Early outcomes of robot-assisted subxiphoid approach and intercostal approach for anterior mediastinal tumors: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZENG Weiqiang ¹ , DANG Haili ² , WANG Lifei ¹ , PENG Zhen ¹ , BAI Xiangdou ¹ , WANG Bing ¹ , HE Xiaoyang ¹ , JIN Dacheng ³ ,  GOU Yunjiu ³

1. The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, 730000, P. R. China;
2. Department of Gastroenterology, Longnan Hospital of Traditional Chinese Medicine, Longnan, 746000, Gansu, P. R. China;
3. Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, 730000, P. R. China;

Corresponding?author：

GOU Yunjiu, Email: gouyunjiu@163.com

Keywords：

Robot-assisted thoracoscopic surgery; subxiphoid approach; intercostal approach; anterior mediastinal tumor; thymoma; minimally invasive surgery; postoperative pain; enhanced recovery after surgery

DOI：

10.7507/1007-4848.202303011

Video：

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Objective To compare the clinical outcomes of subxiphoid robot-assisted thoracoscopic surgery (SRATS) and intercostal robot-assisted thoracoscopic surgery (IRATS) in the treatment of anterior mediastinal tumors. Methods A retrospective analysis was conducted on patients with anterior mediastinal tumors who underwent robot-assisted surgery in the Department of Thoracic Surgery, Gansu Provincial Hospital, from May 2020 to July 2022. According to the surgical approach, patients were divided into an SRATS group and an IRATS group. Perioperative data were compared between the two groups. Results A total of 87 patients were included. There were 41 patients in the SRATS group [23 males, 18 females; mean age, (44.51±11.28) years] and 46 patients in the IRATS group [21 males, 25 females; mean age, (46.67±8.76) years]. Compared with the IRATS group, the SRATS group had significantly less intraoperative blood loss [(24.41±6.67) mL vs. (37.93±9.23) mL, P<0.001], shorter postoperative drainage duration [(1.73±0.59) days vs. (2.54±0.50) days, P<0.001], lower postoperative drainage volume [(94.46±34.08) mLvs. (116.72±24.90) mL, P=0.001], lower visual analogue scale (VAS) pain scores on postoperative day 1 [(3.66±0.76) points vs. (4.15±0.84) points, P=0.005] and day 3 [(2.41±0.59) points vs. (2.89±0.82) points, P=0.003], shorter postoperative hospital stay [(4.12±0.81) days vs. (4.98±1.02) days, P<0.001], and lower hospitalization costs [(4.51±0.65) ten thousand yuan vs. (4.86±0.68) ten thousand yuan, P=0.020]. There were no statistical differences between the two groups in operative time or incidence of postoperative complications (P>0.05). Conclusion Both SRATS and IRATS are safe and effective for the treatment of anterior mediastinal tumors. However, SRATS is less invasive and more conducive to enhanced postoperative recovery.

Citation： ZENG Weiqiang, DANG Haili, WANG Lifei, PENG Zhen, BAI Xiangdou, WANG Bing, HE Xiaoyang, JIN Dacheng, GOU Yunjiu. Early outcomes of robot-assisted subxiphoid approach and intercostal approach for anterior mediastinal tumors: A retrospective cohort study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(3): 369-375. doi: 10.7507/1007-4848.202303011 Copy

