- 1. Clinical Medical College, North Sichuan Medical College, Nanchong, 637000, Sichuan, P. R. China;
- 2. Department of Cardiothoracic Surgery, Chengdu Sixth People's Hospital, Chengdu, 610000, P. R. China;
REN Fuqiang,
Email: caoguize@163.com
Mediastinal tumors present significant surgical challenges due to their complex anatomical location and close association with the heart, major blood vessels, and principal neural structures. Surgical resection remains the primary treatment for achieving a cure or long-term disease control. With the advancement of imaging techniques and minimally invasive surgery, operative strategies for mediastinal tumors have evolved from conventional open surgery to a diversified approach that includes open surgery, video-assisted thoracoscopic surgery (VATS), and robot-assisted thoracoscopic surgery (RATS). Each surgical modality varies in terms of operative exposure, technical precision, invasiveness, and perioperative risk. Therefore, the selection of a procedure is influenced by tumor location, size, extent of invasion, and the surgeon's experience, and no standardized strategy has been established yet. Based on mediastinal anatomical compartments, this review summarizes the technical characteristics, indications, and limitations of open surgery, VATS via intercostal and subxiphoid approaches, RATS, and other emerging minimally invasive techniques. Emphasis is placed on surgical selection strategies, aiming to provide a practical reference for the individualized surgical management of mediastinal tumors.
Copyright ? the editorial department of Chinese Journal of Clinical Thoracic and Cardiovascular Surgery of West China Medical Publisher. All rights reserved
| 1. | Jiang Y, Lin Y, Yang C, et al. Spatiotemporal distribution of mediastinal neoplasms: a comprehensive multi-center study. Lung Cancer, 2024, 191: 107558. |
| 2. | Liu T, Al-Kzayer LFY, Xie X, et al. Mediastinal lesions across the age spectrum: a clinicopathological comparison between pediatric and adult patients. Oncotarget, 2017, 8(35): 59845-59853. |
| 3. | 滑炎卿, 鄭向鵬, 張國楨. 縱隔解剖"三分區”在占位病變診斷中的應用. 中華放射學雜志, 2001, 35(5): 339-341.Hua YQ, Zheng XP, Zhang GZ. Application of three compartments of mediastinal anatomy in the diagnosis of space-occupying lesions. Chin J Radiol, 2001, 35(5): 339-341. |
| 4. | Juanpere S, Ca?ete N, Ortu?o P, et al. A diagnostic approach to the mediastinal masses. Insights Imaging, 2013, 4(1): 29-52. |
| 5. | White A, Deeb AL. Anatomy of mediastinal veins and nerves. Mediastinum, 2023, 7: 14. |
| 6. | Gerber TS, Porubsky S. Benign lesions of the mediastinum. Histopathology, 2024, 84(1): 183-195. |
| 7. | Carter BW, Tomiyama N, Bhora FY, et al. A modern definition of mediastinal compartments. J Thorac Oncol, 2014, 9(9 Suppl 2): S97-S101. |
| 8. | Tianci C, Shen Z, Chen S, et al. Median sternotomy versus minimally invasive thymectomy for early-stage thymoma: a systematic review and meta-analysis protocol. Medicine (Baltimore), 2019, 98(51): e18359. |
| 9. | Mayer N, Kestenholz P, Minervini F. Surgical access to the mediastinum- all roads lead to Rome: a literature review. Mediastinum, 2024, 8: 28. |
| 10. | Petrella F, Rizzo SMR. The hemiclamshell approach to bulky cervico-mediastinal lesions: how to do it. Mediastinum, 2023, 8: 9. |
| 11. | Odaka M, Akiba T, Mori S, et al. Oncological outcomes of thoracoscopic thymectomy for the treatment of stages Ⅰ-Ⅲ thymomas. Interact Cardiovasc Thorac Surg, 2013, 17(2): 285-290. |
