Uniportal midline subxiphoid thymectomy: Our experience from a single oncology centre in India

ABSTRACT

Background:

Thymoma is the most common anterior mediastinal neoplasm in adults and often requires surgical resection for curative treatment. Traditional approaches, including open surgery and multiportal thoracoscopic techniques, are associated with significant morbidity. The uniportal subxiphoid approach offers a minimally invasive, patient-friendly alternative, with potential benefits in operative efficiency and post-operative recovery. This technique may be particularly advantageous in low-resource settings, given its simplicity and reduced need for specialized equipment or personnel.

Methods:

This study included 27 patients who underwent uniportal subxiphoid thymectomy at our institution between January 2022 and December 2024. The technique involves pre-operative planning based on tumour staging, with resections possible for tumours up to 15 cm. The patient is placed supine, with no carbon dioxide insufflation or epidural anaesthesia used. An incision below the xiphoid process provides access for tumour dissection, utilizing a thoracoscope. The thymoma is carefully removed through the incision, followed by a mediastinal drain placement.

Results:

In 27 patients, tumour sizes ranged from 2 to 15 cm. The mean operative time was 106.9 min, with minimal blood loss (46.7 mL). All procedures were R0 resections, with no conversions to open surgery. Post-operative pain was minimal, and the mean hospital stay was 2.6 days.

Conclusions:

The uniportal subxiphoid thymectomy is an effective, minimally invasive technique, offering excellent outcomes in terms of operative time, blood loss, and recovery. It provides a safe, efficient, and cost-effective alternative, especially for low-resource settings.

INTRODUCTION

Thymoma, a rare epithelial neoplasm of the thymus, is the most common anterior mediastinal mass in adults, accounting for up to 35% of such cases.[1] Its frequent association with autoimmune disorders—including myasthenia gravis, myositis, myocarditis, Grave’s disease, autoimmune hepatitis, limbic encephalitis, and pure red cell aplasia—adds complexity to both diagnosis and treatment planning.[2] Complete surgical excision (thymectomy) remains the cornerstone of curative-intent treatment, often supplemented by adjuvant therapies depending on stage and histology.[3] Early diagnosis and definitive surgical management are crucial for improving long-term outcomes.

In recent years, minimally invasive surgical techniques, such as video-assisted thoracoscopic surgery (VATS), have increasingly supplanted open surgery due to their advantages in reducing post-operative pain, shortening hospital stays, and achieving comparable oncological outcomes.[4] However, standard VATS approaches typically require lateral intercostal access, which carries risks of intercostal nerve damage, post-operative neuropathic pain, pneumothorax, and longer recovery—particularly problematic in patients with preexisting neuromuscular compromise, such as those with myasthenia gravis.

To address these limitations, we present our experience with a modified uniportal midline subxiphoid thymectomy, a technique that utilizes a single incision below the xiphoid process to access the anterior mediastinum without traversing intercostal spaces. This approach offers multiple advantages, particularly in resource-limited settings. It avoids intercostal nerve injury and muscle trauma, allows stable midline access for improved visualization, and eliminates the need for CO₂ insufflation—thereby minimizing the risks of respiratory or hemodynamic compromise. Additionally, suction can be used freely during the procedure for better field clearance without the concern of pressure-related complications.

What sets this technique apart is its feasibility and safety using standard instruments, without reliance on costly specialized equipment or large surgical teams. The procedure can be performed by a single surgeon and assistant, making it ideal for high-volume, low-resource oncology centres where operative efficiency and cost-effectiveness are paramount. By simplifying the surgical workflow while maintaining excellent exposure and resection quality, this technique aligns well with the needs of developing healthcare systems.

Although our sample size is modest (n = 27) and the analysis descriptive, this report adds to the evolving literature by demonstrating the practical implementation, safety, and effectiveness of this technique in a real-world, resource-constrained environment. Our aim is to share insights that may guide broader adoption of this approach in similar settings globally.

METHODS

This study included 27 patients who underwent uniportal subxiphoid thymectomy for thymoma and had subsequent follow-up at our institution between January 2022 and December 2024. Data were retrospectively retrieved from a prospectively maintained Thoracic surgery database at our centre.

