Thymoma Resection in the Era of Minimally Invasive Surgery - Is There Still a need for Open Surgery?

Introduction
Thymomas are rare malignancies originating from the thymic epithelium. While the majority of
thymomas can be successfully treated by minimally invasive approaches like video-assisted thoracic
surgery (VATS) or robotic-assisted thoracic surgery (RATS), more advanced disease may still require
open surgery. Factors such as tumor size, invasion into adjacent structures, and oncologic safety play
a crucial role in determining the optimal surgical strategy. Accordingly, we compared the minimally
invasive to the open surgical approach regarding selection criteria, safety and outcome.

Methods
A retrospective study was conducted, including 28 patients from a single center, all of whom had a
preoperative diagnosis of thymoma. They underwent thymoma resection between 2022 and 2025.
Patients were divided into two groups: those who had open surgery (n = 10) and those treated with
minimally invasive surgery (VATS, n = 18). Postoperative outcomes were analyzed, including operation
time, tumor size, duration of drainage, length of hospital stay, and histological findings.

Results
A total of 28 patients were included in the study, with 18 undergoing minimally invasive surgery and
10 undergoing open surgery. Histological findings mainly included thymomas but also thymic cysts,
thymic hyperplasias and others.
Tumors in the open surgery group were significantly bigger (median size 8.2 cm) compared to the
VATS group (median size 4 cm; p < 0.01). The median duration of surgery was not significantly longer
in the open surgery group (162 min) compared to the VATS group (125 min, p < 0.265).
The number of drains used postoperatively was higher in the open surgery group, and the median
duration until removal was significantly longer (4 days vs. 1 days in the VATS group, p < 0.01).
The postoperative hospital stay was prolonged in the open surgery group (median: 5days) compared
to the VATS group (median: 3 days, p < 0.01). All tumor patients received microscopic complete (R0)
resection.
Conclusion
Open surgery remains a safe and effective method for treating extensive mediastinal disease, with
low complication rates and acceptable postoperative outcome. However, given the significantly
reduced drainage duration, and shorter hospital stay, minimally invasive surgery should be preferred
when possible.