| 12. | Leivaditis V, Liolis E, Baltayiannis N, et al. Diving retrosternal goiter and the dilemma of sternotomy: indications, predictors and surgical considerations. Kardiol Torakochirurgia Pol, 2025, 22(3): 174-181. |
| 13. | Cappellacci F, Canu GL, Rossi L, et al. Differences in surgical outcomes between cervical goiter and retrosternal goiter: an international, multicentric evaluation. Front Surg, 2024, 11: 1341683. |
| 14. | Vaidya Y, Polycarpou A, Gibbs S, et al. Surgical approaches for thymectomy: a narrative review. Mediastinum, 2025, 9: 5. |
| 15. | Bains MS, Ginsberg RJ, Jones WG, et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg, 1994, 58(1): 30-33. |
| 16. | Kanl?o?lu Kuman N, Sen S, Cokp?nar S, et al. A hemiclamshell incision for a giant solitary fibrous tumor of the right hemithorax. Case Rep Surg, 2012, 2012: 826454. |
| 17. | Alcasid NJ, Vasic I, Brennan PG, et al. The clinical significance of open vs. minimally invasive surgical approaches in the management of thymic epithelial tumors and myasthenia gravis. Front Surg, 2024, 11: 1457029. |
| 18. | Zhang H, Huang L, Li Z, et al. Robotic-assisted thymectomy for locally advanced thymic malignancy: technical refinement and oncologic outcomes from a 20-year cohort. J Thorac Dis, 2025, 17(10): 9121-9130. |
| 19. | Safdie FM, Sanchez MV, Sarkaria IS. Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion. J Vis Surg, 2017, 3: 87. |
| 20. | Puri V, Patel A, Majumder K, et al. Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications. J Thorac Cardiovasc Surg, 2015, 149(1): 55-62. |
| 21. | Hazelrigg SR, Landreneau RJ, Mack MJ, et al. Thoracoscopic resection of mediastinal cysts. Ann Thorac Surg, 1993, 56(3): 659-660. |
| 22. | Chen K, Zhang X, Jin R, et al. Robot-assisted thoracoscopic surgery for mediastinal masses: a single-institution experience. J Thorac Dis, 2020, 12(2): 105-113. |
| 23. | Khanh HQ, Van Khoi N, Vuong NL. Long-term outcome in mediastinal malignancies: video-assisted thoracoscopic versus open surgery. Indian J Thorac Cardiovasc Surg, 2021, 37(1): 44-52. |
| 24. | Friedant AJ, Handorf EA, Su S, et al. Minimally invasive versus open thymectomy for thymic malignancies: systematic review and meta-analysis. J Thorac Oncol, 2016, 11(1): 30-38. |
| 25. | Ke L, Liu J, Shuai Y, et al. Intercostal approach VATS is feasible for large-sized anterior mediastinal tumors. Sci Rep, 2024, 14(1): 17227. |
| 26. | Wang L, Liu J, Xu W, et al. Three different surgical methods for large-sized anterior mediastinal tumors in real-world practice. BMC Cancer, 2024, 24(1): 1475. |
| 27. | Mao Y, Lan Y, Cui F, et al. Comparison of different surgical approaches for anterior mediastinal tumor. J Thorac Dis, 2020, 12(10): 5430-5439. |
| 28. | Xie X, Gan X, Chen B, et al. Left- and right-sided video-assisted thoracoscopic thymectomy exhibit similar effects on myasthenia gravis. J Thorac Dis, 2016, 8(1): 124-132. |
| 29. | Liu Z, Yang R, Sun Y. Nonintubated uniportal thoracoscopic thymectomy with laryngeal mask. Thorac Cardiovasc Surg, 2020, 68(5): 450-456. |
| 30. | Ye B, Tantai JC, Ge XX, et al. Surgical techniques for early-stage thymoma: video-assisted thoracoscopic thymectomy versus transsternal thymectomy. J Thorac Cardiovasc Surg, 2014, 147(5): 1599-1603. |