This retrospective study was conducted using anonymized clinical data from patients who underwent uniportal subxiphoid thymectomy at our institution. As the analysis involved previously recorded data and did not require patient interaction or intervention, separate ethical approval was not required in accordance with institutional and national guidelines. However, all patients provided written informed consent before surgery. The consent process included a detailed explanation of the diagnosis, proposed surgical technique, potential risks and benefits, and available alternatives, conveyed in a language and format easily understood by the patient. Importantly, the consent also included permission for clinical data to be stored in a departmental database and used for research and publication purposes after anonymization.

Each case was discussed in a multidisciplinary team (MDT) meeting comprising thoracic surgeons, medical oncologists, anesthesiologists, and neurologists where applicable, to ensure personalized, evidence-based care. Patients were informed that the procedure involved a modified minimally invasive approach, and specific consent was obtained for this technique. This process ensured adherence to ethical standards, respect for patient autonomy, and transparent communication in line with best clinical practices.

Inclusion criteria

• Patients diagnosed with thymoma, of age group 18–70 years with good performance status (Eastern Cooperative Oncology Group: 0–2), regardless of tumour size (up to 15 cm), where thymectomy was indicated

• Patients with no major comorbidities preventing a minimally invasive approach

• Patients who consented to the modified uniportal subxiphoid thymectomy technique.

Exclusion criteria

• Patients with distant metastasis or other contraindications to surgery (e.g., severe cardiac or pulmonary conditions)

• Patients with tumours that could not be adequately resected using the uniportal subxiphoid approach due to size or extensive invasion of adjacent structures.

Our technique

Pre-operative planning

All patients underwent comprehensive pre-operative evaluation, including contrast-enhanced computed tomography of the chest and upper abdomen to characterize the primary thymic lesion, assess its anatomical relationships with adjacent mediastinal structures, and evaluate for local invasion. In selected cases, especially when metastatic disease was suspected or further staging was warranted, positron emission tomography-computed tomography was additionally performed to identify distant metastases and aid surgical decision-making [Figure 1].

Figure 1.

Chest computed tomography finding during the evaluation of anterior mediastinal mass (thymoma). (a) Well-circumscribed anterior mediastinal mass (black arrow) in the prevascular compartment. (b) Mass (white arrow) seen abutting the ascending aorta and main pulmonary artery without infiltration. (c) No pleural or pericardial infiltration by the mass (white arrow)

Each case was subsequently reviewed in a MDT meeting involving thoracic surgeons, medical oncologists, anesthesiologists, and neurologists (in patients with associated myasthenia gravis), to determine the most appropriate treatment strategy. Patients were planned for either standard thymectomy or extended/radical thymectomy based on tumour size, location, and clinical stage.

In addition to imaging, all patients underwent routine pre-anaesthetic work-up, including pulmonary function tests, electrocardiography, and echocardiography where indicated, to assess fitness for general anaesthesia and single-lung ventilation if required.

Our uniportal midline subxiphoid approach was designed to accommodate both standard and radical resections. Tumours up to 15 cm in size could be safely resected using this technique; in cases with larger tumours, the subxiphoid incision was extended to facilitate specimen retrieval. The single-port access provided sufficient working space for the use of energy devices, endoscopic staplers, and suturing instruments, allowing for effective and safe resection tailored to tumour complexity.

Preparation and patient positioning

Under general anaesthesia, the lung ventilation is provided through double-lumen endotracheal intubation, which can be converted to a single-lumen endotracheal intubation if needed. Artificial ventilation is performed using the pressure-controlled method. The patient is placed in the French position (supine with legs separated). Since our technique does not involve using a special port for the uniportal access, hypercapnia associated with carbon dioxide (CO2) insufflation is avoided. Epidural anaesthesia is not used.

Patient positioning

The French position (supine with legs separated) is preferred for this procedure, as it allows the operator to remain centrally aligned, facilitating optimal access to the surgical site. Both arms should be positioned at attention. The drape should cover the upper abdomen, the sternal notch, and extend to the mid-axillary line on both sides, ensuring comprehensive exposure of the surgical area for thorough access and precise dissection. This set-up accommodates potential adjustments during the procedure, especially in cases where conversion to a more extensive approach, such as sternotomy, becomes necessary.

Surgical procedure

Surgical incision

A vertical incision is made 1 cm below the xiphoid process [Figure 2a]. This incision can be easily extended for tumour removal if deemed necessary. Using an electric scalpel, the rectus abdominis is dissected from its attachment to the xiphoid process, followed by the removal the xiphoid sternum. An incision of approximately 5 mm is made caudally on the underlying rectus abdominis fascia, followed by a careful blunt dissection to create a retrosternal extraperitoneal plane, while avoiding breaching the peritoneum underneath.

