The expanding role of robotic surgery in thymectomy: a narrative review

Introduction

Background

Surgical resection for thymic epithelial tumors has traditionally been performed via a median sternotomy or video-assisted thoracoscopic surgery (VATS). In recent years, however, robot-assisted thoracoscopic surgery (RATS) has been increasingly adopted as a minimally invasive alternative, with a growing number of reports.

Rationale and knowledge gap

Robot-assisted thymectomy has gained increasing attention as a minimally invasive surgical approach with potential advantages in precision and safety over conventional methods (1-3). However, existing reviews have largely discussed RATS within the broader context of minimally invasive thymic surgery. Consequently, RATS thymectomy has often been evaluated primarily in terms of perioperative feasibility or short-term outcomes, with limited integration of its historical development, accumulated oncologic evidence, and future potential.

Objective

In this review, RATS thymectomy is examined as an independent and evolving surgical modality. We provide a comprehensive narrative synthesis of current evidence regarding its safety and oncologic validity, outline the historical evolution of robotic thymic surgery, and discuss future perspectives, including technological advancements, expanding surgical indications, and unresolved clinical issues. By adopting this integrated and longitudinal framework, this review aims to clarify the current role of RATS thymectomy and to highlight its potential future impact on the management of thymic disease. We present this article in accordance with the Narrative Review reporting checklist (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-67/rc).

Methods

This narrative review was conducted through a structured literature search of PubMed, including articles published up to November 2025. The search strategy combined the terms (“thymectomy”[MeSH] OR thymectomy) AND (“video-assisted thoracoscopic surgery” OR VATS OR “robot-assisted thoracoscopic surgery” OR RATS OR “robotic surgery”). Eligible articles included original clinical studies, comparative analyses, large case series, and selected case reports evaluating robotic approaches to thymectomy. Both retrospective and prospective studies were considered. Non-English-language publications were excluded. Reference lists of relevant articles were also manually screened to identify additional pertinent studies. Given the narrative nature of this review, no formal meta-analysis was performed (the detailed search strategy is provided in Table 1).

Results

History of robotic surgery in thymectomy

RATS has undergone remarkable development since its first clinical application for thymic tumors (key representative studies are summarized in Table 2). The world’s first robot-assisted thymectomy was reported by Yoshino et al. in 2001, demonstrating the safety and technical feasibility of using the da Vinci Surgical System (Surgical Intuitive, Sunnyvale, CA, USA) for mediastinal surgery (4).

Following this pioneering work, over the next two decades, numerous studies from the United States and Europe compared RATS with conventional VATS and open approaches (1,5-9). A substantial proportion of these studies demonstrated advantages associated with RATS thymectomy, which in turn supported its clinical use and promoted its broader adoption (13).

Nevertheless, the rarity of thymoma has historically constrained the clinical evidence base to relatively small study populations. Accumulating data from larger and multicenter experiences have helped clarify the surgical feasibility and oncological validity of the RATS approach. In this context, Comacchio et al. reported a large multicenter study evaluating both early and long-term outcomes of RATS thymectomy for thymic epithelial tumors, demonstrating that the procedure is technically reliable and safe, with low perioperative morbidity and favorable oncological outcomes (2).

More recently, technical refinements and the introduction of next-generation robotic systems (such as the da Vinci Xi and SP) have further expanded the indications for robotic thymectomy (14). Current RATS system provides a three-dimensional, high-definition magnified view that enables precise identification and dissection of vessels and phrenic nerves, facilitating safer and more complete thymectomy. The articulating instruments offer enhanced dexterity with seven degrees of freedom, allowing delicate maneuvers in the narrow and deep mediastinal space where conventional thoracoscopic instruments have limited mobility. Moreover, tremor filtration and motion scaling functions further enhance surgical precision, while surgeon-controlled camera operation provides a stable and consistently optimal field of view, independent of an assistant’s handling.