1.	Garrana SH, Rosado-de-Christenson ML. Imaging of the anterior/prevascular mediastinum. Radiol Clin North Am, 2021, 59(2): 155-168.
2.	中國醫師協會醫學機器人醫師分會胸外科專業委員會籌備組. 機器人輔助縱隔腫瘤手術中國專家共識(2019版). 中國胸心血管外科臨床雜志, 2020, 27(2): 117-125.Preparatory Committee of Chinese College of Robot-assisted Thoracic Surgeons. Chinese expert consensus of robot-assisted surgery for mediastinal tumor (2019). Chin J Clin Thorac Cardiovasc Surg, 2020, 27(2): 117-125.
3.	Wightman SC, Shrager JB. Non-myasthenia gravis immune syndromes and the thymus: is there a role for thymectomy. Thorac Surg Clin, 2019, 29(2): 215-225.
4.	Ashrafian H, Clancy O, Grover V, et al. The evolution of robotic surgery: surgical and anaesthetic aspects. Br J Anaesth, 2017, 119(Suppl 1): i72-i84.
5.	Li R, Ma Z, Qu C, et al. Comparison of perioperative outcomes between robotic-assisted and video-assisted thoracoscopic surgery for mediastinal masses in patients with different body mass index ranges: a population-based study. Front Surg, 2022, 9: 963335.
6.	Wu CF, Hsieh MJ, Liu HP, et al. Management of post-operative pain by placement of an intraoperative intercostal catheter after single port video-assisted thoracoscopic surgery: a propensity-score matched study. J Thorac Dis, 2016, 8(6): 1087-1093.
7.	Fiorelli A, Mazzella A, Cascone R, et al. Bilateral thoracoscopic extended thymectomy versus sternotomy. Asian Cardiovasc Thorac Ann, 2016, 24(6): 555-561.
8.	Guerrero WG, González-Rivas D. Multiportal video-assisted thoracic surgery, uniportal video-assisted thoracic surgery and minimally invasive open chest surgery: selection criteria. J Vis Surg, 2017, 3: 56.
9.	Zhang L, Li M, Jiang F, et al. Subxiphoid versus lateral intercostal approaches thoracoscopic thymectomy for non-myasthenic early-stage thymoma: a propensity score-matched analysis. Int J Surg, 2019, 67: 13-17.
10.	Lee JH, Hwang J, Park TH, et al. Subxiphoid single-port robotic thymectomy using the single-port robotic system versus VATS: a multi-institutional, retrospective, and propensity score-matched study. Cancers (Basel), 2024, 16(16): 2856.
11.	王晨晗, 王鋒, 胡文滕, 等. 達芬奇機器人與胸腔鏡經劍突下入路治療前縱隔腫瘤臨床療效的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2024, 31(2): 236-242.Wang CH, Wang F, Hu WT, et al. Clinical efficacy of da Vinci robotic and thoracoscopic transxiphoid approach in the treatment of anterior mediastinal tumors: a retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(2): 236-242.
12.	Limmer KK, Kernstine KH. Minimally invasive and robotic-assisted thymus resection. Thorac Surg Clin, 2011, 21(1): 69-83.
13.	Takeo S, Tsukamoto S, Kawano D, et al. Outcome of an original video-assisted thoracoscopic extended thymectomy for thymoma. Ann Thorac Surg, 2011, 92(6): 2000-2005.
14.	Dhamija A, Kakuturu J, Hayanga JWA, et al. Difficult decisions in minimally invasive surgery of the thymus. Cancers (Basel), 2021, 13(23): 5887.
15.	Marulli G, Maessen J, Melfi F, et al. Multi-institutional European experience of robotic thymectomy for thymoma. Ann Cardiothorac Surg, 2016, 5(1): 18-25.
16.	Yoshino I, Hashizume M, Shimada M, et al. Thoracoscopic thymomectomy with the da Vinci computer-enhanced surgical system. J Thorac Cardiovasc Surg, 2001, 122(4): 783-785.
17.	蔡劍橋, 施哲, 吳亮, 等. 經劍突下與經肋間單孔胸腔鏡胸腺切除術傾向性評分匹配對比研究. 中華胸心血管外科雜志, 2021, 37(11): 660-663.Cai JQ, Shi Z, Wu L, et al. Subxiphoid versus lateral intercostal uniportal thoracoscopic thymectomy: a propensity score matching study. Chin J Thorac Cardiovasc Surg, 2021, 37(11): 660-663.
18.	Li B, Niu L, Gu C, et al. Clinical analysis of subxiphoid vs. lateral approaches for treating early anterior mediastinal thymoma. Front Surg, 2022, 9: 984043.
19.	Kang CH, Na KJ, Song JW, et al. The robotic thymectomy via the subxiphoid approach: technique and early outcomes. Eur J Cardiothorac Surg, 2020, 58(Suppl 1): i39-i43.
20.	Zhang H, Chen L, Zheng Y, et al. Robot-assisted thymectomy via subxiphoid approach: technical details and early outcomes. J Thorac Dis, 2018, 10(3): 1677-1682.
21.	Suda T, Kaneda S, Hachimaru A, et al. Thymectomy via a subxiphoid approach: single-port and robot-assisted. J Thorac Dis, 2016, 8(Suppl 3): S265-S271.
22.	Marulli G, Schiavon M, Perissinotto E, et al. Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis. J Thorac Cardiovasc Surg, 2013, 145(3): 730-735.
23.	Park JH, Na KJ, Kang CH, et al. Robotic subxiphoid thymectomy versus lateral thymectomy: a propensity score-matched comparison. Eur J Cardiothorac Surg, 2022, 62(1): ezac288.
24.	Lu Q, Zhao J, Wang J, et al. Subxiphoid and subcostal arch "three ports" thoracoscopic extended thymectomy for myasthenia gravis. J Thorac Dis, 2018, 10(3): 1711-1720.
25.	Qiu Z, Chen L, Lin Q, et al. Perioperative outcomes and mid-term effects in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis: subxiphoid versus right thoracic approaches. J Thorac Dis, 2020, 12(4): 1529-1539.
26.	Mao M, Hughes R, Papadimos TJ, et al. Complications of chest tubes: a focused clinical synopsis. Curr Opin Pulm Med, 2015, 21(4): 376-386.
27.	王有鈺, 錢有輝, 姚達, 等. 單孔胸腔鏡縱隔良性腫瘤術后免胸管24例臨床分析. 中國微創外科雜志, 2021, 21(6): 553-555.Wang YY, Qian YH, Yao D, et al. Clinical analysis of 24 patients with benign mediastinal tumor treated with uniportal video-assisted thoracoscopic surgery without chest tube drainage. Chin J Min Inv Surg, 2021, 21(6): 553-555.
28.	Cui W, Huang D, Liang H, et al. Tubeless video-assisted thoracoscopic surgery in mediastinal tumor resection. Gland Surg, 2021, 10(4): 1387-1396.

