Comparison of Open Thoracotomy, Video-Assisted Thoracoscopic Surgery, and Robot-Assisted Thoracoscopic Surgery for Resection of Mediastinal Tumors in Pediatric Patients

Comparison of Open Thoracotomy, Video-Assisted Thoracoscopic Surgery, and Robot-Assisted Thoracoscopic Surgery for Resection of Mediastinal Tumors in Pediatric Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Open Thoracotomy, Video-Assisted Thoracoscopic Surgery, and Robot-Assisted Thoracoscopic Surgery for Resection of Mediastinal Tumors in Pediatric Patients Miaomiao Sun, Sijia Guo, Chen Wang, Kang Li, Yongzhong Mao, Yong Wang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7957331/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Dec, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 11 You are reading this latest preprint version Abstract This study aims to compare the clinical outcomes of robot-assisted thoracoscopic surgery (RATS), traditional video-assisted thoracoscopic surgery (VATS), and open thoracotomy (OT) in children with mediastinal tumors, while also evaluating the technical advantages associated with RATS. This study conducted a retrospective analysis of clinical data from 184 pediatric patients who underwent surgery for mediastinal tumors at our center between December 2014 and January 2025. Baseline characteristics, surgical technical parameters and perioperative outcomes were compared among the three groups.184 patients were identified, all surgeries were completed successfully, with no recorded perioperative deaths. There were no significant differences in baseline characteristics. The length of hospital stay for minimally invasive group was significantly shorter than for OT group. The intraoperative blood loss in minimally invasive group was significantly less than in OT group. Total hospital charges for RATS were significantly higher than for VATS and OT groups. Mean usage of diclofenac sodium suppositories for postoperative analgesia was lowest in RATS group, significantly lower than that in other groups. Multivariate analysis indicated significant influences on hospital stay, including operative time, blood transfusion, chest tube duration, age, and surgical approach. RATS demonstrates superior perioperative outcomes compared to VATS and OT in the management of mediastinal tumors in pediatric patients. Key advantages include shorter chest drainage time and length of hospital stay, lower rates of postoperative complications and postoperative pain. However, RATS is associated with higher treatment costs. Robotic surgery Minimally invasive Mediastinal tumor resection Pediatric surgery Figures Figure 1 Introduction Mediastinal tumor is a prevalent type of thoracic tumor in children, accounting for approximately 7% of malignant tumors within this population, and surgical resection is the preferred treatment for most benign tumors and for malignant tumors, excluding lymphomas[ 1 ]. Traditional open thoracotomy (OT) has long been regarded as the "gold standard" for mediastinal tumor resection[ 2 ]. However, with the rapid advancement of minimally invasive techniques and the progress in single-lung ventilation anesthesia for children, Video-assisted thoracoscopic surgery (VATS) and, more recently, robotic-assisted thoracoscopic surgery (RATS), have increased in popularity and benefit patients by reducing incisional trauma and postoperative pain, among other outcomes[ 3 , 4 ]. The mediastinum possesses a complex anatomical structure, lying in proximity to vital organs such as the heart, great vessels, trachea, and esophagus[ 5 ]. relatively narrow mediastinal space in children, along with the diverse tissue origins of these tumors, complicates complete tumor resection for pediatric surgeons. It is critical for surgical teams to avoid damaging adjacent vital structures during the procedure[ 6 ]. OT approach can provide an adequate surgical field and ample operating space[ 7 ], however, it typically necessitates a large incision, which may require cutting through chest wall muscles or even dividing ribs for sufficient exposure. Consequently, these steps can result in significant drawbacks, including substantial trauma, increased bleeding, severe postoperative pain, prolonged recovery times, prominent chest scars, and potential chest wall deformities[ 1 ]. Minimally invasive surgery offers several advantages, including minimal trauma, rapid recovery, reduced postoperative pain, and improved cosmetic outcomes. The robotic platform has overcome some inherent technical limitations of conventional thoracoscopic techniques. For example, a VATS approach requires a surgeon to contend with suboptimal angles, using chopstick instrumentation, rather than the increased flexibility with multi-degree-of-freedom robotic arms on the robotic platform[ 8 ]. Besides, the thoracoscope’s two-dimensional image limits depth perception, whereas the three-dimensional visualization of the robotic platform can enhance the surgeon's visibility[ 9 ]. In 2001, Yoshino et al[ 10 ] reported the first robot-assisted resection of a mediastinal thymoma, establishing a foundation for precise robotic applications in confined mediastinal spaces. Subsequently, in 2008, Meehan et al[ 11 ] pioneered the use of the da Vinci robotic system for mediastinal tumor resection in pediatric patients. Their initial experience highlighted significant potential benefits, particularly in performing complex procedures within the narrow thoracic cavities of this population. Although RATS has gained widespread acceptance in adult thoracic surgery, its application in treating mediastinal tumors in children remains limited. Current research primarily consists of small case reports or single-center experiences[ 12 ], and large-scale, systematic comparative studies are notably lacking. Therefore, a comprehensive analysis of these three approaches is warranted, focusing on their safety, effectiveness, and cost implications. This study evaluated 184 consecutive cases of pediatric mediastinal tumors treated at our center over the past decade, providing a detailed comparison of these three approaches, and examined perioperative outcomes, complication rates, and postoperative recovery across these surgical approaches. Additionally, this study explored the technical features and clinical benefits of RATS. This study aimed to offer evidence-based guidance for selecting the optimal surgical strategy in these cases, thereby addressing key gaps in the existing literature. Materials and methods Study design This study was a single-center retrospective cohort analysis. Clinical data from 184 consecutive pediatric patients diagnosed with mediastinal tumors were collected, who underwent surgical treatment at the Pediatric Surgery Department of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, between December 2014 and January 2025. Patients were divided into three groups based on the surgical approach. Inclusion criteria for patients were younger than 18 years of age; preoperative imaging (chest CT or MRI) confirming a mediastinal mass; postoperative pathology confirming the presence of a tumor; first-time treatment at our institution with no prior interventions for this tumor at other facilities; availability of complete clinical and follow-up data. Exclusion criteria for patients were comorbid severe underlying conditions, such as cyanotic congenital heart disease, bronchopulmonary dysplasia, or pulmonary hypertension; cases involving only thoracoscopic tumor biopsy or those diagnosed as thoracic cavity or lung parenchymal tumors; preoperative imaging indicating extensive metastasis or mediastinal metastatic tumors; incomplete clinical data or loss to follow-up. Data collection and definitions Clinical data were collected by reviewing the medical records and outpatient or telephone follow-up records of all patients retrospectively. The outcomes included sex, age at surgery, weight at surgery, maximum tumor diameter, tumor location (anterior, middle, or posterior mediastinum), symptoms, associated anomalies, and pathological type, operative time, conversion, estimated operative blood loss, intraoperative transfusion, intraoperative complications, length of hospital stay, postoperative intensive care unit (ICU), duration of chest tube placement, chest drainage volume, postoperative fever, pain scores at 24, 48, and 72 hours, diclofenac suppository dosage, total hospitalization costs and unplanned readmission. Pain scores and body temperatures were recorded at 24, 48, and 72 hours postoperatively. For children aged 3 years and older, the Faces Pain Scale (FPS) was employed: 0: no pain, calm facial expression; 1–3: mild pain, slight frowning or discomfort; 4–6: moderate pain, obvious frowning or eye closure; 7–10: severe pain, distressed expression, such as open mouth or tearing. For infants and 3 years younger, the Face, Legs, Activity, Cry and Consolability (FLACC) Scale was utilized. Surgical Techniques All procedures were performed by senior attending surgeons or associate chief surgeons