Figure 2.

Our technique: Uniportal midline subxiphoid thymectomy. (a) Incision marked on the patient. (b) Operative set-up. (c) Instruments inside the port. (d) Closure of incision over mediastinal drain

One of the key advantages of using a vertical incision is that it allows for the preservation of the rectus muscle, which can help maintain the integrity of the abdominal wall and reduce post-operative complications related to muscle disruption. Additionally, if a sternotomy is required during the procedure, the vertical incision can be extended and seamlessly connected to the sternotomy incision, creating a continuous, well-aligned surgical pathway. This approach ensures a more efficient and cohesive surgical access, minimizing the need for additional incisions and enhancing overall operative convenience.

Instrumental set-up

The blunt end of a standard Czerny retractor is then inserted into this space. It is kept vertically suspended by tying to a retractor [Figure 2b]. This helps provide retrosternal retraction, obviating the need of CO2 insufflation. A Weitlaner self-retaining retractor is then inserted with the jaws closed and parallel to the margins of the incision. The jaws are then opened up and adjusted till adequate transverse exposure is achieved, followed by fixation of the jaws at that place. Two stay sutures using 0 Silk are taken to retract the skin and subcutaneous tissue over the jaws.

This set-up provides adequate exposure and space for insertion of multiple instruments into the thoracic cavity simultaneously [Figure 2c]. The surgeon stands between the legs of the patient during the surgery, while the assistant stands to the right of the patient to operate the thoracoscope. We usually use a rigid 10 mm thoracoscope with 30* oblique view.

Uniportal approach

The dissection is performed using the single subxiphoid incision, with no additional ports needed. There is no need for additional ports, making the procedure simpler and less invasive. The dissection is performed with a single port, and the lungs are ventilated alternately to ensure optimal exposure, avoiding the need for CO2 insufflation or the complications it may introduce. The use of a single incision not only reduces invasiveness but also this streamlined approach further minimizes surgical complexity while maintaining a clear surgical field for tumour removal.

Surgical dissection

The initial step involves the dissection of prepericardial fat off the pericardium [Figure 3a]. This is followed by standard thymectomy with lateral boundaries of dissection being from left phrenic [Figure 3b] to right phrenic nerve [Figure 3c], while safeguarding both of them. The superior margin of dissection is till the thyrothymic ligament. The thymic veins are then identified, clipped, and divided [Figure 3d]. When encountering the innominate vein during the dissection, the thymic tissue is carefully lifted to expose the vein. The dissection then proceeds along the front of the vein, allowing for controlled removal of the thymoma while preserving critical vascular structures. This method ensures thorough resection while maintaining the integrity of surrounding tissues, which is crucial for achieving clear margins and minimizing the risk of recurrence. The tumour is then dissected off the superior vena cava and left brachiocephalic vein [Figure 3e], following which the specimen in its entirety is delivered out, in an endo-bag, of the subxiphoid incision [Figure 3f].

Figure 3.

Intraoperative thoracoscopic views. (a) Pericardial fat (arrow) dissected off pericardium. (b) Left phrenic nerve (arrow). (c) Right phrenic nerve (arrow). (d) Thymic vein (arrow). (e) Tumour dissected off superior vena cava and left brachiocephalic vein (arrow). (f) Resected specimen in anatomical orientation

If there is suspicion that the thymic tumour may have invaded surrounding organs, these structures should be resected together to the greatest extent possible. In cases where both lungs are adherent or infiltrated by the tumour, the use of an endostapler is recommended for en bloc resection, allowing for the tumour and surrounding tissues to be removed as a single unit, rather than attempting to dissect the lungs away from the mass. This approach reduces the risk of damaging adjacent structures and ensures a more complete resection.

Haemostasis is ensured, followed by closure of the subxiphoid incision over a 28-F drain placed in the mediastinum [Figure 2d].

Fascial and wound closure technique

At the conclusion of the procedure, closure of the rectus abdominis fascia is performed meticulously to restore abdominal wall integrity and minimize the risk of post-operative herniation. The fascial defect is closed using either interrupted or continuous non-absorbable sutures, typically No. 1 or 2 loop nylon (polyamide), depending on the size of the incision and the surgeon’s preference. Loop nylon provides a secure, high-tensile strength closure, especially suitable for midline fascial repair. Care is taken to ensure precise edge-to-edge approximation without excessive tension.