Current evidence comparing the outcomes of minimally invasive procedures including robot-assisted thymectomy and conventional transsternal approaches

Current comparative evidence generally demonstrates that RATS offers perioperative outcomes that are comparable or superior to those of open surgery, including reduced blood loss, shorter duration and lower volume of postoperative pleural drainage, and decreased length of hospital stay (5). Moreover, when RATS and VATS are considered together as minimally invasive approaches, no consistent increase in margin positivity, or short-term mortality has been observed compared with open surgery (6). Regarding long-term outcomes, 5-year overall survival also appears comparable between minimally invasive and open approaches; however, oncologic results beyond 10 years have yet to be fully clarified (5,6).

Current evidence comparing the outcomes of VATS and RATS thymectomy

Overall, current comparative data indicate that RATS thymectomy and VATS thymectomy provide comparable oncologic outcomes while RATS tends to show modest advantages in several short-term recovery metrics. Specifically, single-institution comparative series reported that RATS was associated with reduced intraoperative blood loss, lower postoperative pleural drainage volume and shorter duration of drainage, and a shorter postoperative hospital stay compared with VATS (2).

Zhu et al. compared perioperative outcomes between RATS and VATS thymectomy in patients with large thymic epithelial tumors (≥5.0 cm) (9). In their series, RATS was associated with a significantly shorter operative time and substantially lower intraoperative blood loss compared with VATS. No conversions to open surgery occurred in the RATS cohort, whereas five conversions were required in the VATS group. The rate of concomitant resections was comparable between the two approaches. Furthermore, no significant differences were observed in chest tube duration, postoperative complications, or length of postoperative hospital stay (7).

Large database analyses with propensity matching have generally found no significant differences between RATS and VATS in terms of mean hospital stay, margin positivity, 30-day readmission rates, or short-term (30–90 days) mortality. However, robotic approaches have been associated with fewer conversions to open surgery compared with VATS. Additionally, no differences in 5-year overall survival have been observed between the two approaches (4).

Meta-analytic summaries of available comparative studies similarly indicate that RATS is associated with less estimated blood loss, fewer postoperative drainage days and lower drainage volumes, a shorter hospital stay, and a lower overall postoperative complication rate versus VATS, with no consistent difference in operative time or rates of myasthenia gravis between groups (5). These pooled results support faster postoperative recovery after RATS, although the magnitude of benefit is generally modest.

Taje et al. compared the ergonomic characteristics of robotic versus thoracoscopic thymectomy and reported that the robotic group achieved a higher total maneuverability score, particularly in peri-thymic fat dissection and exposure (1). In addition, robotic thymectomy demonstrated superior intraoperative safety, with significantly fewer adverse events—mainly minor parenchymal bleeding requiring only conservative management—suggesting greater ergonomic precision compared with thoracoscopic surgery. However, no significant differences were observed between the groups regarding operative morbidity, residual disease, major intraoperative adverse events, or conversion rates (6).

Various approaches to robotic thymectomy

Unilateral/bilateral approach

Unilateral and bilateral approaches have been widely adopted in VATS thymectomy. In the early era of robotic surgery, these same approaches were also commonly employed in robotic thymectomy (15) and continued to gain popularity as the use of RATS expanded. As noted above, the robotic platform offers several advantages over VATS, including superior visualization, enhanced instrument dexterity, and greater surgical precision, which may contribute to improved safety and completeness of resection.

Subxiphoid approach

The robotic subxiphoid approach was first described by Suda et al., who demonstrated its feasibility and safety in performing thymectomy (16). Compared with the conventional lateral approaches, the subxiphoid approach provides a wider operative field, enables simultaneous visualization of both phrenic nerves, and facilitates safe and complete dissection of the upper poles of the thymus (17). A propensity-score matched analysis demonstrated that the robotic subxiphoid approach was associated with better early outcomes—specifically, shorter hospital stays and less postoperative pain—compared with robotic lateral thymectomy (18).