with extensive experience in thoracic surgery. The choice of surgical approach was determined by a comprehensive evaluation of factors including tumor size and location, its relationship to adjacent tissues, the surgeon's expertise, and patient’s preferences. For robot-assisted thoracoscopic surgery, patient position and trocar placement followed the methods described by Zeng et al[ 13 ]. Video-assisted thoracoscopic surgery techniques were performed as outlined by Marshall et al[ 14 ]. Open thoracotomy procedures were conducted according to the approach reported by Wu et al[ 15 ]. Follow-Up Follow-up data were collected until April 2025. All patients followed a standardized protocol with scheduled assessments at 1 month, 3 months, 6 months, and 1 year postoperatively, followed by annual visits until adulthood. Key follow-up elements included incision healing, postoperative complications, tumor recurrence or metastasis. Patients with malignant tumors received standardized care and long-term monitoring in the pediatric oncology department. Follow-up was conducted through a combination of outpatient visits, medical record reviews, and telephone consultations. Statistical Analyses Statistical analyses were performed using SPSS version 26.0 (IBM Corporation, Armonk, NY, USA). Continuous variables with normal distributions were presented as mean ± standard deviation and compared across groups using one-way analysis of variance (ANOVA). Non-normally distributed continuous variables were expressed as median [IQR; M (P25, P75)] and analyzed using the Kruskal- Wallis test. Categorical variables were reported as counts or percentages (%) and compared using the χ² test or Fisher's exact test (for expected frequencies < 5), with Bonferroni correction applied for multiple comparisons. A P < 0.05 was considered statistically significant. Result Comparison of baseline data As shown in Table 1 , a total of 184 pediatric patients with mediastinal tumors were reviewed. 84 patients receiving RATS, 56 patients receiving VATS and 44 patients receiving OT were included for comparative analysis. No significant differences were observed among the groups in age, gender, weight, tumor location, presenting symptoms, or pathological type (p > 0.05), however, the median maximum tumor diameter was larger in the OT group than the RATS group [7.00 (5.00, 10.25) vs. 5.00 (3.50, 7.00) cm; p < 0.05)]. Incidental, asymptomatic discoveries were common, occurring in 23.81%, 39.29%, and 27.27% of patients in each group, respectively. Most of these cases were identified during routine physical examinations or evaluations for unrelated conditions. Tumors were most frequently located in the posterior mediastinum, representing 59.52%, 57.14%, and 40.91% of cases in the RATS, VATS, and OT groups, respectively. In the VATS group, four patients presented with symptoms of nerve compression: one with scoliosis and limping, two with lower limb pain, and one with ptosis. Table 1 General information of patients Characteristic RATS group (n = 84) VATS group (n = 56) OT group (n = 44) p Sex (Male) 32(38.10%) 26(46.43%) 30(68.18%) 0.060 † Age (year) 6.03 ± 3.52 6.44 ± 4.38 6.29 ± 4.88 0.917 Weight (kg) 19.25(14.00, 19.25) 18.25(13.13, 39.25) 19.5(12.25, 36.75) 0.941 § Maximum tumor diameter (cm) 5.00(3.50,7.00) z 5.00(4.00,7.75) zy 7.00(5.00,10.25) y 0.034 § Tumor location 0.676 ‡ Anterior mediastinum 14(16.67%) 14(25.00%) 16(36.36%) Middle mediastinum 12(14.29%) 8(14.29%) 4(9.09%) Posterior mediastinum 50(59.52%) 32(57.14%) 18(40.91%) Cervicomediastinal junction 6(7.14%) 2(3.57%) 4(9.09%) Thoracoabdominal junction 2(2.38%) 0(0%) 2(4.55%) Symptoms 0.582* None 20(23.81%) 22(39.29%) 12(27.27%) 0.392 † Respiratory 48(57.14%) 20(35.71%) 20(45.45%) 0.185 † Chest pain 10(11.90%) 8(14.29%) 10(22.73%) 0.528 ‡ Fever 12(14.29%) 4(7.14%) 6(10.71%) 0.706 ‡ Neuro 0(0%) 4(7.14%) 0(0%) 0.145 ‡ Other 2(2.38%) 6(10.71%) 0(0%) 0.195 ‡ Pathological type 0.297 ‡ Immune or Lymphatic 2(2.38%) 2(3.57%) 2(4.55%) Neurogenic 40(47.61%) 26(46.43%) 18(40.91%) Embryonal 12(14.29%) 8(14.29%) 12(27.27%) Cystic 16(19.05%) 6(10.71%) 4(9.09%) Lipomas 6(7.14%) 0(0%) 0(0%) Vascular 8(9.52%) 14(25.00%) 4(9.09%) Fibrous or Sarcomatous 0(0%) 0(0%) 4(9.09%) Follow-up time (month) 17.00(13.75,22.00) y 36.00(22.5,46.00) y 91.50 (55.75,107.25) z 0.001 § Notes: Values were expressed as mean (SD = standard deviation) or n (%). § Kruskal-Wallis test, † Pearson’s chi-squared test, ‡ Fisher’s exact test, * Bonferroni correction for multiple comparisons. Abbreviation: RATS Robot-assisted thoracoscopic surgery, VATS Video-assisted thoracoscopic surgery, OT open thoracotomy and median sternotomy. Different letters (z and y) marked on the right side of the cell frequency indicated that there is a statistically different between the two groups that is the probability of the significance test for the comparison between the two groups is less than 0.05 (p < 0.05) Comparison of intraoperative data and postoperative outcomes The intraoperative data and postoperative outcomes are shown in Table 3 . Four patients in RATS group and six in VATS group were converted to open resection and no intraoperative complications occurred. There were no significant differences in operative time, intraoperative transfusion rates, chest drainage volumes and postoperative complication. Estimated operative blood loss was lowest in RATS group, compared to VATS group and OT group [5.00 (2.00, 7.00) vs. 10.00 (5.00, 20.00) vs. 30.00 (15.00, 65.00) mL], and the differences were statistically significant between the RATS and OT groups (p < 0.05). Postoperative ICU admission was required for 18.18% of OT group, compared to only 2.38% in RATS group and 3.57% in VATS group (p = 0.001). The chest tube duration was shortest in RATS group [2.00 (1.00, 2.00) days], followed by VATS group [3.50 (2.00, 5.00) days] and OT group [7.00 (5.00, 8.50) days], with significant differences across all pairwise comparisons (p < 0.001). The length of hospital stay was significantly shorter in both RATS group and VATS group compared to the OT group [(5.00 (4.00, 5.00) vs. 5.50 (4.00, 7.00) vs. 8.00 (6.00, 9.50) days; p < 0.001)], but no significant difference was noted between the RATS and VATS. Median total hospitalization costs were highest in the RATS group at [ $ 8442.67 (7789.60, 9919.11)], significantly exceeding those in the VATS group [ $ 5725.25 (4990.11, 6574.83)] and the OT group [ $ 5901.33 (3179.63, 6623.04)] (p < 0.001). Table 2 Surgical data of patients Characteristic RATS group (n = 84) VATS group (n = 56) OT group (n = 44) p Conversion (n, %) 4(4.76%) 6(10.71%) / 0.383 ‡ Intraoperative complications (n, %) 0 0 0 — Operative duration (min) 106.50(89.75,136.25) 122.50(82.50,192.50) 111.50(77.50,140.00) 0.469 § Estimated operative blood loss (ml) 5.00(2.00,7.00) y 10.00(5.00,20.00) y 30.00 (15.00,65.00) z 0.002 § Blood transfusion 14(16.67%) y 12(21.43%) y 20(45.45%) z 0.036 † ICU admissions 2(2.38%) y 2(3.57%) y 8(18.18%) z 0.001 † Chest drainage time (d) 2.00(1.00,2.00) y 3.50(2.00,5.00) z 7.00(5.00,8.50) a 0.001 § Average daily chest-tube drainage volume(ml) 30.83(15.00,39.33) 31.67(11.67,56.67) 49.95(5.00,108.33) 0.596 § Diclofenac suppository dosage (mg) 13.47 ± 4.27 y 16.86 ± 5.40 z 18.68 ± 6.93 z 0.003 Length of hospital stay (days) 5.00(4.00,5.00) y 5.50(4.00,7.00) y 8.00(6.00,9.50) z 0.001 § Postoperative complication (n, %) 6(7.14%) 6(10.71%) 8(18.18%) 0.428 ‡ Cost(💲) 8442.67 (7789.60,9919.11) y 5725.25 (4990.11,6574.83) z 5901.33 (3179.63,6623.04) yz 0.001 § Notes: Values were expressed as mean (SD = standard deviation) or n (%). § Kruskal-Wallis test, † Pearson’s chi-squared test, ‡ Fisher’s exact test, * Bonferroni correction for multiple comparisons. Abbreviation: RATS Robot-assisted thoracoscopic surgery, VATS Video-assisted thoracoscopic surgery, OT open thoracotomy and median sternotomy. Different letters (z and y) marked on the right side of the cell frequency indicated that there is a statistically different between the two groups that is the probability of the significance test for the comparison between the two groups is less than 0.05 (p < 0.05) Mean usage of diclofenac sodium suppositories for postoperative analgesia was lowest in RATS group (13.47 ± 4.27 mg), significantly lower than that in VATS group (16.86 ± 5.40 mg) and OT group (18.68 ± 6.93 mg), (p = 0.003). Pain scores at 24, 48, and 72 hours postoperatively were significantly lower in minimally invasive groups compared to the OT group (p < 0.05). Although pain scores were descriptively lower in the RATS group than in the VATS group, these differences had no statistical significance. Surgical approach had a significant impact on postoperative body temperature profiles. At 24 and 48 hours postoperatively, temperatures were significantly lower in the RATS group compared to the OT group (p 0.05). Multivariable linear regression analysis of factors affecting length of hospital stay A multivariable linear regression model was developed to identify factors associated with