 Presentation of some anatomical structures after the operation.

Benign mass (Figures 7,8) (as shown in the Video 2: https://amepc.wistia.com/medias/u360fwx0y2): the procedure was similar to that for thymic tumors, but the surgery was simpler. In some cases, only the affected side pleural cavity needed to be opened. The height of the mediastinal pleura behind the sternum which was cut could be adjusted according to the location of the tumor. In some cases, it was sufficient to exceed the upper edge of the tumor. Important nerves and blood vessels such as the phrenic nerve, superior vena cava, left brachiocephalic vein, and brachiocephalic trunk artery did not all need to be exposed.

Figure 7 Preoperative CT presentation of benign mass. CT, computed tomography.

Figure 8 Benign mass specimen.

Observational index

The operation duration, blood loss, drainage volume, chest tube duration, and the postoperative hospital stay were recorded. Postoperative complications such as fever, bleeding, incision infection, or pulmonary infection were also observed. The postoperative pain condition was assessed using the Numerical Rating Scale (NRS) (17).

Statistical analysis

Statistical analysis was conducted using SPSS 23.0 software. Descriptive statistical methods were employed to analyze the demographic data and outcomes. Normally distributed continuous data were expressed as mean ± standard deviation. Categorical data were presented as counts and proportions.

Results

All patients successfully completed the surgery without major bleeding, conversion to open chest surgery, phrenic nerve injury, secondary surgery, or perioperative deaths. The mean operation duration was 101.19±42.45 minutes, ranging from 30 to 201 minutes. The intraoperative blood loss was 10 to 100 mL, with an average of (32.88±22.65) mL. The postoperative thoracic fluid drainage volume was 50 to 1,175 mL (mean, 357.73±246.55 mL). The postoperative thoracic tube duration was 3 to 8 days (mean, 4.42±1.26 days). The postoperative hospital stay was 3 to 9 days (mean, 5.65±1.357 days). Minor complications included one patient of postoperative fever, three cases of incision fat liquefaction (all in obese patients), and one case of pulmonary infection requiring ICU transfer. The specific details of the perioperative period are shown in Table 2. On the first postoperative day, the NRS score was mostly 2 points, with a few being 3 points, all indicating mild pain. On the day of discharge, the NRS score was 1 or 0, and some patients were pain-free.

Postoperative pathological report revealed 33 benign lesions (bronchial cysts, n=13; thymic cysts, n=5; thymic hyperplasia, n=4; teratoma, n=2; parathyroid cyst, n=1; other benign cystic lesions, n=8) and 19 thymic tumors (Table 3). Among them, 3 cases of type A thymic tumors, 3 cases of AB type thymic tumors, 3 cases of B1 type thymic tumors, 4 cases of B2 type thymic tumors, 1 case of mixed type B1 and B2 thymic tumors, 1 case of mixed type B2 and B3 thymic tumors, 1 case of B3 type thymic tumor, and 3 cases of thymic cancer. According to the TNM staging, 16 thymic tumors were stage I and 3 thymic carcinomas were stage II. According to the Masaoka-Koga staging, except for 1 case of stage IIB, all the thymic tumors were stage I; all the thymic carcinomas were stage III.

In addition, 50 patients were still under follow-up. The follow-up period ranged from 7 to 37 months. Follow-up (7–37 months) showed no recurrences in the 44 patients (including 15 with thymoma) followed for over 12 months.

Discussion

Currently, except for malignant lymphoma which is suitable for radiotherapy and chemotherapy, the majority of anterior mediastinal tumors, especially thymomas, are treated primarily through surgical resection. While the lateral transthoracic approach is standard for VATS mediastinal resection, it often causes damage to the intercostal muscles and nerves, resulting in postoperative neuralgia. The surgical field is not well exposed, making it difficult to handle lesions above the left brachiocephalic vein, and it is challenging to perform a true extended thymectomy in patients with thymomas.