Single port approach

da Vinci Xi system

In recent years, several reports have described uniportal robot-assisted thoracoscopic surgery (U-RATS) using the da Vinci Xi system (19,20). Suda et al. described the techniques for performing uniportal robotic thymectomy using a subxiphoid approach (SURT) with the da Vinci Xi system and demonstrated its effectiveness (21). The subxiphoid uniportal approach does not require port insertion through the intercostal space; therefore, it theoretically avoids intercostal nerve injury and reduces postoperative pain (22). However, further data are warranted to confirm this hypothesis. SURT combines the minimal invasiveness of single-port surgery with the superior operability of robotic technology, addressing one of the limitations of conventional robotic surgery—the need for multiple ports. However, because all instruments are introduced through a single incision of less than 4 cm, instrument interference can become a significant issue. They note that further technical refinements are required to limit the range of motion of the left and right robotic arms during SURT.

da Vinci SP system

With the advent of the da Vinci SP system, emerging reports have highlighted its potential to advance single-port RATS beyond the technical limitations of the conventional da Vinci Xi platform, thereby opening new possibilities in thoracic surgery. This system enables the insertion of a fully wristed three-dimensional camera and three articulating instruments through a single 2.5-cm cannula, thereby minimizing intercostal nerve injury and reducing postoperative pain. A recent study demonstrated the feasibility and safety of performing thymectomy via a subxiphoid incision using the da Vinci SP system, with no conversions to other minimally invasive or open approaches (23). In malignant cases, the rate of complete resection was 100%, and no intraoperative or serious adverse events occurred. Furthermore, no unanticipated device-related adverse effects were reported. These outcomes suggest that this approach may serve as a viable alternative to conventional multi-port robotic or lateral thoracic approaches. Further refinement and studies with larger cohorts, standardized protocols, and long-term follow-up are required to validate oncologic efficacy and define the indications clearly. Despite these promising advances, several disadvantages of SP systems have limited their widespread adoption. These include their high cost and restricted procedural capabilities, which reduce overall versatility. Moreover, obtaining a clear view of the narrow neck area using a flexible endoscope camera remains challenging, indicating that further technological refinement is required to facilitate broader clinical integration (24).

Robotic thymectomy using systems developed by companies other than Intuitive Surgical

Although robotic platforms from companies other than Intuitive Surgical—such as the Hugo RAS system (Medtronic plc, Minneapolis, MN, USA), the SHURUI Single-Port Surgical Robot (Beijing Surgerii Robotics Co., Ltd., Beijing, China), the Saroa Surgical System (Riverfield Inc., Tokyo, Japan), and the hinotori Surgical Robot System (Medicaroid Corporation, Kobe, Japan)—are beginning to gain traction in thoracic surgery, their application in thymectomy has not yet been reported.

How far can robotic thymectomy go?

Large tumors

The optimal tumor size for minimally invasive thymectomy remains a matter of debate. Earlier experiences with VATS approach suggested that safe resections were limited to thymomas smaller than 3 cm (25). Girard et al. further demonstrated that the improved three-dimensional visualization and instrument dexterity of the robotic platform allow for safe resection of thymomas up to approximately 4 cm in diameter (26). More recently, several groups have reported successful robotic resections of even larger thymomas. Keijzers et al. described robotic resection of thymomas with a median diameter of 5.1 cm, including advanced stage III/IVa cases (27). The multicenter European study by Marulli et al. included patients with thymic tumors up to 10 cm (28). Huang et al. performed a retrospective single-center study comparing outcomes of robotic-assisted extended thymectomy between patients with large (≥5 cm) and small thymomas. Except for a longer operative time in the large thymoma group, surgical and postoperative outcomes were similar. Midterm oncological outcomes, including 5-year overall and recurrence-free survival, were also comparable between the two groups (29). Large tumor size is not necessarily an absolute contraindication to the robotic approach.

Extended thymectomy

Traditionally, median sternotomy has been the most widely adopted approach for performing extended thymectomy in patients with myasthenia gravis, as it allows complete removal of thymic and perithymic tissue (30,31). In recent years, RATS has gained increasing popularity as a minimally invasive alternative. Freeman et al. reported long-term outcomes of RATS thymectomy for nonthymomatous MG in 75 patients, with a mean follow-up of 45±14 months. Significant clinical improvement was observed in 87% of patients, including complete stable remission in 28%, pharmacologic remission in 25%, and minimal manifestations in 47%. No patient experienced worsening of MG symptoms postoperatively (10).

