The prevalence of anterior mediastinal lesions is on the rise, primarily encompassing mediastinal goiter and thymoma [1,2,3, 11,12,13]. While some cases may not necessitate intervention, the potential for malignant tumors requires adherence to oncological principles, often calling for surgical intervention to enhance prognosis [14]. In recent years, minimally invasive techniques have garnered attention in the surgical management of anterior mediastinal lesions, as they ensure complete tumor resection without the drawbacks of open surgery. Notably, video-assisted thoracoscopic surgery (VATS) has gained traction due to its perceived advantages, including low morbidity, shortened hospitalization, and comprehensive resection [4, 15,16,17]. However, the advent of robot-assisted technology has introduced a less invasive surgical approach with a broader operative field, enabling access to every aspect of the anterior mediastinum. Initially employed in cardiac surgery, robots were primarily utilized for procedures such as mitral valve repair, atrial fibrillation ablation, left ventricular bipolar pacing lead placement, and atrial septal defect repair [18, 19]. With the rich surgical experience of operators, some scholars have found that compared with video-assisted thoracoscopy, robotics has a steep learning curve, and with the increase of the number of operations, the operation time is also reducing [20, 21]. It is also gradually applied to other thoracic operations. Although, robot-assisted thoracoscopic surgery for anterior mediastinal lesions have been recognized as feasible and safe [20, 22,23,24]. But no consensus on the surgical method of AML.

The three-port inflation robot-assisted thoracoscopic surgery for mediastinal tumor resection primarily employs a lateral approach, facilitating artificial pneumothorax establishment in the affected side’s pleural cavity. This technique broadens the field of vision, aids in lung collapse, and exposes crucial structures such as the phrenic nerve, thymus vein, and innominate vein, thereby facilitating surgery. Typically, a right-side approach is adopted. Traditional thoracoscopy encounters challenges in thymoma removal and fat dissection, particularly at the contralateral hilum, diaphragmatic angle, neck root, and rear of the innominate vein. This method effectively accomplishes anterior mediastinal fat dissection, including intricate areas of operation.

The robot’s intricate installation process, taking nearly 10 min, results in the actual operation time being shorter for robot-assisted thoracoscopic surgery (RATS) compared to VATS. Intraoperative blood loss was observed to be less in the RATS group than in the VATS group. The robot’s advanced surgical instruments and expanded visual field facilitate superior vessel separation and protection, ultimately reducing intraoperative bleeding. With reduced bleeding, trauma, and correspondingly diminished drainage volume, the duration of chest tube placement is also shortened, leading to expedited patient discharge. Consequently, postoperative hospital stays for patients in the RATS group were notably shorter than those in the VATS group.

One of the common complications of mediastinal surgery is phrenic nerve injury, which can be as high as 7% when using certain energy equipment or when using blunt dissection [25]. By fully utilizing good energy devices and minimizing energy manipulation, it is best to set a sufficient distance between electric coagulation or electric cutting and the nerve to prevent heat damage postoperatively. The right thoracic approach generally displays the right phrenic nerve along the vena cava with minimal variation, whereas the left phrenic nerve can be clearly visualized and protected through the left thoracic approach. When tumors invade the phrenic nerve, it is typically possible to remove it entirely; while attempting to preserve the phrenic nerve as much as possible when the tumor invades it. The robotic anterior mediastinum tumor resection allows for a full, clear, and complete visualization of the phrenic nerve, and effectively reduces the likelihood of phrenic nerve injury. Some researchers have shown that the left-sided approach is better suited to protect the phrenic nerve, while it should be noted that a lack of familiarity with the placement of ports can lead to cardiac injury during left-sided thymectomy [26].

Innominate venous injury and bleeding during surgery is possible. When the patient is bleeding, especially from the left subclavian vein, identifying it is difficult. We usually use titanium clips, hom-look or 4 − 0 ETHI-CON barbed thread for continuous suture, and have achieved good results. When the tumor invades surrounding tissues, such as lung, left pericardium, pharyngeal muscle, or vessel, complete resection of the tumor with reduced surgical trauma to the patient can be achieved without an auxiliary hole, and the technique is feasible and reliable.

However, this study has some limitations, such as its retrospective nature and the fact that the technical procedure used depends on the surgeon and patient preferences. The small sample size may lead to selection bias.

In conclusion, this technique for the anterior mediastinum is safe and effective, and it offers the surgeon advice on treatment selection. Overall, the technique has several advantages.

Legends for illustrations:

Fig. 1: Port positions for robot-assisted thoracic surgery (RATS). Fig. 2: (A, B) Representative computed tomography images of 2 patients with anterior mediastinal lesion. (C, D) A 31-year-old woman underwent robot-assisted thoracic surgery on December16, 2019. Fig. 3: A, The innominate vein was carefully dissected just above the right phrenic nerve. B, When dissect the thymus superior, keep the anatomical triangle of the Internal thoracic vein, Internal thoracic artery and Superior Vena Cava as far as possible, and conduct the grips to dissect the thymus superior through this area. C, The Left Internal thoracic vein was carefully dissected. D, Sweep the thymus and reduce misdamage in Brachiocephalic Trunk. E, The contralateral phrenic nerve was carefully dissected. F, Remove all of the pericardial surface fat. Fig. 4: (A, B) Specimens harvested from AML patients after RATS.