In cases where a larger incision is required for specimen retrieval, layered closure is carried out, beginning with the posterior rectus sheath (if incised), followed by the anterior sheath using the same suture material. Subcutaneous tissue is approximated with absorbable sutures to reduce dead space and the risk of seroma formation. Skin closure is achieved using either subcuticular absorbable sutures or staples, based on the patient’s clinical profile and cosmetic considerations. A closed suction drain is placed if indicated, and patients are monitored post-operatively for wound healing and fascial integrity.

Post-operative care and follow-up

Early ambulation and physiotherapy are encouraged to support optimal recovery. The chest drain is usually removed by post-operative day 2 following complete expansion of bilateral lungs as seen on a chest radiograph. The patients are usually discharged on the day of drain removal once repeat radiograph following the removal shows no signs of pneumomediastinum or pneumothorax. All these patients were followed up three monthly for the first two years, as per the institutional protocol.

Advantages of this approach: Uniportal midline subxiphoid thymectomy

The uniportal midline subxiphoid thymectomy technique presents numerous advantages, particularly in terms of reducing surgical trauma and improving patient outcomes. By utilizing a single small incision below the xiphoid process, this technique minimizes the need for larger incisions and avoids the complications associated with lateral thoracic incisions, such as intercostal nerve damage, pneumothorax, and muscle weakness. These lateral incisions are traditionally more prone to complications, including nerve injury and prolonged recovery, making the subxiphoid approach a safer alternative.

Additionally, the midline subxiphoid approach is inherently physiologically optimal. Since the incision is made along the natural anatomical line of the body, it is associated with lower complication rates compared to incisions made in the lateral thoracic or intercostal regions. This is particularly important as it reduces the risks of wound infections, bleeding, and delayed healing. The midline also allows for more stable retraction and better exposure of the thymus, facilitating complete tumour resection with minimal dissection of adjacent structures.

Since CO2 insufflation is not required in this technique, suction can be used freely throughout the procedure, allowing for better visualization and easier removal of debris without the risk of increased intra-thoracic pressure. Additionally, the absence of CO2 flow significantly reduces the risk of cardiac and pulmonary compromise, as there is no need to manage the effects of CO2 insufflation on haemodynamics and respiratory function. This provides a safer environment for the patient, as it minimizes the potential for adverse effects such as CO2 retention, respiratory acidosis, or cardiovascular instability, which are common concerns in traditional minimally invasive procedures.

A further advantage of this technique is its efficiency in reducing the number of surgeons and required resources. With only one small port, this approach can be performed by a primary surgeon and a single assistant, reducing the need for additional surgical staff. This makes the procedure particularly useful in low-resource settings, such as in India, where specialized surgical teams may not always be available. The simplicity of the approach, coupled with the minimal instrumentation required, allows for the surgery to be performed with fewer resources while maintaining safety and efficacy.

The technique also remains cost-effective, as it requires only standard, readily available instruments, avoiding the need for expensive specialized ports or equipment. This can significantly reduce the financial burden on patients and healthcare systems, especially in low-resource countries. The ease of performing this procedure with fewer staff and resources, combined with its excellent oncological and recovery outcomes, makes it an ideal option for hospitals in low-resource settings, while still maintaining high standards of care.

RESULTS

A total of 27 patients were taken up for uniportal subxiphoid approach using midline incision. The demographic characteristics of the patients are described in Table 1. There were 17 males and 10 females with mean age of 47.20 (range 16–69). Four of these patients had myasthenia gravis as well, whereas one patient had both myasthenia gravis and pure red cell aplasia associated with thymoma. The majority of our patients according to the Masaoka staging[5] were having Stage I disease (13 patients) with seven patients belonging to Stage II, six patients in Stage III, and one patient having Stage IV disease.

Table 1.

Patient parameters (n=27)

Parameters	Mean (Range)
Age mean (range)	47.2 (16–69)
Sex (male/female)	17:10
Diagnosis
Thymoma	27
Associated autoimmune conditions
MG	4
MG with pure red cell aplasia	1
Others	0
Masaoka staging[5]
I	13
II	8
III	6
IV	0
Received neoadjuvant chemotherapy (yes/no)
No	27

MG=Myasthenia gravis

The intraoperative findings are summarized in Table 2. The mean tumour size was 6.04 cm (range 2–15 cm) [Figure 4], with 10 out of the 27 patients having structures adherent to the tumour requiring additional dissection. Tumour was delivered completely intact in all the 26 patients who underwent thymectomy. The mean operative time was 106.9 min (range 65–155) with the mean blood loss being 46.7 mL (range 20–200). No patient required any blood transfusion. All 27 patients had a mediastinal drain inserted.