the length of hospital stay. The model demonstrated adequate fit with R 2 = 0.522 and adjusted R 2 = 0.487 (p < 0.001). Key predictors included operative time, transfusion requirement, chest tube duration, patient age, and surgical approach. Specifically, longer operative times, the need for transfusion, extended chest tube placement, and younger patient age were all associated with prolonged hospital stays. Compared to OT group, RATS was linked to a significant reduction in length of stay by 4.25 days (p < 0.001). The VATS showed a non-significant decrease of 2.33 days (p = 0.072). Full regression results are detailed in Table 3 . Table 3 Multivariate linear regression models for the LOS B SE Beta t p Operative duration 0.012 0.004 0.214 2.613 0.011 Blood transfusion (%) 2.500 1.192 0.190 2.097 0.039 Chest drainage time (d) 0.627 0.137 0.394 4.570 < 0.001 Age -0.395 0.109 -0.280 -3.617 < 0.001 RATS -4.250 1.144 -0.369 -3.714 < 0.001 VATS -2.333 1.278 -0.184 -1.825 0.072 Notes: The RATS and VATS groups were analyzed using the OA group as the reference category. Discussion In this study, we compared the clinical outcomes of robot-assisted thoracoscopic surgery, traditional video-assisted thoracoscopic surgery and open thoracotomy in children with mediastinal tumors. The chest drainage time and length of hospital stay were shorter in RATS group compared with VATS and OT. In addition, the robotic group had a lower rate of postoperative complications and postoperative pain. To our knowledge, no comparative studies have reported the perioperative outcomes of RATS with VATS and OT for mediastinal tumors in children. Our study focused on children with mediastinal tumors. A systematic review and meta-analys reported VATS is associated with significant reductions in LOS, complication rates, intraoperative blood loss, and transfusion requirements compared to OT, without compromising oncological outcomes[ 2 ], which lacked the data of RATS. However, in our study, robotic surgery showed significant advantages in terms of improving perioperative outcomes. For complete tumor resection, minimally invasive approaches have demonstrated encouraging results in pediatric oncology when applied selectively, without sacrificing oncologic outcomes[ 16 ]. Evidence indicates that VATS effectively removes small tumors and early-stage lesions, including neuroblastoma, while preserving oncologic integrity[ 17 ]. However, conventional thoracoscopic instruments approach the pelvic cavity almost vertically, offering only a limited range of motion horizontally[ 11 ]. In the confined space, instrument crowding is common and can compromise surgical quality. By contrast, robotic instruments feature articulated, wristed tips that maneuver freely in tight spaces, effectively overcoming these constraints[ 18 ]. Besides, the ergonomic console design minimizes surgeon fatigue, further contributing to procedural safety[ 19 ]. RATS provides distinct technical advantages, enabling more precise intraoperative maneuvers, minimizing tissue trauma, and enhancing overall surgical safety. The operative times were comparable between the RATS and OT groups and shorter than in the VATS group. Previous research indicates that RATS procedures may initially require more time due to the complexities of equipment setup and the surgeon’s learning curve[ 20 ]. However, as surgical teams gain experience and proficiency, these times can be significantly reduced, which aligns with our findings. Similarly, intraoperative blood loss was minimal in the RATS group, significantly less than in the OT group, corresponding to a lower transfusion rate. The significant reductions in intraoperative blood loss and transfusion rates seen with VATS are consistent with previous research, which associated these benefits with the enhanced precision of minimally invasive surgery[ 21 ]. This reduction is particularly important in pediatric patients, as even minor blood losses can cause notable hemodynamic instability[ 22 ]. Moreover, the diminished need for transfusion lowers the likelihood of transfusion-related complications, further reinforcing the safety and reliability[ 23 ]. The shortened chest drainage time and length of stay (LOS) observed in this study aligns with the increasing evidence supporting minimally invasive approaches such as RATS and VATS over OT, and the multivariable regression analysis further substantiated these findings, indicating a reduction in length of stay of 4.25 days for RATS compared to OT. Likewise, previous reports have shown that pediatric patients undergoing VATS experience shorter hospitalizations, likely due to less surgical trauma and more rapid postoperative recovery[ 24 , 25 ]. These results emphasize the significance of adopting minimally invasive techniques, especially in pediatric patients, where shortened recovery is essential for lowering long-term healthcare demands and alleviating psychological distress[ 26 ]. The minimally invasive nature of RATS significantly reduces surgical trauma, facilitating earlier recovery and improving comfort. Although the overall complication rates did not show significant differences across the groups, the RATS group reported the lowest incidence at 7.14%, which may be attributed to the enhanced precision of the procedure, facilitating more complete clearance of mediastinal fat[ 27 ]. The significant reduction in complication rates among patients undergoing minimally invasive surgery compared to OT has been echoed in prior studies[ 28 ]. An important contributing factor is the decrease in postoperative stress markers, including nitric oxide, interleukin-1β (IL-1β), and IL-6, which are linked to inflammation and pain[ 29 ]. These results indicate that VATS elicits a milder systemic inflammatory response, which may help reduce the likelihood of infections and other postoperative complications[ 30 ]. Postoperative pain was reported to be mildest in the RATS group, which demonstrated a significantly lower requirement for diclofenac sodium suppositories compared to both VATS and OT. Interestingly, despite the use of larger 8-mm trocars, the RATS procedure resulted in less pain than VATS. Furthermore, their impact on sensory and motor function is minimal, thereby decreasing chest wall trauma that could otherwise hinder effective respiration and coughing as a result of increased postoperative pain[ 31 ]. This study has several inherent limitations. As a single-center retrospective analysis, it is susceptible to both selection and information biases. Additionally, significant disparities in follow-up durations across groups hindered robust comparisons of long-term outcomes. The relatively modest sample size may have also restricted statistical power, particularly in subgroup analyses. Furthermore, we did not conduct detailed stratification by tumor location or pathology, factors that could affect the precision of our findings. To address these gaps, future research should focus on large-scale, multicenter prospective studies for validation. Moreover, the cumbersome equipment and high costs associated with current robotic systems present substantial barriers to their wider adoption in pediatric surgery. The development of compact, child-specific robotic platforms holds promise for overcoming these challenges, potentially expanding the accessibility and application of robotic techniques within this patient population. Conclusion This large retrospective comparative study demonstrates that RATS provides significant advantages over VATS and OT for pediatric mediastinal tumors, including shorter chest drainage time and length of hospital stay, lower rates of postoperative complications and postoperative pain—albeit at increased costs. As a safe and effective minimally invasive option, RATS shows promise as a preferred modality in this context. Continued technological advancements and the increasing expertise in clinical practice are likely to enhance its role in pediatric thoracic surgery. Declarations Ethics declarations Conflict of interest The authors have no relevant financial or non-financial interests to disclose. Ethics approval This retrospective observational study was approved by the Medical Research Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (ethics approval number: 2025 − 0975). As this was a non-interventional retrospective study, the requirement for additional informed consent for participation was waived by the committee. Written informed consent for surgical procedures was obtained preoperatively from the parents or legal guardians of all pediatric patients. The research strictly adhered to the principles of the Declaration of Helsinki, and the reporting of this study followed the STROBE guidelines. Consent to publish Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the conception and design of the study. Miaomiao Sun made substantial contributions to data acquisition, analysis, and interpretation and drafted the manuscript. Sijia Guo, Chen Wang, and Kang Li revised it critically for important intellectual content. Shuai Li approved the final version to be published. Yongzhong Mao, Yong Wang, and Shaotao Tang were responsible for ensuring the accuracy and integrity of the work. All authors read and approved the final manuscript. 