| 31. | Miyazaki T, Doi R, Matsumoto K. Post-thoracotomy pain syndrome in the era of minimally invasive thoracic surgery. J Thorac Dis, 2024, 16(5): 3422-3430. |
| 32. | Numanami H, Yano M, Yamaji M, et al. Thoracoscopic thymectomy using a subxiphoid approach for anterior mediastinal tumors. Ann Thorac Cardiovasc Surg, 2018, 24(2): 65-72. |
| 33. | Cho S. Video-assisted thoracic surgery thymectomy: subxiphoid approach. J Chest Surg, 2021, 54(4): 314-318. |
| 34. | Hsu CP, Chuang CY, Hsu NY, et al. Subxiphoid approach for video-assisted thoracoscopic extended thymectomy in treating myasthenia gravis. Interact Cardiovasc Thorac Surg, 2002, 1(1): 4-8. |
| 35. | Chiu CH, Chao YK, Liu YH. Subxiphoid approach for video-assisted thoracoscopic surgery: an update. J Thorac Dis, 2018, 10(Suppl 14): S1662-S1665. |
| 36. | Yin X, Xue S, Wang H, et al. Clinical comparative analyses of thymectomy between subxiphoid and subcostal arch thoracoscopic resection and median sternotomy for the treatment of thymoma with myasthenia gravis in Chinese patients. J Surg Res, 2023, 285: 107-113. |
| 37. | Yang X, Jiang J, Ao Y, et al. Perioperative outcomes and survival of modified subxiphoid video-assisted thoracoscopic surgery thymectomy for T2-3 thymic malignancies: a retrospective comparison study. J Thorac Cardiovasc Surg, 2024, 168(6): 1550-1559. |
| 38. | 俞經生, 高從榮, 裴韶華, 等. 經劍突下與經側胸入路胸腔鏡輔助前縱隔腫瘤切除術的療效對比及對應激反應和炎性因子的影響. 現代生物醫學進展, 2024, 24(17): 3332-3336.Yu JS, Gao CR, Pei SH, et al. Comparison of the efficacy of thoracoscopic assisted anterior mediastinal tumor resection via subxiphoid and lateral thoracic approach and its effects on stress response and inflammatory factors. Prog Mod Biomed, 2024, 24(17): 3332-3336. |
| 39. | Chen WC, Bai YY, Zhang LH, et al. Prevalence and predictors of chronic postsurgical pain after video-assisted thoracoscopic surgery: a systematic review and meta-analysis. Pain Ther, 2023, 12(1): 117-139. |
| 40. | Chen J, Volpi S, Ali JM, et al. Comparison of post-operative pain and quality of life between uniportal subxiphoid and intercostal video-assisted thoracoscopic lobectomy. J Thorac Dis, 2020, 12(7): 3582-3590. |
| 41. | Xu H, Lai Y, Li G, et al. Comparison of subxiphoid vs intercostal VATS approaches for anterior mediastinal tumors: a retrospective cohort study with focus on elderly patients. Eur J Med Res, 2025, 30(1): 1259. |
| 42. | Suda T. Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg, 2016, 5(1): 56-58. |
| 43. | Zielinski M, Czajkowski W, Gwozdz P, et al. Resection of thymomas with use of the new minimally-invasive technique of extended thymectomy performed through the subxiphoid-right video-thoracoscopic approach with double elevation of the sternum. Eur J Cardiothorac Surg, 2013, 44(2): e113-e119. |
| 44. | 朱峻民, 王俊杰, 岳建明, 等. 無管化天平拉鉤經皮懸吊劍突下單孔胸腔鏡輔助前縱隔腫物手術. 中國胸心血管外科臨床雜志, 2025, 32(11): 1603-1609.Zhu JM, Wang JJ, Yue JM, et al. Tubeless subxiphoid uniportal video-assisted thoracoscopic surgery with percutaneous suspension technique via balance-shaped sternal elevation device in anterior mediastinal masses. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(11): 1603-1609. |
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| 49. | 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. |
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- 1. Jiang Y, Lin Y, Yang C, et al. Spatiotemporal distribution of mediastinal neoplasms: a comprehensive multi-center study. Lung Cancer, 2024, 191: 107558.
