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Introduction
The authors present a right-sided robotic resection of an enlarging anterior mediastinal mass, emphasizing the operative strategy, anatomic landmarks, and key decision points.
Clinical Presentation and Workup
A 54-year-old man with several years of intermittent, non-specific chest pressure underwent coronary calcium scoring computed tomography (CT) in November 2023, which incidentally identified an anterior mediastinal lesion measuring approximately 2.5 cm. Serial CT and magnetic resonance imaging (MRI) demonstrated interval growth, most recently measuring 2.5 × 3.5 cm in November 2025, with imaging characteristics consistent with a nonenhancing thymic cyst. The patient had no clinical features of myasthenia gravis.
Management options, including continued surveillance vs surgical resection, were discussed. Given the interval growth and the need to definitively exclude thymoma, the patient elected resection. A right robotic approach was planned, with readiness to proceed to complete thymectomy if intraoperative findings suggested thymoma.
Operative Technique
The patient was positioned supine with the right chest elevated and the right arm positioned posteriorly to facilitate right thoracic access. Preparation was performed widely in anticipation of possible sternotomy. One-lung ventilation was established.
Four ports were placed above the rib to avoid the intercostal neurovascular bundle. An -mm camera port was inserted in the fifth intercostal space. A 12 mm AirSeal assistant port was placed in the mid-clavicular line. An 8 mm superior port in the third intercostal space accommodated forceps, and an 8mm inferior port in the sixth intercostal space accommodated a long bipolar grasper. Intercostal nerve block with liposomal bupivacaine was performed.
Using the superior vena cava and azygos vein as landmarks, the mediastinum was entered. The right phrenic nerve was identified early and protected throughout the case. The dissection plane was developed between the mediastinal fat and the pericardium, beginning approximately 1 cm medial to the phrenic nerve. The pericardial fat pad was retracted superiorly to optimize exposure.
Dissection proceeded in a systematic fashion—superior, medial, inferior, then lateral—maintaining traction-countertraction to identify avascular planes. The innominate vein was identified superiorly. Thymic venous branches draining into the innominate vein were clipped and divided. The right internal thoracic vein was visualized coursing into the innominate vein and preserved.
The cystic mass was encountered in the expected location and dissected circumferentially with a margin of surrounding thymic and mediastinal fat. The specimen was placed in a retrieval bag and extracted via the assistant port. Intraoperative assessment demonstrated no concern for thymoma; therefore, completion thymectomy was deferred pending final pathology. Hemostasis was confirmed, and a 24-French chest tube was placed.
Postoperative Course and Pathology
The patient was extubated and transferred to recovery in stable condition. The chest tube was removed on postoperative day one, and the patient was discharged home the same day. At the two-week follow-up, he was recovering well.
Final pathology demonstrated fibroadipose and thymic tissue without malignancy. The histomorphologic findings were consistent with a benign thymic cyst.
References
- Palleiko BA, Singh A, Uy K, W. Maxfield M. Robotic Bilateral Thymectomy. August 2023. doi:10.25373/ctsnet.23902092
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