Abstract
BACKGROUND: Median sternotomy has been considered the gold standard approach for anterior mediastinal tumor resection. However, recent advances in video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery with carbon dioxide insufflation have allowed minimally invasive approaches even for large and locally invasive tumors of the upper-anterior mediastinum. The subxiphoid robotic optical approach is a recently developed technique for accessing the mediastinum. The trans-subxiphoid technique offers excellent exposure of the surgical field, reduces postoperative pain, facilitates specimen retrieval even for large tumors, and potentially improves early surgical outcomes. AIM: To evaluate the safety, feasibility, and outcomes of a robotic subxiphoid approach for the resecting of large/invasive mediastinal tumors. METHODS: Between July 2024 and September 2025, 12 patients underwent subxiphoid robotic mediastinal resection. The diameter of the operated lesions ranged from 30 mm to 70 mm. A 3 cm subxiphoid incision was made at the subxiphoid level for GelPort placement, allowing for optical port access. Two operating ports were placed at the sixth intercostal space bilaterally. Carbon dioxide insufflations (8-10 mmHg) enlarged the surgical field, improving visualization of critical anatomical landmarks, such as the internal mammary arteries and phrenic nerves. This approach allowed complete resection of large or invasive tumors, preserving thoracic stability and reducing the risk of postoperative myasthenic crisis. RESULTS: The mean operating time was 170.2 minutes, and the median hospital stay was 3.5 days. No major postoperative complications occurred. Two conversions were necessary: One with a lateral robotic approach due to previous abdominal surgery, and one with a sternotomy for tumor invasion of the aortic arch. Histopathological analysis identified nine thymomas and one solitary fibrous tumor. CONCLUSION: Subxiphoid robotic approach is a safe, effective technique for extended thymectomy, fulfilling both oncological and myasthenia gravis surgical objectives.