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Impact of Blood Sampling Methods on Blood Loss and Transfusion After Pediatric Cardiac Surgery: An Observational Study. J Cardiothorac Vasc Anesth 2024;38:2002–8. https://doi.org/10.1053/j.jvca.2024.04.005 . Hwang SK, Park S, Kim Y-H, et al. Clinical results of surgical resection of mediastinal teratoma: efficacy of video-assisted thoracic surgery. Surg Endosc 2016;30:4065–8. https://doi.org/10.1007/s00464-015-4721-9 . Chan JWY, Yu PSY, Yang JH, et al. Surgical access trauma following minimally invasive thoracic surgery. Eur J Cardiothorac Surg 2020;58:i6–13. https://doi.org/10.1093/ejcts/ezaa025 . Tan H, Huang E, Deng X, et al. Effects of minimally invasive and traditional surgeries on the quality of life of children with congenital heart disease: a retrospective propensity score-matched study. BMC Pediatr 2021;21:522. https://doi.org/10.1186/s12887-021-02978-5 . Shen C, Che G. Tubeless minimally invasive treatment: taking a new step in enhanced recovery after surgery (ERAS). Thorac Cancer 2019;10:2067–70. https://doi.org/10.1111/1759-7714.13206 . Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010;139:366–78. https://doi.org/10.1016/j.jtcvs.2009.08.026 . Zhai B, Zhang Y, Chen Z, et al. Effect of video–assisted thoracoscopic surgery on pain stress indicators NO, IL–1β and IL–6 in the treatment of mediastinal tumor in children. Oncol Lett 2020. https://doi.org/10.3892/ol.2020.11515 . Drevin G, Andersson B, Svensson JF. Thoracoscopy or Thoracotomy for Esophageal Atresia: A Systematic Review and Meta-analysis. Ann Surg 2021;274:945–53. https://doi.org/10.1097/SLA.0000000000004239 . Kaseda S, Aoki T, Hangai N, et al. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg 2000;70:1644–6. https://doi.org/10.1016/S0003-4975(00)01909-3 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Dec, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 31 Oct, 2025 Reviews received at journal 30 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviews received at journal 30 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers agreed at journal 28 Oct, 2025 Reviewers invited by journal 27 Oct, 2025 Editor assigned by journal 27 Oct, 2025 Submission checks completed at journal 27 Oct, 2025 First submitted to journal 27 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Guo","email":"","orcid":"","institution":"Union Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Sijia","middleName":"","lastName":"Guo","suffix":""},{"id":537840633,"identity":"a19e1c71-5bc2-4935-9336-765a42f3a31b","order_by":2,"name":"Chen Wang","email":"","orcid":"","institution":"Union Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Wang","suffix":""},{"id":537840634,"identity":"fdb40ce5-65c9-43b3-87f7-0e0447ff01b9","order_by":3,"name":"Kang Li","email":"","orcid":"","institution":"Union Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Kang","middleName":"","lastName":"Li","suffix":""},{"id":537840635,"identity":"96110070-e070-431a-b993-26e9af9a8171","order_by":4,"name":"Yongzhong 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05:18:01","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98959,"visible":true,"origin":"","legend":"","description":"","filename":"88a6908fd7464d9d91762276a33f25a71structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7957331/v1/d11edca0d2823684b3d3b97c.xml"},{"id":95500093,"identity":"9d20c098-d4c5-49bd-89c4-6cbe1da97671","added_by":"auto","created_at":"2025-11-10 05:18:01","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105827,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7957331/v1/91bdced467d9d6171ba49218.html"},{"id":95500086,"identity":"afe227fa-9597-4954-88ae-7770784fd0a8","added_by":"auto","created_at":"2025-11-10 05:18:01","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101039,"visible":true,"origin":"","legend":"\u003cp\u003ePost-procedural data of pain score and temperature\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7957331/v1/6ecd657ee92cafce9a397ad5.jpg"},{"id":98245601,"identity":"788422c0-5530-4c4c-85e8-848de907cf14","added_by":"auto","created_at":"2025-12-15 16:18:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":838158,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7957331/v1/d1d0ed4f-528a-439e-852c-f315aa3e821b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Open Thoracotomy, Video-Assisted Thoracoscopic Surgery, and Robot-Assisted Thoracoscopic Surgery for Resection of Mediastinal Tumors in Pediatric Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMediastinal tumor is a prevalent type of thoracic tumor in children, accounting for approximately 7% of malignant tumors within this population, and surgical resection is the preferred treatment for most benign tumors and for malignant tumors, excluding lymphomas[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Traditional open thoracotomy (OT) has long been regarded as the \"gold standard\" for mediastinal tumor resection[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, with the rapid advancement of minimally invasive techniques and the progress in single-lung ventilation anesthesia for children, Video-assisted thoracoscopic surgery (VATS) and, more recently, robotic-assisted thoracoscopic surgery (RATS), have increased in popularity and benefit patients by reducing incisional trauma and postoperative pain, among other outcomes[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mediastinum possesses a complex anatomical structure, lying in proximity to vital organs such as the heart, great vessels, trachea, and esophagus[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. relatively narrow mediastinal space in children, along with the diverse tissue origins of these tumors, complicates complete tumor resection for pediatric surgeons. It is critical for surgical teams to avoid damaging adjacent vital structures during the procedure[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. OT approach can provide an adequate surgical field and ample operating space[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], however, it typically necessitates a large incision, which may require cutting through chest wall muscles or even dividing ribs for sufficient exposure. Consequently, these steps can result in significant drawbacks, including substantial trauma, increased bleeding, severe postoperative pain, prolonged recovery times, prominent chest scars, and potential chest wall deformities[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Minimally invasive surgery offers several advantages, including minimal trauma, rapid recovery, reduced postoperative pain, and improved cosmetic outcomes. The robotic platform has overcome some inherent technical limitations of conventional thoracoscopic techniques. For example, a VATS approach requires a surgeon to contend with suboptimal angles, using chopstick instrumentation, rather than the increased flexibility with multi-degree-of-freedom robotic arms on the robotic platform[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Besides, the thoracoscope\u0026rsquo;s two-dimensional image limits depth perception, whereas the three-dimensional visualization of the robotic platform can enhance the surgeon's visibility[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In 2001, Yoshino et al[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] reported the first robot-assisted resection of a mediastinal thymoma, establishing a foundation for precise robotic applications in confined mediastinal spaces. Subsequently, in 2008, Meehan et al[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] pioneered the use of the da Vinci robotic system for mediastinal tumor resection in pediatric patients. Their initial experience highlighted significant potential benefits, particularly in performing complex procedures within the narrow thoracic cavities of this population.\u003c/p\u003e\u003cp\u003eAlthough RATS has gained widespread acceptance in adult thoracic surgery, its application in treating mediastinal tumors in children remains limited. Current research primarily consists of small case reports or single-center experiences[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and large-scale, systematic comparative studies are notably lacking. Therefore, a comprehensive analysis of these three approaches is warranted, focusing on their safety, effectiveness, and cost implications. This study evaluated 184 consecutive cases of pediatric mediastinal tumors treated at our center over the past decade, providing a detailed comparison of these three approaches, and examined perioperative outcomes, complication rates, and postoperative recovery across these surgical approaches. Additionally, this study explored the technical features and clinical benefits of RATS. This study aimed to offer evidence-based guidance for selecting the optimal surgical strategy in these cases, thereby addressing key gaps in the existing literature.