Trans-subxiphoid robotic surgery for anterior mediastinal disease: an initial case series

Video-assisted thoracoscopic trans-subxiphoid surgery is an ideal technique for removing anterior mediastinal lesions. The diffusion of this method, however, has been limited by the complexity of surgical maneuvers to be performed in the narrow retrosternal space. Robotic surgery holds promise to overcome the technical limitations of the thoracoscopic trans-subxiphoid approach. Here, we describe a case series of patients who had undergone trans-subxiphoid robotic surgery-with a special focus on short-term outcomes.

Between January 2018 and January 2019, a total of 20 patients underwent trans-subxiphoid robotic surgery for maximal thymectomy or removal of anterior mediastinal masses. A 3-cm longitudinal incision was performed below the xiphoid process, through which carbon dioxide was insufflated and a camera port was inserted. Subsequently, the lower sections of the mediastinal pleura were detached bilaterally-followed by the creation of two bilateral 1-cm skin incisions on the anterior axillary line in the sixth intercostal space for the insertion of robotic arms. Upon completion of port positioning, the surgical robot was docked.

All robotic surgery procedures were successfully completed. Neither conversion to open surgery nor the creation of additional ports was required. The median operating time and console time were 118 min [interquartile range (IQR): 84-147 min] and 92.5 min (IQR: 78.5-133.5 min), respectively. Drainage tube positioning was not required in 11 (55%) patients. There were no operative deaths, and the median length of postoperative hospital stay was 2.5 days (IQR: 2-3 days). One patient had postoperative chylothorax and received conservative treatment.

The results of this case series provide initial support to the clinical feasibility, safety, and short-term positive outcomes of trans-subxiphoid robot-assisted surgery for anterior mediastinal disease.