1. Garrana SH, Rosado-de-Christenson ML. Imaging of the anterior/prevascular mediastinum. Radiol Clin North Am, 2021, 59(2): 155-168.
2. 中國醫師協會醫學機器人醫師分會胸外科專業委員會籌備組. 機器人輔助縱隔腫瘤手術中國專家共識(2019版). 中國胸心血管外科臨床雜志, 2020, 27(2): 117-125.Preparatory Committee of Chinese College of Robot-assisted Thoracic Surgeons. Chinese expert consensus of robot-assisted surgery for mediastinal tumor (2019). Chin J Clin Thorac Cardiovasc Surg, 2020, 27(2): 117-125.
3. Wightman SC, Shrager JB. Non-myasthenia gravis immune syndromes and the thymus: is there a role for thymectomy. Thorac Surg Clin, 2019, 29(2): 215-225.
4. Ashrafian H, Clancy O, Grover V, et al. The evolution of robotic surgery: surgical and anaesthetic aspects. Br J Anaesth, 2017, 119(Suppl 1): i72-i84.
5. Li R, Ma Z, Qu C, et al. Comparison of perioperative outcomes between robotic-assisted and video-assisted thoracoscopic surgery for mediastinal masses in patients with different body mass index ranges: a population-based study. Front Surg, 2022, 9: 963335.
6. Wu CF, Hsieh MJ, Liu HP, et al. Management of post-operative pain by placement of an intraoperative intercostal catheter after single port video-assisted thoracoscopic surgery: a propensity-score matched study. J Thorac Dis, 2016, 8(6): 1087-1093.
7. Fiorelli A, Mazzella A, Cascone R, et al. Bilateral thoracoscopic extended thymectomy versus sternotomy. Asian Cardiovasc Thorac Ann, 2016, 24(6): 555-561.
8. Guerrero WG, González-Rivas D. Multiportal video-assisted thoracic surgery, uniportal video-assisted thoracic surgery and minimally invasive open chest surgery: selection criteria. J Vis Surg, 2017, 3: 56.
9. Zhang L, Li M, Jiang F, et al. Subxiphoid versus lateral intercostal approaches thoracoscopic thymectomy for non-myasthenic early-stage thymoma: a propensity score-matched analysis. Int J Surg, 2019, 67: 13-17.
10. Lee JH, Hwang J, Park TH, et al. Subxiphoid single-port robotic thymectomy using the single-port robotic system versus VATS: a multi-institutional, retrospective, and propensity score-matched study. Cancers (Basel), 2024, 16(16): 2856.
11. 王晨晗, 王鋒, 胡文滕, 等. 達芬奇機器人與胸腔鏡經劍突下入路治療前縱隔腫瘤臨床療效的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2024, 31(2): 236-242.Wang CH, Wang F, Hu WT, et al. Clinical efficacy of da Vinci robotic and thoracoscopic transxiphoid approach in the treatment of anterior mediastinal tumors: a retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(2): 236-242.
12. Limmer KK, Kernstine KH. Minimally invasive and robotic-assisted thymus resection. Thorac Surg Clin, 2011, 21(1): 69-83.
13. Takeo S, Tsukamoto S, Kawano D, et al. Outcome of an original video-assisted thoracoscopic extended thymectomy for thymoma. Ann Thorac Surg, 2011, 92(6): 2000-2005.
14. Dhamija A, Kakuturu J, Hayanga JWA, et al. Difficult decisions in minimally invasive surgery of the thymus. Cancers (Basel), 2021, 13(23): 5887.
