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De Iaco et al. Mini-invasive Surg 2020;4:63 I http://dx.doi.org/10.20517/2574-1225.2020.37 Page 7 of 16

Figure 5. A: Gross specimen after en bloc video-assisted thoracic surgery thymectomy; B: gross cross section revealing a thymoma 3.5
cm × 3 cm in size (the zoomed-in nodule is shown in the circle)

[49]
Aramini et al. described the subxiphoid thymectomy approach aided by a double sternum retractor to
better visualize the mass at the level of the anterior mediastinum, particularly in patients with large invasive
tumors. The double sternum retractors provide the surgeon with a better view of the tumor, improving the
surgical technique and thus preserving the principles of surgical radicality related to the surgical margins.

VATS AND ROBOTIC-ASSISTED THORACOSCOPIC SURGERY THYMECTOMY
VATS was introduced in the 1990s; since then, it has totally changed thoracic surgeons’ approach to surgery.
The advantages of minimally invasive techniques (MIT) compared with conventional open approaches are
well known: shorter hospital stay, quicker recovery, better aesthetic result, lower perioperative morbidity,
minor surgical access trauma, postoperative pain, and better preservation of pulmonary function. Despite
this, the use of MITs in thymic surgery is still controversial. The main surgeons’ concerns relate to the
higher risk of rupture of the capsule with the consequent spread of tumoral cells, increased risk of local
recurrence, and reduced safety margins [Figure 5].

Although recent studies have reported similar oncological outcomes for early-stage thymoma resections
performed both by open and minimally invasive approaches [50-53] , the first one remains the gold standard
[19]
treatment . This is because evidence is sparse and mostly deriving from case reports or retrospective
studies due to the low incidence of these tumors. Moreover, given the indolent behavior of many thymic
tumors, an adequate 5-10 years of follow-up should be carried out to establish the exact FFR and overall
survival. Currently, few data about long-term follow-ups have been published and therefore statistics are
still ineffectual.

No tremor filter, two-dimensional view of the operative field, and inability of the instruments to articulate
are well-known VATS limitations, and they make it difficult to operate in such a rigid and tiny space as
the mediastinum. The development of robotic technologies has solved some of the above-mentioned
problems, allowing a better and safer surgical technique. The robotic system, in fact, is endowed by a
three-dimensional, high resolution vision camera that enables the best possible view of the operative site;
moreover, every endoscopic procedure around anatomic structures is easier and safer because the surgical
EndoWrist can articulate and rotate 360 degrees with seven degrees of freedom articulation. These features
make robotic surgery extremely appropriate for thymic surgery, enabling the surgeons to do a safe and