Balance-Shaped Sternal Elevation-Assisted Uniportal Subxiphoid VATS for Thymoma with Persistent Left Superior Vena Cava: A Case Report

The subxiphoid approach for video-assisted thoracoscopic surgery (VATS) thymectomy offers a midline view but is constrained by the limited retrosternal space. This limitation is accentuated in cases with complex vascular anatomy, such as a persistent left superior vena cava (PLSVC). We describe and evaluate a novel balance-shaped sternal elevation technique designed to overcome this spatial challenge. A 52-year-old male with a 6.3 cm anterior mediastinal mass and a concomitant PLSVC underwent uniportal subxiphoid VATS thymectomy. A percutaneous suspension system utilizing a balance-shaped retractor was employed to indirectly elevate the sternum via subcutaneous tunnels, thereby expanding the anterior mediastinal operating domain without direct bone contact. The procedure's safety profile, including preventive measures against skin injury, is discussed. The sternal elevation technique increased the retrosternal space from a preoperative computed tomography (CT)-measured average of 3.5 cm to 8.2 cm intraoperatively (135% increase). This provided simultaneous and clear visualization of both the right superior vena cava and the PLSVC. The thymoma, located 0.8 cm from the PLSVC, was successfully dissected free. The procedure was completed in 58 minutes with 5 mL blood loss. No chest tube was required. The patient reported minimal pain (Visual Analog Scale (VAS) score 1 on postoperative day 1) and was discharged on day 3. Final pathology confirmed a type AB thymoma. No skin or soft tissue complications occurred at the suspension sites. The balance-shaped sternal elevation technique is a safe and effective adjunct to uniportal subxiphoid VATS in selected cases with complex anterior mediastinal anatomy, such as those with major venous anomalies. While its applicability may be limited to VATS and requires dedicated equipment, it significantly improves exposure in anatomically challenging scenarios and may serve as a valuable rescue technique when conventional methods prove inadequate.