- 2. Liu T, Al-Kzayer LFY, Xie X, et al. Mediastinal lesions across the age spectrum: a clinicopathological comparison between pediatric and adult patients. Oncotarget, 2017, 8(35): 59845-59853.
- 3. 滑炎卿, 鄭向鵬, 張國楨. 縱隔解剖"三分區”在占位病變診斷中的應用. 中華放射學雜志, 2001, 35(5): 339-341.Hua YQ, Zheng XP, Zhang GZ. Application of three compartments of mediastinal anatomy in the diagnosis of space-occupying lesions. Chin J Radiol, 2001, 35(5): 339-341.
- 4. Juanpere S, Ca?ete N, Ortu?o P, et al. A diagnostic approach to the mediastinal masses. Insights Imaging, 2013, 4(1): 29-52.
- 5. White A, Deeb AL. Anatomy of mediastinal veins and nerves. Mediastinum, 2023, 7: 14.
- 6. Gerber TS, Porubsky S. Benign lesions of the mediastinum. Histopathology, 2024, 84(1): 183-195.
- 7. Carter BW, Tomiyama N, Bhora FY, et al. A modern definition of mediastinal compartments. J Thorac Oncol, 2014, 9(9 Suppl 2): S97-S101.
- 8. Tianci C, Shen Z, Chen S, et al. Median sternotomy versus minimally invasive thymectomy for early-stage thymoma: a systematic review and meta-analysis protocol. Medicine (Baltimore), 2019, 98(51): e18359.
- 9. Mayer N, Kestenholz P, Minervini F. Surgical access to the mediastinum- all roads lead to Rome: a literature review. Mediastinum, 2024, 8: 28.
- 10. Petrella F, Rizzo SMR. The hemiclamshell approach to bulky cervico-mediastinal lesions: how to do it. Mediastinum, 2023, 8: 9.
- 11. Odaka M, Akiba T, Mori S, et al. Oncological outcomes of thoracoscopic thymectomy for the treatment of stages Ⅰ-Ⅲ thymomas. Interact Cardiovasc Thorac Surg, 2013, 17(2): 285-290.
- 12. Leivaditis V, Liolis E, Baltayiannis N, et al. Diving retrosternal goiter and the dilemma of sternotomy: indications, predictors and surgical considerations. Kardiol Torakochirurgia Pol, 2025, 22(3): 174-181.
- 13. Cappellacci F, Canu GL, Rossi L, et al. Differences in surgical outcomes between cervical goiter and retrosternal goiter: an international, multicentric evaluation. Front Surg, 2024, 11: 1341683.
- 14. Vaidya Y, Polycarpou A, Gibbs S, et al. Surgical approaches for thymectomy: a narrative review. Mediastinum, 2025, 9: 5.
- 15. Bains MS, Ginsberg RJ, Jones WG, et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg, 1994, 58(1): 30-33.
- 16. Kanl?o?lu Kuman N, Sen S, Cokp?nar S, et al. A hemiclamshell incision for a giant solitary fibrous tumor of the right hemithorax. Case Rep Surg, 2012, 2012: 826454.
- 17. Alcasid NJ, Vasic I, Brennan PG, et al. The clinical significance of open vs. minimally invasive surgical approaches in the management of thymic epithelial tumors and myasthenia gravis. Front Surg, 2024, 11: 1457029.
- 18. Zhang H, Huang L, Li Z, et al. Robotic-assisted thymectomy for locally advanced thymic malignancy: technical refinement and oncologic outcomes from a 20-year cohort. J Thorac Dis, 2025, 17(10): 9121-9130.
- 19. Safdie FM, Sanchez MV, Sarkaria IS. Prevention and management of intraoperative crisis in VATS and open chest surgery: how to avoid emergency conversion. J Vis Surg, 2017, 3: 87.
- 20. Puri V, Patel A, Majumder K, et al. Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications. J Thorac Cardiovasc Surg, 2015, 149(1): 55-62.