In 1999, Kido et al. first reported the subxiphoid approach video-assisted thoracic surgery (S-VATS) for the resection of anterior mediastinal masses (18). The advantages of the subxiphoid approach compared to the lateral thoracic approach are as follows: (I) the surgical field is similar to that of thoracotomy through sternotomy, allowing for a clearer exposure of important anatomical landmarks such as bilateral phrenic nerves and brachiocephalic veins, reducing secondary injuries; (II) the operation can be completed in the supine position, and there is no need to change the patient’s position during the operation; (III) if there is uncontrollable massive bleeding during the operation, the sternum can be immediately split to convert to thoracotomy without changing the patient’s position, providing a guarantee of safety for the surgical operation; (IV) it does not damage the intercostal muscles and nerves, resulting in significantly reduced postoperative pain, which is conducive to patients’ coughing and early ambulation, promoting rapid recovery; (V) for patients with thymoma, especially those with myasthenia gravis, a complete thymectomy can be truly achieved; (VI) due to the absence of bony structures in the subxiphoid anatomy, large solid tumors with a diameter of over 5 cm can be removed more easily; (VII) thoracic adhesions have little impact on the surgery.

Over the past 20 years, Chinese and foreign scholars have successively used the subxiphoid approach for video-assisted thoracoscopic resection of anterior mediastinal tumors. To create a favorable surgical operating space, some have used CO₂ artificial pneumothorax assistance (6-9), some have used steel wires to elevate the sternum (11), some have used double or multiple retractor hooks to elevate the sternum (12,13), and some have used CO₂ artificial pneumothorax assistance combined with sternum retractor hooks (14,15). CO₂ artificial pneumothorax may cause adverse cardiovascular reactions (19) and coagulation dysfunction (20,21). Additionally, the high pressure of CO₂ pneumothorax may also lead to tumor cell invasion and metastasis (22,23). Using double or multiple retractor hooks to elevate the sternum, but as the number of incisions increased, the trauma also increased. In order to minimize the trauma to the patient and eliminate the potential complications of CO₂ artificial pneumothorax, based on previous clinical practice, our team attempted to avoid CO₂ artificial pneumothorax assistance and only placed a single retractor hook at the lower end of the sternum to elevate the sternum, and made a 4 cm or so small incision under the xiphoid process for video-assisted thoracoscopic resection of anterior mediastinal tumors.

This surgical procedure has been successfully performed on 52 cases so far. The surgical process was smooth, without conversion to open chest surgery. No serious complications occurred during the perioperative period, and all patients were discharged successfully. The postoperative pain NRS score was all 3 points or below. The longest operation time was 201 minutes, and the shortest was 30 minutes, with an average of (101.19±42.45) minutes. There was no significant prolongation compared with other surgical approaches reported in the literature (1,24). Most cases had no obvious bleeding during the operation, and only a few patients with large tumors had a blood loss of about 100 mL. Compared with our center’s lateral thoracic approach, there was no increase in postoperative thoracic drainage volume, thoracic drainage tube retention time, or hospital stay. The shortest postoperative hospital stay was 3 days, and the longest was 9 days. This patient, a 72-year-old female weighing 48 kg with a BMI of 21.3 kg/m², had a history of chronic bronchitis, was considered to have thymoma before the operation, and the tumor was found to be cystic in nature. Only cystectomy was performed, with an operation time of 49 minutes. There was no obvious bleeding during the operation. The patient was transferred to the ICU 12 hours after the operation due to chest tightness, shortness of breath, weak expectoration, and a decrease in blood oxygen saturation. The postoperative pathology confirmed a bronchial cyst, with a size of 4 cm × 3 cm × 2.5 cm. The possible reason might be that anesthesia and surgery-induced acute exacerbation of chronic bronchitis in the patient, thick sputum, the patient’s advanced age and frailty, and weak expectoration led to acute respiratory failure. After 5 days of treatment with ventilator-assisted ventilation, airway management, anti-infection, and nutritional support in the ICU, the patient improved. One 16-year-old patient developed a fever after the operation, which was caused by a combined respiratory infection. Three patients developed incision fat liquefaction, all of whom were obese with a BMI over 28 kg/m². Besides obesity, it might be related to the placement position and method of the thoracic drainage tube in our previous study. Later, we adjusted the placement position and method of the tube, and no more patients with fat liquefaction occurred.