Table 2.

Intraoperative findings, immediate post-operative outcomes, follow-up details, histopathological parameters

Operative findings	Mean (range)
Incision length (cm)	4.4 (4–6)
Size of tumour (in cm)	6.04 (2–15)
Adhered to surrounding structures? (yes/no)
Yes	10
No	17
Structures involved (n=10)
Phrenic nerve	4
Pleura	1
Lung	4
Pericardium	0
Heart	0
Great vessels	0
Tumour specimen delivered intact? (yes/no)
Yes	27
Operative time (in min)	106.9 (65–155)
Blood loss (in mL)	46.7 (20–200)
Blood transfused? (yes/no)
Yes	0
No	27
ICD inserted (yes/no)
Yes	27
No	0
Post-operative findings	Mean (range)
Post-operative stay (days)	2.6 (2–4)
Post-operative pneumonia	None
Post-operative fever	None
Post-operative lung expansion on chest X-ray	All
Surgical site infection	None
ICD removed on POD2 (yes/no)
Yes	27
No	0
Need for epidural analgesia	None
Pain on post-operative day 1 (VAS)	4.96 (4–6)
Pain on post-operative day 2 (VAS)	2.72 (2–4)
Pain on discharge (VAS)	2.46 (2–3)
Follow-up findings	Mean (range)
Pain on post-operative day 5 (VAS)	1.76 (1–3)
Pain on follow-up two weeks (VAS)	1.33 (1–2)
Surgical site infection	None
30-day mortality	None
Final histopathological status
Diagnosis (n=27)
Thymoma	27
Others	0
WHO grade of thymoma (n=27)
A	1
AB	2
B1	14
B2	8
B3	2
C	0
Resection status (n=26)
R0	27
R1	0
R2	0

ICD=Implantable cardioverter-defibrillator, VAS=Visual analog scale, POD=Post-operative day, WHO=World Health Organization

Figure 4.

A large tumour (10 cm × 12 cm) removed through the subxiphoid approach

The post-operative findings are described in Table 2. In all patients, the mediastinal drain was removed on post-operative day (POD) 2, with the mean post-operative hospital stay being 2.6 days (range 2–4 days). There was no need for epidural analgesia in any patient with intravenous analgesics given for the first two post-operative days and then tapered to oral analgesics for 10 days. Assessment of pain was performed using the visual analogue scale. Pain at POD1 on mean was 4.96 (range 4–6), which fell to 2.46 (range 2–3) when the patient got discharged. On follow-up, the pain was 1.33 (range 1–2). There were no instances of post-operative fever, pneumonia, or surgical site infection.

Based on final histopathological status, all 27 suspected patients were confirmed to have thymoma with the most common World Health Organization grading being B1 (14 patients), followed by B2 (eight patients). All of which had their margins cleared, thus undergoing an R0 resection.

All patients were followed up every three months for the first two years as per institutional protocol. There was no 30-day or 90-day mortality, and no major morbidity (Clavien–Dindo Grade III or IV) was observed within 30 or 90 days of surgery.

DISCUSSION

In this study, we describe our early institutional experience with a modified uniportal midline subxiphoid thymectomy, a pragmatic adaptation of the minimally invasive approach, designed to optimize outcomes in a resource-limited, high-volume oncology centre. This technique utilizes a single subxiphoid incision to allow bilateral pleural access and adequate visualization for en bloc resection, without requiring advanced robotic platforms or multi-port access. Although the sample size is modest (n = 27) and the analysis descriptive, we aim to highlight the feasibility, safety, and patient-centric advantages of this cost-effective technique, especially in low-resource settings. Our findings add to the evolving literature by demonstrating that such an approach is implementable and well-tolerated, even outside highly resourced environments.