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eThis study was a single-center retrospective cohort analysis. Clinical data from 184 consecutive pediatric patients diagnosed with mediastinal tumors were collected, who underwent surgical treatment at the Pediatric Surgery Department of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, between December 2014 and January 2025. Patients were divided into three groups based on the surgical approach. Inclusion criteria for patients were younger than 18 years of age; preoperative imaging (chest CT or MRI) confirming a mediastinal mass; postoperative pathology confirming the presence of a tumor; first-time treatment at our institution with no prior interventions for this tumor at other facilities; availability of complete clinical and follow-up data. Exclusion criteria for patients were comorbid severe underlying conditions, such as cyanotic congenital heart disease, bronchopulmonary dysplasia, or pulmonary hypertension; cases involving only thoracoscopic tumor biopsy or those diagnosed as thoracic cavity or lung parenchymal tumors; preoperative imaging indicating extensive metastasis or mediastinal metastatic tumors; incomplete clinical data or loss to follow-up.\u003c/p\u003e\u003cp\u003eData collection and definitions\u003c/p\u003e\u003cp\u003eClinical data were collected by reviewing the medical records and outpatient or telephone follow-up records of all patients retrospectively. The outcomes included sex, age at surgery, weight at surgery, maximum tumor diameter, tumor location (anterior, middle, or posterior mediastinum), symptoms, associated anomalies, and pathological type, operative time, conversion, estimated operative blood loss, intraoperative transfusion, intraoperative complications, length of hospital stay, postoperative intensive care unit (ICU), duration of chest tube placement, chest drainage volume, postoperative fever, pain scores at 24, 48, and 72 hours, diclofenac suppository dosage, total hospitalization costs and unplanned readmission.\u003c/p\u003e\u003cp\u003ePain scores and body temperatures were recorded at 24, 48, and 72 hours postoperatively. For children aged 3 years and older, the Faces Pain Scale (FPS) was employed: 0: no pain, calm facial expression; 1\u0026ndash;3: mild pain, slight frowning or discomfort; 4\u0026ndash;6: moderate pain, obvious frowning or eye closure; 7\u0026ndash;10: severe pain, distressed expression, such as open mouth or tearing. For infants and 3 years younger, the Face, Legs, Activity, Cry and Consolability (FLACC) Scale was utilized. Surgical Techniques\u003c/p\u003e\u003cp\u003eAll procedures were performed by senior attending surgeons or associate chief surgeons with extensive experience in thoracic surgery. The choice of surgical approach was determined by a comprehensive evaluation of factors including tumor size and location, its relationship to adjacent tissues, the surgeon's expertise, and patient\u0026rsquo;s preferences. For robot-assisted thoracoscopic surgery, patient position and trocar placement followed the methods described by Zeng et al[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Video-assisted thoracoscopic surgery techniques were performed as outlined by Marshall et al[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Open thoracotomy procedures were conducted according to the approach reported by Wu et al[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFollow-Up\u003c/p\u003e\u003cp\u003eFollow-up data were collected until April 2025. All patients followed a standardized protocol with scheduled assessments at 1 month, 3 months, 6 months, and 1 year postoperatively, followed by annual visits until adulthood. Key follow-up elements included incision healing, postoperative complications, tumor recurrence or metastasis. Patients with malignant tumors received standardized care and long-term monitoring in the pediatric oncology department. Follow-up was conducted through a combination of outpatient visits, medical record reviews, and telephone consultations.\u003c/p\u003e\u003cp\u003eStatistical Analyses\u003c/p\u003e\u003cp\u003eStatistical analyses were performed using SPSS version 26.0 (IBM Corporation, Armonk, NY, USA). Continuous variables with normal distributions were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and compared across groups using one-way analysis of variance (ANOVA). Non-normally distributed continuous variables were expressed as median [IQR; M (P25, P75)] and analyzed using the Kruskal- Wallis test. Categorical variables were reported as counts or percentages (%) and compared using the χ\u0026sup2; test or Fisher's exact test (for expected frequencies\u0026thinsp;\u0026lt;\u0026thinsp;5), with Bonferroni correction applied for multiple comparisons. A P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eComparison of baseline data\u003c/p\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a total of 184 pediatric patients with mediastinal tumors were reviewed. 84 patients receiving RATS, 56 patients receiving VATS and 44 patients receiving OT were included for comparative analysis. No significant differences were observed among the groups in age, gender, weight, tumor location, presenting symptoms, or pathological type (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), however, the median maximum tumor diameter was larger in the OT group than the RATS group [7.00 (5.00, 10.25) vs. 5.00 (3.50, 7.00) cm; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)].\u003c/p\u003e\u003cp\u003eIncidental, asymptomatic discoveries were common, occurring in 23.81%, 39.29%, and 27.27% of patients in each group, respectively. Most of these cases were identified during routine physical examinations or evaluations for unrelated conditions. Tumors were most frequently located in the posterior mediastinum, representing 59.52%, 57.14%, and 40.91% of cases in the RATS, VATS, and OT groups, respectively. In the VATS group, four patients presented with symptoms of nerve compression: one with scoliosis and limping, two with lower limb pain, and one with ptosis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGeneral information of patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRATS group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVATS group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOT group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32(38.10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26(46.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30(68.18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.060\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.44\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.29\u0026thinsp;\u0026plusmn;\u0026thinsp;4.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.917\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.25(14.00, 19.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.25(13.13, 39.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.5(12.25, 36.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.941\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaximum tumor diameter (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.00(3.50,7.00) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.00(4.00,7.75) zy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.00(5.00,10.25) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.034\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTumor location\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.676\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnterior mediastinum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(16.67%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14(25.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16(36.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle mediastinum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(14.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8(14.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(9.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePosterior mediastinum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50(59.52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32(57.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(40.91%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCervicomediastinal junction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(3.57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(9.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThoracoabdominal junction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(2.38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(4.55%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.582*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20(23.81%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22(39.