Sicolo et al. conducted a multicenter study comparing RATS and open thymectomy in patients with myasthenia gravis. They demonstrated that robotic thymectomy was associated with shorter hospital stays and lower postoperative complication rates, despite a longer operative time, with no significant differences in neurological or oncological outcomes (32).

Vascular replacement

Suda et al. reported a case of vascular prosthetic replacement of the left brachiocephalic vein performed via a subxiphoid robotic-assisted thymectomy, demonstrating the feasibility and safety of this approach even in complex cases involving great vessel invasion, and highlighting its potential as a minimally invasive alternative for extended thymic resections (33).

Phrenic nerve reconstruction

During thymectomy, en bloc resection of the phrenic nerve is recommended when the nerve is encased by the tumor, except in patients with poor respiratory function or symptomatic myasthenia gravis, as attempting to dissect the nerve from the tumor carries a high risk of local recurrence even with adjuvant radiotherapy (34). Phrenic nerve reconstruction represents an effective treatment for respiratory dysfunction caused by unilateral phrenic nerve paralysis and provides outcomes comparable to those of diaphragmatic plication (35). Several studies have reported phrenic nerve reconstruction with peroneal nerve grafts performed under a magnifying loupe or microscope during open surgery (36). Tamagawa et al. reported a first case of phrenic nerve reconstruction by interposing an intercostal nerve graft during robot-assisted thymectomy (37). It was demonstrated that robotic assistance facilitated meticulous dissection and precise anastomosis of the intercostal nerve graft. The enhanced visualization and magnification, combined with the superior instrument dexterity and fine control provided by the robotic system, were particularly advantageous for performing phrenic nerve reconstruction.

Resection of neighboring organs

Some reports have addressed the resection of the pericardium and other adjacent organs in the context of robotic thymectomy. For example, Kodia et al. described a case of a 9-cm thymoma treated via robotic thymectomy, including pericardial repair using a Gore-Tex Preclude pericardial membrane sutured with non-absorbable 0 V-Loc suture, and a partial lung resection performed with a robotic stapler (38). Yang et al. reported a similar case of locally advanced thymic carcinoma in which partial lung resection was performed with a robotic stapler, whereas the pericardium was resected and subsequently reconstructed with a PTFE membrane secured with a running 3-0 polypropylene suture (39). These findings suggest that en bloc resection of neighboring structures of the thymus can be achieved via a robotic-assisted approach.

Challenges to the adoption of RATS

There are several hurdles to the implementation of RATS in clinical practice. One major obstacle is the learning curve associated with robotic thymectomy. Kamel et al. suggested that an initial experience of approximately 15–20 robotic thymectomy cases is required before a significant reduction in operative time and intraoperative blood loss can be achieved, indicating that a period of adaptation is necessary for surgeons to perform RATS thymectomy proficiently (11).

In addition, cost remains a substantial barrier to widespread adoption. Several studies have reported that robotic thymectomy is associated with higher hospitalization or procedural costs compared with conventional thoracoscopic approaches, largely due to the initial capital investment for the robotic platform, ongoing maintenance expenses, and the cost of disposable instruments. Although these increased costs may be partially offset by shorter hospital stays and lower rates of postoperative complications or reoperations, robust cost-effectiveness data remain limited, and no definitive conclusions can be drawn at present (12,40).

Conclusions

The increasing body of evidence on robot-assisted thymectomy suggests continued technical advancement and a gradual expansion of its indications, including complex and extended procedures. Current data indicate that, when performed by experienced surgeons, robotic thymectomy is a safe and oncologically sound approach with favorable perioperative outcomes.

Nevertheless, as a relatively new surgical technique, adequate surgeon training, institutional experience, and careful patient selection remain essential to achieve proficiency and ensure optimal results. Further high-quality multicenter studies with standardized protocols, long-term oncological follow-up, and robust cost-effectiveness analyses are warranted to better define the role of robotic thymectomy and to facilitate its responsible integration into routine clinical practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-67/rc

Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-67/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-67/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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