15. Marulli G, Maessen J, Melfi F, et al. Multi-institutional European experience of robotic thymectomy for thymoma. Ann Cardiothorac Surg, 2016, 5(1): 18-25.
16. Yoshino I, Hashizume M, Shimada M, et al. Thoracoscopic thymomectomy with the da Vinci computer-enhanced surgical system. J Thorac Cardiovasc Surg, 2001, 122(4): 783-785.
17. 蔡劍橋, 施哲, 吳亮, 等. 經劍突下與經肋間單孔胸腔鏡胸腺切除術傾向性評分匹配對比研究. 中華胸心血管外科雜志, 2021, 37(11): 660-663.Cai JQ, Shi Z, Wu L, et al. Subxiphoid versus lateral intercostal uniportal thoracoscopic thymectomy: a propensity score matching study. Chin J Thorac Cardiovasc Surg, 2021, 37(11): 660-663.
18. Li B, Niu L, Gu C, et al. Clinical analysis of subxiphoid vs. lateral approaches for treating early anterior mediastinal thymoma. Front Surg, 2022, 9: 984043.
19. Kang CH, Na KJ, Song JW, et al. The robotic thymectomy via the subxiphoid approach: technique and early outcomes. Eur J Cardiothorac Surg, 2020, 58(Suppl 1): i39-i43.
20. Zhang H, Chen L, Zheng Y, et al. Robot-assisted thymectomy via subxiphoid approach: technical details and early outcomes. J Thorac Dis, 2018, 10(3): 1677-1682.
21. Suda T, Kaneda S, Hachimaru A, et al. Thymectomy via a subxiphoid approach: single-port and robot-assisted. J Thorac Dis, 2016, 8(Suppl 3): S265-S271.
22. Marulli G, Schiavon M, Perissinotto E, et al. Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis. J Thorac Cardiovasc Surg, 2013, 145(3): 730-735.
23. Park JH, Na KJ, Kang CH, et al. Robotic subxiphoid thymectomy versus lateral thymectomy: a propensity score-matched comparison. Eur J Cardiothorac Surg, 2022, 62(1): ezac288.
24. Lu Q, Zhao J, Wang J, et al. Subxiphoid and subcostal arch "three ports" thoracoscopic extended thymectomy for myasthenia gravis. J Thorac Dis, 2018, 10(3): 1711-1720.
25. Qiu Z, Chen L, Lin Q, et al. Perioperative outcomes and mid-term effects in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis: subxiphoid versus right thoracic approaches. J Thorac Dis, 2020, 12(4): 1529-1539.
26. Mao M, Hughes R, Papadimos TJ, et al. Complications of chest tubes: a focused clinical synopsis. Curr Opin Pulm Med, 2015, 21(4): 376-386.
27. 王有鈺, 錢有輝, 姚達, 等. 單孔胸腔鏡縱隔良性腫瘤術后免胸管24例臨床分析. 中國微創外科雜志, 2021, 21(6): 553-555.Wang YY, Qian YH, Yao D, et al. Clinical analysis of 24 patients with benign mediastinal tumor treated with uniportal video-assisted thoracoscopic surgery without chest tube drainage. Chin J Min Inv Surg, 2021, 21(6): 553-555.
28. Cui W, Huang D, Liang H, et al. Tubeless video-assisted thoracoscopic surgery in mediastinal tumor resection. Gland Surg, 2021, 10(4): 1387-1396.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Early outcomes of robot-assisted subxiphoid approach and intercostal approach for anterior mediastinal tumors: A retrospective cohort study

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