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(27.27%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.392\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespiratory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48(57.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20(35.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20(45.45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.185\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(11.90%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8(14.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(22.73%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.528\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(14.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6(10.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.706\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeuro\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.145\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(2.38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(10.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.195\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathological type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.297\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImmune or Lymphatic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(2.38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(3.57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(4.55%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurogenic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40(47.61%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26(46.43%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(40.91%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmbryonal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(14.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8(14.29%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(27.27%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCystic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16(19.05%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(10.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(9.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLipomas\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVascular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(9.52%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14(25.00%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(9.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFibrous or Sarcomatous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(9.09%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFollow-up time (month)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.00(13.75,22.00) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.00(22.5,46.00) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e91.50 (55.75,107.25) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: Values were expressed as mean (SD\u0026thinsp;=\u0026thinsp;standard deviation) or n (%). \u0026sect; Kruskal-Wallis test, \u0026dagger; Pearson\u0026rsquo;s chi-squared test, \u0026Dagger; Fisher\u0026rsquo;s exact test, * Bonferroni correction for multiple comparisons. Abbreviation: RATS Robot-assisted thoracoscopic surgery, VATS Video-assisted thoracoscopic surgery, OT open thoracotomy and median sternotomy. Different letters (z and y) marked on the right side of the cell frequency indicated that there is a statistically different between the two groups that is the probability of the significance test for the comparison between the two groups is less than 0.05 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003ch2\u003eComparison of intraoperative data and postoperative outcomes\u003c/h2\u003e\u003cp\u003eThe intraoperative data and postoperative outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Four patients in RATS group and six in VATS group were converted to open resection and no intraoperative complications occurred. There were no significant differences in operative time, intraoperative transfusion rates, chest drainage volumes and postoperative complication. Estimated operative blood loss was lowest in RATS group, compared to VATS group and OT group [5.00 (2.00, 7.00) vs. 10.00 (5.00, 20.00) vs. 30.00 (15.00, 65.00) mL], and the differences were statistically significant between the RATS and OT groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Postoperative ICU admission was required for 18.18% of OT group, compared to only 2.38% in RATS group and 3.57% in VATS group (p\u0026thinsp;=\u0026thinsp;0.001). The chest tube duration was shortest in RATS group [2.00 (1.00, 2.00) days], followed by VATS group [3.50 (2.00, 5.00) days] and OT group [7.00 (5.00, 8.50) days], with significant differences across all pairwise comparisons (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eThe length of hospital stay was significantly shorter in both RATS group and VATS group compared to the OT group [(5.00 (4.00, 5.00) vs. 5.50 (4.00, 7.00) vs. 8.00 (6.00, 9.50) days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)], but no significant difference was noted between the RATS and VATS. Median total hospitalization costs were highest in the RATS group at [\u003cspan\u003e$\u003c/span\u003e 8442.67 (7789.60, 9919.11)], significantly exceeding those in the VATS group [\u003cspan\u003e$\u003c/span\u003e 5725.25 (4990.11, 6574.83)] and the OT group [\u003cspan\u003e$\u003c/span\u003e5901.33 (3179.63, 6623.04)] (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurgical data of patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRATS group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;84)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVATS group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOT group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eConversion (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(4.76%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6(10.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.383\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eIntraoperative\u003c/p\u003e\u003cp\u003ecomplications (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOperative duration (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e106.50(89.75,136.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e122.50(82.50,192.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e111.50(77.50,140.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.469\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEstimated operative blood loss (ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.00(2.00,7.00) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.00(5.00,20.00) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.00 (15.00,65.00) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.002\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBlood transfusion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14(16.67%) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(21.43%) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20(45.45%) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.036\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eICU admissions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(2.38%) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(3.57%) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8(18.18%) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eChest drainage time (d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.00(1.00,2.00) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.50(2.00,5.00) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.00(5.00,8.50) a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAverage daily chest-tube drainage volume(ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.83(15.00,39.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.67(11.67,56.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49.95(5.00,108.