Subxiphoid Thoracoscopic Surgery Is Safe and Feasible for the Treatment of Anterior Mediastinal Teratomas: A Multicentre Retrospective Study

Abstract

Background: Mediastinal benign teratoma is rare, with surgery being the only effective treatment. Few studies reported the surgical outcomes of resecting mediastinal benign teratomas via the subxiphoid approach by thoracoscopy. This study retrospectively compares the subxiphoid with other surgical approaches, aiming to assess the safety and feasibility of this technique.

Methods: We retrospectively analysed the clinical data of 159 patients with pathologically confirmed mediastinal benign teratomas who underwent surgery in 5 hospitals from July 2014 to June 2024. Various parameters of the subxiphoid approach were compared with those of other surgical methods.

Results: The surgical approaches included median sternotomy in 26 cases, lateral thoracotomy in 14 cases, lateral thoracoscopic surgery in 80 cases, subxiphoid thoracoscopic surgery in 26 cases, and robotic surgery in 13 cases. For patients who underwent the subxiphoid approach, the median surgery time was 80 min (70, 90), the median intraoperative blood loss was 20 mL (10, 20), the median postoperative drainage volume was 200 mL (0, 350), and the median time to drain removal was 3 days (0, 3). Complete tumour resection was achieved in all 26 patients (100%). The subxiphoid approach showed advantages in the aforementioned aspects compared to other surgical methods.

Conclusions: The subxiphoid and subcostal arch approach is a safe and feasible surgical technique for benign anterior mediastinal teratoma, with a potentially faster postoperative recovery and less cost. It is a valuable alternative to conventional median sternotomy, lateral thoracotomy, and lateral thoracoscopic surgery in resection of anterior mediastinal teratoma.

Keywords: anterior mediastinal tumour; subxiphoid; teratoma; thoracoscopic surgery.

Graphical abstract

Figure 1.

Flowchart of the Patients Screened

Figure 2.

Tumour Location. (A) Tumour anatomical location diagram. (B) Preoperative CT, mediastinal window (width: 400, level: 50)

Figure 3.

Schematic Diagram of Surgical Incision and Position

Figure 4.

Schematic Diagram of Surgical Process. (A) Apply upward tension to the tumour using instruments, and use an ultrasonic knife to separate the gap between the tumour and the pericardium. If the pericardium is severely invaded, consider cutting the pericardium. (B) If the tumour is cystic or cystic-solid and too large, consider using an ultrasonic scalpel to open the tumour capsule. Quickly aspirate the internal fluid with a suction device. The process should be rapid and ensure complete suction of the liquid to avoid allergic reactions caused by liquid leakage. (C) Gently retract the tumour to expose the junction between the tumour and the upper part of the sternum. Gradually separate the tissues using an ultrasonic scalpel, with the dissection typically marked by the severing of the thyrothymic ligament. (D) The primary challenge of the surgery is the separation of the tumour from the brachiocephalic vein. The tumour is closely adherent to the vein, with almost no discernible space between them. Careful dissection with an ultrasonic scalpel is required. If the adhesion is too tight, consider blunt dissection with instruments instead of blindly using energy devices to avoid damaging the lateral wall of the brachiocephalic vein. Additionally, caution should be taken regarding the potential heat generated by the ultrasonic scalpel to prevent heat-induced injury. (E) The image below shows the surgical site after tumour resection. The tumour was completely removed with no residual tissue on the sternum or pericardium. The brachiocephalic vein was fully exposed and remained uninjured, with both phrenic nerves intact. The lungs were not adherent to the tumour; otherwise, a wedge resection of the lung would have been considered. Postoperatively, absorbable haemostatic gauze can be applied to the surgical site, and a drainage tube may be placed