Compared with the CO₂ inflation-assisted three-port method and the sternum double-hook suspension method, this surgical approach has the following advantages: (I) it avoids potential complications such as unstable respiration and circulation and tumor cell dissemination caused by artificial CO₂ pneumothorax; (II) there is only one incision on the xiphoid process, resulting in less trauma and a more concealed and aesthetic incision; (III) postoperative pain is less, which is conducive to patients’ coughing and expectoration, early ambulation, and faster recovery, and shortens the hospital stay. With the accumulation of experience, we believe that for benign lesions, the sharp dissection can be carried out closely against the tumor mass, only opening one side of the mediastinal pleural cavity, without the need to fully expose the left brachiocephalic vein, diaphragmatic nerve, and other important blood vessels and nerves. This further shortens the operation time. However, there are also the following disadvantages: (I) the single incision on the xiphoid process, and the camera and various operating instruments of the thoracoscope all enter the posterior gap behind the sternum from below the xiphoid process. The entire operation space is relatively narrow, and the surgical instruments are prone to interfering with each other, which requires higher skills from the surgeon and higher requirements for the assistant holding the camera. After the surgical team performed 20 cases, the surgeon and the assistant holding the camera cooperated more closely, and the surgical speed was greatly improved; (II) the exposure of the upper extreme area of the left brachiocephalic vein and the anterior part of the thymus is relatively poor, which requires higher surgical operation skills from the surgeon; (III) a double-lumen endotracheal tube anesthesia is required, and the left and right lungs need to be alternately collapsed during the operation to facilitate the operation. A single-lumen endotracheal tube anesthesia cannot meet the surgical requirements.

Patients with a substernal angle less than 70° have a narrower single incision, and there is more interference among the surgical instruments. For beginners, it is recommended to perform the surgery on patients with benign tumors whose substernal angle is greater than 90°. Later, after becoming proficient, the influence of the substernal angle on the surgical operation will decrease. However, for patients with solid tumors such as thymoma and teratoma with a diameter greater than 5 cm, if the substernal angle of the patient is less than 90°, the intraoperative operation may be very difficult, and the operation time will be relatively longer. Therefore, this surgical method is not recommended.

For beginners, it is recommended to select patients with a BMI less than 25 kg/m² for the surgery. After becoming proficient, the influence of BMI becomes less significant. In this study, the surgeon completed a thymectomy for a 55-year-old female patient with AB-type thymoma and a BMI of 33.2 kg/m² within 83 minutes. The size of the tumor was 2.5 cm × 2.2 cm × 1.5 cm.

After becoming proficient in the technique, for benign cystic masses where the longest diameter exceeds 5 cm, the affected patients can also have the entire mass removed through this surgical method. In this study, there was one patient whose cyst was assessed by preoperative CT to be approximately 8.2 cm × 4.3 cm × 2.6 cm in size. It was completely removed, and the postoperative pathological diagnosis was a foregut cyst. For patients with solid tumors in the substernal angle exceeding 100°, even if the longest diameter of the tumor exceeds 5 cm, it is not necessarily an absolute contraindication. In this study, a patient with thymic cancer whose preoperative CT assessment was approximately 7.6 cm × 5.3 cm × 4.8 cm and whose substernal angle was about 110° underwent radical thymic cancer surgery (extended thymectomy+ wedge resection of the right upper lobe + partial resection of the pericardium). Currently, half a year after the surgery, there has been no local recurrence.

Limitations of this study include its retrospective nature, single-center data, and small sample size. Further multi-center prospective studies are required to evaluate long-term oncological efficacy.

Conclusions

Uniportal subxiphoid VATS without artificial pneumothorax is a safe and feasible technique for selected anterior mediastinal tumors. For hospitals without robotic systems, uniportal subxiphoid VATS offers a high-quality, minimally invasive alternative with excellent short-term outcomes and high patient satisfaction. It is worthy of clinical promotion and application.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE and SUPER reporting checklists. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0870/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0870/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0870/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0870/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was carried out in accordance with the Declaration of Helsinki and its subsequent amendments, and was approved by Medical Research Ethics Committee of The First Affiliated Hospital of University of Science and Technology of China (No. XJS2022-2-37(WK)). Written informed consent was obtained from all patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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