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.596\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eDiclofenac suppository\u003c/p\u003e\u003cp\u003edosage (mg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.27 y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.86\u0026thinsp;\u0026plusmn;\u0026thinsp;5.40 z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.93 z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLength of hospital stay\u003c/p\u003e\u003cp\u003e(days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.00(4.00,5.00) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.50(4.00,7.00) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.00(6.00,9.50) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePostoperative complication (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(7.14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6(10.71%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8(18.18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.428\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCost(\u0026#128178;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8442.67\u003c/p\u003e\u003cp\u003e(7789.60,9919.11) y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5725.25\u003c/p\u003e\u003cp\u003e(4990.11,6574.83) z\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5901.33\u003c/p\u003e\u003cp\u003e(3179.63,6623.04) yz\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNotes: Values were expressed as mean (SD\u0026thinsp;=\u0026thinsp;standard deviation) or n (%). \u0026sect; Kruskal-Wallis test, \u0026dagger; Pearson\u0026rsquo;s chi-squared test, \u0026Dagger; Fisher\u0026rsquo;s exact test, * Bonferroni correction for multiple comparisons. Abbreviation: RATS Robot-assisted thoracoscopic surgery, VATS Video-assisted thoracoscopic surgery, OT open thoracotomy and median sternotomy. Different letters (z and y) marked on the right side of the cell frequency indicated that there is a statistically different between the two groups that is the probability of the significance test for the comparison between the two groups is less than 0.05 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMean usage of diclofenac sodium suppositories for postoperative analgesia was lowest in RATS group (13.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.27 mg), significantly lower than that in VATS group (16.86\u0026thinsp;\u0026plusmn;\u0026thinsp;5.40 mg) and OT group (18.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.93 mg), (p\u0026thinsp;=\u0026thinsp;0.003). Pain scores at 24, 48, and 72 hours postoperatively were significantly lower in minimally invasive groups compared to the OT group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Although pain scores were descriptively lower in the RATS group than in the VATS group, these differences had no statistical significance. Surgical approach had a significant impact on postoperative body temperature profiles. At 24 and 48 hours postoperatively, temperatures were significantly lower in the RATS group compared to the OT group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), however, there were no differences among the groups by 72 hours (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMultivariable linear regression analysis of factors affecting length of hospital stay\u003c/p\u003e\u003cp\u003eA multivariable linear regression model was developed to identify factors associated with the length of hospital stay. The model demonstrated adequate fit with R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.522 and adjusted R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.487 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Key predictors included operative time, transfusion requirement, chest tube duration, patient age, and surgical approach. Specifically, longer operative times, the need for transfusion, extended chest tube placement, and younger patient age were all associated with prolonged hospital stays. Compared to OT group, RATS was linked to a significant reduction in length of stay by 4.25 days (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The VATS showed a non-significant decrease of 2.33 days (p\u0026thinsp;=\u0026thinsp;0.072). Full regression results are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate linear regression models for the LOS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBeta\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.214\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.613\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood transfusion (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.097\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest drainage time (d)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.627\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.394\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.570\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.395\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.280\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-3.617\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRATS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-4.250\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.369\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-3.714\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVATS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-2.333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.278\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.825\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNotes: The RATS and VATS groups were analyzed using the OA group as the reference category.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we compared the clinical outcomes of robot-assisted thoracoscopic surgery, traditional video-assisted thoracoscopic surgery and open thoracotomy in children with mediastinal tumors. The chest drainage time and length of hospital stay were shorter in RATS group compared with VATS and OT. In addition, the robotic group had a lower rate of postoperative complications and postoperative pain. To our knowledge, no comparative studies have reported the perioperative outcomes of RATS with VATS and OT for mediastinal tumors in children.\u003c/p\u003e\u003cp\u003eOur study focused on children with mediastinal tumors. A systematic review and meta-analys reported VATS is associated with significant reductions in LOS, complication rates, intraoperative blood loss, and transfusion requirements compared to OT, without compromising oncological outcomes[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], which lacked the data of RATS. However, in our study, robotic surgery showed significant advantages in terms of improving perioperative outcomes. For complete tumor resection, minimally invasive approaches have demonstrated encouraging results in pediatric oncology when applied selectively, without sacrificing oncologic outcomes[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Evidence indicates that VATS effectively removes small tumors and early-stage lesions, including neuroblastoma, while preserving oncologic integrity[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, conventional thoracoscopic instruments approach the pelvic cavity almost vertically, offering only a limited range of motion horizontally[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the confined space, instrument crowding is common and can compromise surgical quality. By contrast, robotic instruments feature articulated, wristed tips that maneuver freely in tight spaces, effectively overcoming these constraints[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Besides, the ergonomic console design minimizes surgeon fatigue, further contributing to procedural safety[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRATS provides distinct technical advantages, enabling more precise intraoperative maneuvers, minimizing tissue trauma, and enhancing overall surgical safety. The operative times were comparable between the RATS and OT groups and shorter than in the VATS group. Previous research indicates that RATS procedures may initially require more time due to the complexities of equipment setup and the surgeon\u0026rsquo;s learning curve[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, as surgical teams gain experience and proficiency, these times can be significantly reduced, which aligns with our findings. Similarly, intraoperative blood loss was minimal in the RATS group, significantly less than in the OT group, corresponding to a lower transfusion rate. The significant reductions in intraoperative blood loss and transfusion rates seen with VATS are consistent with previous research, which associated these benefits with the enhanced precision of minimally invasive surgery[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This reduction is particularly important in pediatric patients, as even minor blood losses can cause notable hemodynamic instability[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Moreover, the diminished need for transfusion lowers the likelihood of transfusion-related complications, further reinforcing the safety and reliability[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe shortened chest drainage time and length of stay (LOS) observed in this study aligns with the increasing evidence supporting minimally invasive approaches such as RATS and VATS over OT, and the multivariable regression analysis further substantiated these findings, indicating a reduction in length of stay of 4.25 days for RATS compared to OT. Likewise, previous reports have shown that pediatric patients undergoing VATS experience shorter hospitalizations, likely due to less surgical trauma and more rapid postoperative recovery[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These results emphasize the significance of adopting minimally invasive techniques, especially in pediatric patients, where shortened recovery is essential for lowering long-term healthcare demands and alleviating psychological