Comparative Study of Surgical Approaches for Mediastinal Masses

Background: Treatment of mediastinal masses poses a significant challenge in modern thoracic surgery. Video-assisted thoracic surgery (VATS) is gaining popularity due to its minimally invasive approach compared with traditional methods, such as thoracotomy and sternotomy.

Objective: To study differences in intraoperative and perioperative periods among patients who underwent VATS, thoracotomy, or sternotomy.

Material and methods: The study included a total of 616 patients with mediastinal masses who underwent surgery at the Republican Specialized Scientific Practical Medical Center of Surgery named after Academician V. Vakhidov (Tashkent, Uzbekistan): thoracotomy (n=420), sternotomy (n=84), and VATS (n=112). Propensity score matching was used for comparison to ensure balanced distribution across key preoperative characteristics.

Results. In the VATS group, surgery duration was significantly shorter (83.2±17.5 minutes) compared with thoracotomy (125.7±61.9 minutes, P <.001) and sternotomy (128.8±46.1 minutes, P <.001). Intraoperative blood loss was also lower in the VATS group (125.8±7.4 mL) compared with thoracotomy (350.4±11.4 mL, P <.001) and sternotomy (400.6±13.5 mL, P <.001). The mean duration of mechanical ventilation was 2.49±0.5 hours in the VATS group, which was significantly shorter than in the thoracotomy group (8.3±2.1 hours, P <.001) and the sternotomy group (10.1±3.3 hours, P <.001). Postoperative hospital stay was shorter in the VATS group (7.4±2.7 days) compared with thoracotomy (11.5±4.1 days) and sternotomy (11.7±4.3 days, P <.001). The rate of early postoperative complications was also significantly lower in the VATS group with 2 cases (2.6%) compared with 12 cases (15.6%) in the thoracotomy group and 14 cases (18.2%) in the sternotomy group (P =.006 and P =.002, respectively).

Conclusions: VATS demonstrated advantages over traditional methods, such asthoracotomy and sternotomy. It offers shorter surgery duration and hospital stay, decreased blood loss, and fewer complications.

1. Azizad S, Sannananja B, Restrepo CS. Solid tumors of the mediastinum in adults. Semin Ultrasound CT MR. 2016;37(3):196–211. PMID: 27261345. https://doi.org/10.1053/j.sult.2016.03.002

2. Almeida PT, Heller D. Anterior mediastinal mass. In: Stat-Pearls. StatPearls Publishing; 2024.

3. Aleksandrov OA, Pikin OV, Ryabov AB, Stepanov SO, Volchenko NN. Clinical presentations and morphological verification of mediastinal tumors. Onkologiya. Zhurnal imeni PA Gertsena. 2020;9(5):60–70. (In Russ.). https://doi.org/10.17116/onkolog2020905160

4. Aroor AR, Prakasha SR, Seshadri S, S T, Raghuraj U. A study of clinical characteristicsof mediastinal mass. J Clin Diagn Res. 2014;8(2):77–80. PMID: 24701488. PMCID: PMC3972605. https://doi.org/10.7860/JCDR/2014/7622.4013

5. Li WW, van Boven WJ, Annema JT, Eberl S, Klomp HM, de Mol BA. Management of large mediastinal masses: surgical and anesthesiological considerations. J Thorac Dis. 2016;8(3):E175–E184. PMID: 27076967. PMCID: PMC4805811. https://doi.org/10.21037/jtd.2016.02.55

6. Rodriguez M, Milla L, Wee JO. The role of minimally invasive surgery in the management of giant mediastinal tumors: a narrative review. Mediastinum. 2022;6:37. PMID: 36582972. PMCID: PMC9792823. https://doi.org/10.21037/med-21-38

7. Topolnitsky EB, Borodina YuA. Videothoracoscopic interventions for tumors and cysts of the mediastinum. Endoskopicheskaya khirurgiya. 2020;26(6):17–21. (In Russ.). https://doi.org/10.17116/ endoskop20202606117

8. Amore D, Cicalese M, Scaramuzzi R, Di Natale D, Casazza D, Curcio C. Hybrid robotic thoracic surgery for excision of large mediastinal masses. J Vis Surg. 2018;4:105. PMID: 29963394. PMCID: PMC5994465. https://doi.org/10.21037/jovs.2018.05.17

9. Aksoy Y, Şehitoğulları A. Analysis of patients resected for primary mediastinal mass: which surgical approach is superior. Istanbul Medical Journal. 2023;24(3):236–240. https://doi.org/10.4274/imj.galenos.2023.45804

10. Fang Y, Qin Z. Video-assisted thoracoscopic surgery is safe and reliable for large and invasive primary mediastinal tumors. Wideochir Inne Tech Maloinwazyjne. 2021;16(1):163–168. PMID: 33786130. PMCID: PMC7991948. https://doi.org/10.5114/wiitm.2020.94528

11. Kaiser LR. Surgical approaches to the mediastinum. In: Kalhor N, Moran C. Mediastinal Pathology. Springer, Cham; 2019:29–39. https://doi.org/10.1007/978-3-319-98980-8_3

12. Dang J, Sun S, Wu Z, Shan Y, Zhang H. Meta-analysis of clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors. World J Surg Oncol. 2024;22(1):70. PMID: 38413953. PMCID: PMC10900664. https://doi.org/10.1186/s12957-024-03325-5

13. Gülmez G, Hasdiraz L, Önal Ö. Approach to mediastinal masses: a comparison of open surgery and uniportal video-assisted thoracoscopic surgery techniques. Ankyra Medical Journal. 2024;3(1):13–18. https://doi.org/10.51271/ankmj-0003

14. Tang M, Liu J, Shuai Y, et al. Clinical evaluation of the impact of mediastinal tumour size on the subxiphoid approach video-assisted thoracoscopic surgery. Interdiscip Cardiovasc Thorac Surg. 2024;38(2):ivae015. PMID: 38268477. PMCID: PMC10859180. https://doi.org/10.1093/icvts/ivae015

15. Yin X, Xue S, Guo Y, et al. Comparative study of the clinical efficacy of subcostal thoracoscopy and median sternotomy in treating thymoma: a propensity score-matching analysis. J Int Med Res. 2024;52(1):3000605231214470. https://doi.org/10.1177/03000605231214470

16. Tanaka Y, Maniwa Y, Sugio K, et al. The efficacy of thoracoscopic surgery for descending necrotizing mediastinitis. Interdiscip Cardiovasc Thorac Surg. 2023;36(4):ivad053. PMID: 37018143. PMCID: PMC10133401. https://doi.org/10.1093/icvts/ivad053

17. Zhang Z, Wang X, Zhou Z, Jiang G, Li Y. Surgical management of primary mediastinal mature teratoma: a single-center 20 years’ experience. Front Surg. 2022;9:902985. PMID: 36132208. PMCID: PMC9483009. https://doi.org/10.3389/fsurg.2022.902985

18. Cherntanomwong P, Peerapatanapong K, Dejthevaporn C, et al. A comparative study of video-assisted thoracoscopic surgery versus median sternotomy thymectomy in myasthenia gravis. Journal of the Medical Association of Thailand. 2022;105(4):352–358. https://doi.org/10.35755/jmedassocthai.2022.04.13299