The earliest documented VATS subxiphoid approach for benign anterior mediastinal masses was described by Kido et al. in 1999, which required an additional transcervical approach for resection of thymic lesions.[6] While more invasive than modern techniques, it was still a significant advancement over the traditional median sternotomy, offering reduced invasiveness and faster recovery times. The continued evolution of surgical instruments and techniques has contributed to the development of subxiphoid VATS thymectomy as a feasible and effective alternative to the lateral intercostal VATS approach. This method has been shown to produce comparable oncological outcomes, while avoiding the risks of intercostal nerve damage. In addition, it leads to less need for analgesics, reduced surgical duration, less blood loss, and shorter hospital stays, all of which contribute to enhanced patient satisfaction. Furthermore, the subxiphoid approach provides superior cosmetic outcomes, which are particularly important for patients seeking a minimally invasive procedure with minimal visible scarring.[7]

While uniportal subxiphoid approaches for thymectomy have been described by several surgeons, there are numerous factors that have limited their widespread adoption, particularly in low-resource settings.[8,9,10,11,12,13] Most of these techniques involve the use of special uniports to facilitate CO2 insufflation, a process that increases the working space for the thoracoscopic instruments. However, this also reduces the flexibility of instrument use and can limit the range of tools available for surgery. Additionally, such ports may increase the overall cost of the procedure, as they often require specialized equipment that may not be easily accessible in certain clinical environments. Kang et al. proposed a modification of this approach that eliminates the need for CO2 insufflation, using a sternal wire with a wound retractor to achieve adequate exposure.[11] Although more accessible compared to previous methods, this approach still comes at a high cost due to the disposable wound retractor required.

While Jia et al. described a subxiphoid video-assisted thoracoscopic extended thymectomy with sternal suspension to improve the surgical field, we simplify the procedure further by eliminating the need for sternal suspension and CO2 insufflation.[12] This reduction in complexity leads to fewer steps and less equipment, which can be particularly beneficial in low-resource settings. Additionally, our approach involves a single vertical incision below the xiphoid process, which allows for a direct and minimally invasive path to the thymus without the need for multiple ports or manipulation of the sternum. This results in reduced post-operative pain, quicker recovery, and fewer complications such as lung damage or adhesions.

While Jia et al.’s technique provides a flexible surgical field through the use of multiple observation ports, our method maintains a high level of efficiency and safety with minimal invasiveness, providing equally effective outcomes with fewer risks. Overall, our approach offers a simpler, more cost-effective, and patient-friendly alternative to the extended thymectomy technique described by Jia et al. Furthermore, unlike Jia et al.’s technique, which may leave multiple scars due to the use of multiple ports, our single-incision approach minimizes scarring and improves aesthetic outcomes for patients.[12]

Cho described an operative technique for VATS thymectomy using a subxiphoid approach, which involves CO2 insufflation and a multiport set-up.[13] In contrast, our modified technique eliminates the need for CO2 insufflation, reducing risks of cardiac and pulmonary compromise. We use a single vertical incision below the xiphoid process, offering direct access with minimal post-operative pain due to no injury to intercostal nerves. This simplified approach streamlines the procedure, avoids unnecessary complications, and is particularly advantageous in low-resource settings. By maintaining excellent oncological outcomes while improving patient comfort, our method offers a safer, more efficient alternative for thymectomy.

Our modified technique addresses many of these challenges. By efficiently lifting the sternum without the need for an additional incision, we minimize the occupation of port space, which allows for better manoeuvrability of the surgical instruments. The procedure also avoids the need for specialized uniports or CO2 insufflation, which reduces both complexity and costs. Moreover, most of the instruments required for this technique are readily available in the operating theatre, further reducing the financial burden. We have reported favourable early outcomes with this technique in the 26 patients who underwent thymectomy using our approach, all of whom were successfully treated without conversion to open surgery. There were no significant intraoperative or post-operative complications, and the oncological clearance was adequate.

Although this is a retrospective study conducted at a single institution, the promising results support the potential of this technique for broader use. Further multi-centric prospective studies are needed to assess the medium- and long-term outcomes of patients undergoing thymectomy with this approach. Such studies will help to establish its efficacy, safety, and overall impact on patient outcomes, and could pave the way for more widespread adoption of this technique in both high- and low-resource settings.

CONCLUSIONS

The uniportal midline subxiphoid thymectomy technique offers a safe, cost-effective, and patient-friendly alternative to traditional intercostal and multiportal approaches. It enables complete resection of large thymic tumours—up to 15 cm in size—through a single incision, without compromising oncological principles or increasing procedural costs. By avoiding intercostal spaces, it reduces the risk of nerve injury and post-operative pain, while maintaining excellent visualization and operative access. Given its simplicity, minimal resource requirements, and favourable outcomes, this approach should be considered a viable and practical option, particularly in low-resource settings and high-volume cancer centres.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.