distress[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The minimally invasive nature of RATS significantly reduces surgical trauma, facilitating earlier recovery and improving comfort. Although the overall complication rates did not show significant differences across the groups, the RATS group reported the lowest incidence at 7.14%, which may be attributed to the enhanced precision of the procedure, facilitating more complete clearance of mediastinal fat[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The significant reduction in complication rates among patients undergoing minimally invasive surgery compared to OT has been echoed in prior studies[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. An important contributing factor is the decrease in postoperative stress markers, including nitric oxide, interleukin-1β (IL-1β), and IL-6, which are linked to inflammation and pain[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These results indicate that VATS elicits a milder systemic inflammatory response, which may help reduce the likelihood of infections and other postoperative complications[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Postoperative pain was reported to be mildest in the RATS group, which demonstrated a significantly lower requirement for diclofenac sodium suppositories compared to both VATS and OT. Interestingly, despite the use of larger 8-mm trocars, the RATS procedure resulted in less pain than VATS. Furthermore, their impact on sensory and motor function is minimal, thereby decreasing chest wall trauma that could otherwise hinder effective respiration and coughing as a result of increased postoperative pain[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study has several inherent limitations. As a single-center retrospective analysis, it is susceptible to both selection and information biases. Additionally, significant disparities in follow-up durations across groups hindered robust comparisons of long-term outcomes. The relatively modest sample size may have also restricted statistical power, particularly in subgroup analyses. Furthermore, we did not conduct detailed stratification by tumor location or pathology, factors that could affect the precision of our findings. To address these gaps, future research should focus on large-scale, multicenter prospective studies for validation. Moreover, the cumbersome equipment and high costs associated with current robotic systems present substantial barriers to their wider adoption in pediatric surgery. The development of compact, child-specific robotic platforms holds promise for overcoming these challenges, potentially expanding the accessibility and application of robotic techniques within this patient population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis large retrospective comparative study demonstrates that RATS provides significant advantages over VATS and OT for pediatric mediastinal tumors, including shorter chest drainage time and length of hospital stay, lower rates of postoperative complications and postoperative pain\u0026mdash;albeit at increased costs. As a safe and effective minimally invasive option, RATS shows promise as a preferred modality in this context. Continued technological advancements and the increasing expertise in clinical practice are likely to enhance its role in pediatric thoracic surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cb\u003eEthics declarations\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eEthics approval\u003c/h2\u003e\u003cp\u003eThis retrospective observational study was approved by the Medical Research Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (ethics approval number: 2025\u0026thinsp;\u0026minus;\u0026thinsp;0975). As this was a non-interventional retrospective study, the requirement for additional informed consent for participation was waived by the committee. Written informed consent for surgical procedures was obtained preoperatively from the parents or legal guardians of all pediatric patients. The research strictly adhered to the principles of the Declaration of Helsinki, and the reporting of this study followed the STROBE guidelines.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003cp\u003eSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the conception and design of the study. Miaomiao Sun made substantial contributions to data acquisition, analysis, and interpretation and drafted the manuscript. Sijia Guo, Chen Wang, and Kang Li revised it critically for important intellectual content. Shuai Li approved the final version to be published. Yongzhong Mao, Yong Wang, and Shaotao Tang were responsible for ensuring the accuracy and integrity of the work. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhang Q, Zhou T, Hou P, et al. A single-center study of thoracoscopic surgery in the treatment of pediatric mediastinal neurogenic tumors. 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Ann Thorac Surg 2000;70:1644\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0003-4975(00)01909-3\u003c/span\u003e\u003cspan address=\"10.1016/S0003-4975(00)01909-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Robotic surgery, Minimally invasive, Mediastinal tumor resection, Pediatric surgery","lastPublishedDoi":"10.21203/rs.3.rs-7957331/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7957331/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study aims to compare the clinical outcomes of robot-assisted thoracoscopic surgery (RATS), traditional video-assisted thoracoscopic surgery (VATS), and open thoracotomy (OT) in children with mediastinal tumors, while also evaluating the technical advantages associated with RATS. This study conducted a retrospective analysis of clinical data from 184 pediatric patients who underwent surgery for mediastinal tumors at our center between December 2014 and January 2025. Baseline characteristics, surgical technical parameters and perioperative outcomes were compared among the three groups.184 patients were identified, all surgeries were completed successfully, with no recorded perioperative deaths. There were no significant differences in baseline characteristics. The length of hospital stay for minimally invasive group was significantly shorter than for OT group. The intraoperative blood loss in minimally invasive group was significantly less than in OT group. Total hospital charges for RATS were significantly higher than for VATS and OT groups. Mean usage of diclofenac sodium suppositories for postoperative analgesia was lowest in RATS group, significantly lower than that in other groups. Multivariate analysis indicated significant influences on hospital stay, including operative time, blood transfusion, chest tube duration, age, and surgical approach. RATS demonstrates superior perioperative outcomes compared to VATS and OT in the management of mediastinal tumors in pediatric patients. Key advantages include shorter chest drainage time and length of hospital stay, lower rates of postoperative complications and postoperative pain. However, RATS is associated with higher treatment costs.\u003c/p\u003e","manuscriptTitle":"Comparison of Open Thoracotomy, Video-Assisted Thoracoscopic Surgery, and Robot-Assisted Thoracoscopic Surgery for Resection of Mediastinal Tumors in Pediatric Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 05:17:56","doi":"10.21203/rs.3.rs-7957331/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-31T05:29:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T19:22:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77393542673090616623155444034475133570","date":"2025-10-30T11:36:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T11:34:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220248928202720118207453624707911641429","date":"2025-10-30T09:08:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5085614220500794489748313555480677359","date":"2025-10-30T06:25:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314480759506214684615107050492687892910","date":"2025-10-28T18:13:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-28T00:46:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-27T22:48:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-27T14:45:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-10-27T10:59:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"366f09b0-65bd-43c2-8f9c-5ef60c60d382","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:15:15+00:00","versionOfRecord":{"articleIdentity":"rs-7957331","link":"https://doi.org/10.1007/s11701-025-02996-w","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2025-12-11 15:59:22","publishedOnDateReadable":"December 11th, 2025"},"versionCreatedAt":"2025-11-10 05:17:56","video":"","vorDoi":"10.1007/s11701-025-02996-w","vorDoiUrl":"https://doi.org/10.1007/s11701-025-02996-w","workflowStages":[]},"version":"v1","identity":"rs-7957331","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7957331","identity":"rs-7957331","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}