- 21. Hazelrigg SR, Landreneau RJ, Mack MJ, et al. Thoracoscopic resection of mediastinal cysts. Ann Thorac Surg, 1993, 56(3): 659-660.
- 22. Chen K, Zhang X, Jin R, et al. Robot-assisted thoracoscopic surgery for mediastinal masses: a single-institution experience. J Thorac Dis, 2020, 12(2): 105-113.
- 23. Khanh HQ, Van Khoi N, Vuong NL. Long-term outcome in mediastinal malignancies: video-assisted thoracoscopic versus open surgery. Indian J Thorac Cardiovasc Surg, 2021, 37(1): 44-52.
- 24. Friedant AJ, Handorf EA, Su S, et al. Minimally invasive versus open thymectomy for thymic malignancies: systematic review and meta-analysis. J Thorac Oncol, 2016, 11(1): 30-38.
- 25. Ke L, Liu J, Shuai Y, et al. Intercostal approach VATS is feasible for large-sized anterior mediastinal tumors. Sci Rep, 2024, 14(1): 17227.
- 26. Wang L, Liu J, Xu W, et al. Three different surgical methods for large-sized anterior mediastinal tumors in real-world practice. BMC Cancer, 2024, 24(1): 1475.
- 27. Mao Y, Lan Y, Cui F, et al. Comparison of different surgical approaches for anterior mediastinal tumor. J Thorac Dis, 2020, 12(10): 5430-5439.
- 28. Xie X, Gan X, Chen B, et al. Left- and right-sided video-assisted thoracoscopic thymectomy exhibit similar effects on myasthenia gravis. J Thorac Dis, 2016, 8(1): 124-132.
- 29. Liu Z, Yang R, Sun Y. Nonintubated uniportal thoracoscopic thymectomy with laryngeal mask. Thorac Cardiovasc Surg, 2020, 68(5): 450-456.
- 30. Ye B, Tantai JC, Ge XX, et al. Surgical techniques for early-stage thymoma: video-assisted thoracoscopic thymectomy versus transsternal thymectomy. J Thorac Cardiovasc Surg, 2014, 147(5): 1599-1603.
- 31. Miyazaki T, Doi R, Matsumoto K. Post-thoracotomy pain syndrome in the era of minimally invasive thoracic surgery. J Thorac Dis, 2024, 16(5): 3422-3430.
- 32. Numanami H, Yano M, Yamaji M, et al. Thoracoscopic thymectomy using a subxiphoid approach for anterior mediastinal tumors. Ann Thorac Cardiovasc Surg, 2018, 24(2): 65-72.
- 33. Cho S. Video-assisted thoracic surgery thymectomy: subxiphoid approach. J Chest Surg, 2021, 54(4): 314-318.
- 34. Hsu CP, Chuang CY, Hsu NY, et al. Subxiphoid approach for video-assisted thoracoscopic extended thymectomy in treating myasthenia gravis. Interact Cardiovasc Thorac Surg, 2002, 1(1): 4-8.
- 35. Chiu CH, Chao YK, Liu YH. Subxiphoid approach for video-assisted thoracoscopic surgery: an update. J Thorac Dis, 2018, 10(Suppl 14): S1662-S1665.
- 36. Yin X, Xue S, Wang H, et al. Clinical comparative analyses of thymectomy between subxiphoid and subcostal arch thoracoscopic resection and median sternotomy for the treatment of thymoma with myasthenia gravis in Chinese patients. J Surg Res, 2023, 285: 107-113.
- 37. Yang X, Jiang J, Ao Y, et al. Perioperative outcomes and survival of modified subxiphoid video-assisted thoracoscopic surgery thymectomy for T2-3 thymic malignancies: a retrospective comparison study. J Thorac Cardiovasc Surg, 2024, 168(6): 1550-1559.
