case_images: PMC11792598_01
case_images: Chest computed tomography revealed a 7.1-cm tumor in the left anterior mediastinum with suspected involvement of the left brachiocephalic vein (yellow arrowhead) and upper lobe of the left lung (white arrowheads)
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case_images: Fig1
case_images: A chest computed tomography (CT) revealed an anterior mediastinal mass measuring 71 mm in maximum diameter, with suspected involvement of the left brachiocephalic vein and upper lobe of the left lung (Fig. 1).
case_images: A Port placement diagram for robotic surgery. An 8-mm port was placed along the anterior axillary line at the third intercostal space, another 8-mm port at the fifth intercostal space on the same line, an additional 8-mm port ventral to the anterior axillary line at the sixth intercostal space, and a 35-mm assist port was positioned along the mid-axillary line at the eighth intercostal space. B Incision for the transmanubrial approach. An L-shaped skin incision was made, extending from the anterior margin of the left sternocleidomastoid muscle, traversing the sternal midline, and following the left second intercostal space. C Overview of the surgical procedure. Dissection of the thymic tissue (enclosed by the dashed line) was performed using a robotic approach, followed by tumor dissection (gray area) from the left brachiocephalic vein via the transmanubrial approach. Subsequently, the involved left upper segment (dotted area) was resected en bloc using a thoracoscopic approach
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case_images: Fig2
case_images: The patient was placed in the supine position with the robot docked over the right anterior axillary line (Fig. 2A). The robot was then undocked, and a transmanubrial osteomuscular sparing approach (TMA) was initiated (Fig. 2B). The patient was repositioned to the right lateral decubitus position, and a thoracoscopic left upper segmentectomy with adhesiolysis was performed, achieving an R0 resection (Fig. 2C).
case_images: Intraoperative findings of robotic surgery. The tumor (yellow arrowheads) was firmly adhered to the left brachiocephalic vein (white arrowheads). Due to the loss of layers (yellow arrows), it was deemed risky to attempt dissection from the left brachiocephalic vein under robotic surgery
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case_images: Fig3
case_images: During the dissection of the thymic tissue, firm adhesion of the mass to the left brachiocephalic vein was noted (Fig. 3).
case_images: Under the transmanubrial approach, the proximal (yellow arrowhead) and distal (yellow arrow) portions of the left brachiocephalic vein (white arrowheads) were secured, enabling the safe detachment of the tumor (black arrowheads). An optimal field of view was achieved via a transection of the costal cartilage (black arrows)
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case_images: Fig4
case_images: The tumor was dissected successfully under the proximal and distal control of the left brachiocephalic vein, preserving the vein intact (Fig. 4).
case_images: The tumor infiltrated within the left upper lobe of the lung (yellow arrowhead marked in A. Hematoxylin-eosin staining (x 20) showed a Type A region (B) with spindle-shaped tumor cells proliferating and a Type B region (C) with a mixture of small oval cells and lymphocytes
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case_images: Fig5
case_images: Negative pressure wound therapy was performed for 17 days (A). After the negative pressure wound therapy (B), the infection was controlled, but the manubrium of the sternum developed a sequestrum (white arrowhead). The wound healed after a sequestrectomy of the manubrium and chest wall reconstruction using a right pectoralis major myocutaneous flap (C)
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case_images: Fig6
case_images: Debridement, sternal wire removal, antibiotic therapy, and negative pressure wound therapy (NPWT) were initiated (Fig. 6A). After 17 days of antibiotic therapy and NPWT, the infection subsided (Fig. 6B), and the patient underwent a sequestrectomy of the affected manubrium with a chest wall reconstruction using a pedicled right pectoralis major myocutaneous flap (Fig. 6C).