Multidisciplinary surgical strategy for an invasive thymoma in an immunocompromised patient: a case of a successful resection and postoperative troubleshooting.

Background: Robot-assisted thoracoscopic surgery has become prevalent as a feasible approach for anterior mediastinal tumor resections, while conventional open surgery, such as a median sternotomy, remains preferred for a combined resection of adjacent organs. However, an additional thoracotomy may be necessary when tumors extend into one hemithorax. This complex approach can cause significant damage to the osseous thoracic cage, increasing the risk of surgical morbidity especially in immunocompromised patients.

Case presentation: A 77-year-old man presented with an anterior mediastinal thymoma measuring 71 mm, detected during an annual health check with suspected involvement of the left brachiocephalic vein and upper lobe of the left lung. The patient had a medical history of recurrent surgical site infections and fasciitis panniculitis syndrome requiring immunosuppressive therapy. To minimize any thoracic cage destruction, a multidisciplinary approach combining robotic surgery with open surgery according to vascular or pulmonary invasion was planned. The patient, initially placed in the supine position with the robot docked over the right side, underwent a thymic dissection, revealing a firm adhesion to the left brachiocephalic vein. The robot was then undocked, and a transmanubrial osteomuscular sparing approach was initiated, enabling a tumor dissection under the proximal and distal control of the left brachiocephalic vein. As invasion into the proximal upper pulmonary vein and extensive dorsal adhesions were observed, the patient was repositioned to the right lateral decubitus position, and a thoracoscopic left upper segmentectomy with adhesiolysis was performed, achieving an R0 resection. The patient was extubated on day 1 but required non-invasive ventilation until day 5. Mediastinitis, likely due to a sternal wire infection, developed on day 9, necessitating debridement, sternal wire removal, and negative pressure wound therapy. After 17 days of treatment, the infection subsided, allowing for a sequestrectomy and chest wall reconstruction with a pedicled pectoralis major myocutaneous flap. By avoiding a total sternotomy, the extent of the mediastinitis was localized, allowing for a limited sequestrectomy. Wound healing was satisfactory, with no recurrent infection at 12 months and minimal functional impairment.

Conclusions: A multidisciplinary approach offers a feasible option for managing an invasive thymoma to minimize postoperative morbidity, particularly in immunocompromised patients. Preoperative surgical planning is essential for guiding intraoperative decision-making and ensuring optimal outcomes.