- 38. 俞經生, 高從榮, 裴韶華, 等. 經劍突下與經側胸入路胸腔鏡輔助前縱隔腫瘤切除術的療效對比及對應激反應和炎性因子的影響. 現代生物醫學進展, 2024, 24(17): 3332-3336.Yu JS, Gao CR, Pei SH, et al. Comparison of the efficacy of thoracoscopic assisted anterior mediastinal tumor resection via subxiphoid and lateral thoracic approach and its effects on stress response and inflammatory factors. Prog Mod Biomed, 2024, 24(17): 3332-3336.
- 39. Chen WC, Bai YY, Zhang LH, et al. Prevalence and predictors of chronic postsurgical pain after video-assisted thoracoscopic surgery: a systematic review and meta-analysis. Pain Ther, 2023, 12(1): 117-139.
- 40. Chen J, Volpi S, Ali JM, et al. Comparison of post-operative pain and quality of life between uniportal subxiphoid and intercostal video-assisted thoracoscopic lobectomy. J Thorac Dis, 2020, 12(7): 3582-3590.
- 41. Xu H, Lai Y, Li G, et al. Comparison of subxiphoid vs intercostal VATS approaches for anterior mediastinal tumors: a retrospective cohort study with focus on elderly patients. Eur J Med Res, 2025, 30(1): 1259.
- 42. Suda T. Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg, 2016, 5(1): 56-58.
- 43. Zielinski M, Czajkowski W, Gwozdz P, et al. Resection of thymomas with use of the new minimally-invasive technique of extended thymectomy performed through the subxiphoid-right video-thoracoscopic approach with double elevation of the sternum. Eur J Cardiothorac Surg, 2013, 44(2): e113-e119.
- 44. 朱峻民, 王俊杰, 岳建明, 等. 無管化天平拉鉤經皮懸吊劍突下單孔胸腔鏡輔助前縱隔腫物手術. 中國胸心血管外科臨床雜志, 2025, 32(11): 1603-1609.Zhu JM, Wang JJ, Yue JM, et al. Tubeless subxiphoid uniportal video-assisted thoracoscopic surgery with percutaneous suspension technique via balance-shaped sternal elevation device in anterior mediastinal masses. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(11): 1603-1609.
- 45. Cerfolio RJ, Bryant AS, Minnich DJ. Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology. J Thorac Cardiovasc Surg, 2012, 143(5): 1138-1143.
- 46. 王鋒, 袁宇航, 王晨晗, 等. 達芬奇機器人與胸腔鏡外科治療后縱隔腫物臨床療效比較的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2024, 31(5): 695-701.Wang F, Yuan YH, Wang CH, et al. The clinical efficacy of Da Vinci robot versus video-assisted thoracoscopic surgery in the treatment of posterior mediastinal tumors: a retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(5): 695-701.
- 47. Park SY, Han KN, Hong JI, et al. Subxiphoid approach for robotic single-site-assisted thymectomy. Eur J Cardiothorac Surg, 2020, 58(Suppl 1): i34-i38.
- 48. Romano G, Zirafa CC, Ceccarelli I, et al. Robotic thymectomy for thymoma in patients with myasthenia gravis: neurological and oncological outcomes. Eur J Cardiothorac Surg, 2021, 60(4): 890-895.
- 49. 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.
- 50. Imielski B, Kurihara C, Manerikar A, et al. Comparative effectiveness and cost-efficiency of surgical approaches for thymectomy. Surgery, 2020, 168(4): 737-742.
- 51. 馬煜成, 何哲浩, 徐金明, 等. 兩種入路下機器人與胸腔鏡縱隔腫瘤切除術的療效比較. 機器人外科學雜志(中英文), 2025, 6(6): 1008-1013.Ma YC, He ZH, Xu JM, et al. Comparison of therapeutic efficacy between robotic and thoracoscopic mediastinal tumor resection via two different approaches. Chin J Robot Surg, 2025, 6(6): 1008-1013.
- 52. Harrison OJ, Maraschi A, Routledge T, et al. A cost analysis of robotic vs. video-assisted thoracic surgery: the impact of the learning curve and the COVID-19 pandemic. Front Surg, 2023, 10: 1123329.
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