Comparison of uniportal and three-portal video-assisted thoracoscopic thymectomy for thymoma: a propensity score-matched study.

Comparison of uniportal and three-portal video-assisted thoracoscopic thymectomy for thymoma: a propensity score-matched study. | 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 uniportal and three-portal video-assisted thoracoscopic thymectomy for thymoma: a propensity score-matched study. Zipu Yu, Guofei Zhang, Gang Shen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5312029/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Minimally invasive thymectomy (MIT) is a surgical approach to thymectomy. To investigate the efficacy of the minimally invasive thymectomy, a retrospective comparison for perioperative outcomes of patients was conducted between uniportal and three-portal video-assisted thoracoscopic thymectomy (UP-VATS and TP-VATS). Methods: A detailed database search identified 135 patients treated withUP-VATS thymectomy technique and 228 patients treated via TP-VATS thymectomy technique between January 2013 and December 2022. Propensity score-matched analysis was used to compare the perioperative outcomes between the two groups. Results: The first 20 patients were excluded respectively to account for the learning curve effect in both groups. 115 patients in each group were screened after propensity match. There were 14.8% morbidity in the UP-VATS group and 12.2% morbidity in the TP-VATS group, no significant differences were exist between two groups. Furthermore, no significant differences in other perioperative outcomes were exist between two groups. Although the volume of drainage (86.2 vs. 76.1, p = 0.078) were similar between the two groups, the operative time in the UP-VATS group (117.2 vs. 96.7, p < 0.001) was longer than that in the TP-VATS group. CONCLUSION: Thymectomy treatment of (TP-VATS) is an advisable procedure for patients with thymoma, while these two minimally invasive thymectomy techniques are both appropriate for thymoma treatment. Video-assisted thoracoscopic surgery Thymectomy Uniportal Three-portal Thymoma Figures Figure 1 Figure 2 Background For over a century, median sternotomy has been considered as the standard approach for the anterior mediastinum tumor(1). However, thoracic surgeons are striving to explore the other less invasive approaches because of the significant morbidity associated with median sternotomy approach(2). On account of endeavor for the past decades, there has been a significant increase in the adoption of minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS). Minimally invasive surgical approaches for thymectomy have gained popularity for patients. A variety of studies suggested that video-assisted thoracoscopic surgery (VATS) has improved surgical treatment outcomes. Video-assisted thoracoscopic surgery (VATS) has many advantages by comparison with the traditional thymectomy. VATS thymectomy has been associated with shorter hospital stay, less operative blood loss and decreased postoperative pain (3-7). To investigate the efficacy of the minimally invasive thymectomy, a retrospective comparison of perioperative outcomes for patients was conducted between the uniportal and three-portal video-assisted thoracoscopic (UP-VATS and TP-VATS) thymectomy. We retrospectively compared clinical data from patients who underwent the UP-VATS thymectomy or the TP-VATS thymectomy technique. Methods From January 2013 to December 2022, patients were admitted for surgical assessment in the Department of Thoracic Surgery of the Second Affiliated Hospital of Zhejiang University. This study was authorized by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University (2021-0696). The operability evaluation included a panel of oncological assessments (including respiratory function tests, computed tomography scanning of the chest or magnetic resonance imaging chest, brain magnetic resonance imaging), and standard pulmonary and cardiac function tests. Based on the results of assessments, the surgical treatment regimen was decided by senior consultant surgeons. Clinical and demographic data (including age, sex, smoking history, body mass index, tumor diameter and location and pathologic style) were recorded. The operative time, estimated volume of blood loss, blood transfusion during the operation, conversion to the traditional thoracotomy, length of hospital stay, chest tube removal, complications, volume of postoperative drainage, mortality within 30 days were collected. The first TP-VATS thymectomy was performed in our department in 2013. The UP-VATS thymectomy technique was employed in 2015, whereas some surgeons still performed TP-VATS thymectomy for individual preference. The first 20 cases in each group were excluded to account for the learning curve effect. Surgical technique General anesthesia and double-lumen endotracheal intubation were routinely used. All patients were in the horizontal position with the surgery side elevating upward. The surgeon and assistant stood on the surgery sides of the patient. For the uniportal video-assisted thoracoscopic (UP-VATS) thymectomy, a 4 cm incision was made between the midaxillary and anterior axillary line in the fourth intercostal space (in the fifth intercostal space for women). For the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy, a 1cm incision was made at the anterior axillary line in the third intercostal space as the assistant utility port. Another 1cm incision was made at the midaxillary line in the fifth intercostal space as the observation port. A 3 cm mini-thoracotomy was made at the fifth intercostal space between the midclavicular line and anterior axillary line in the fifth intercostal space as the major utility port. In the TP-VATS, the major utility port was sealed with a plastic protective jacket. In the UP-VATS, a plastic protective jacket was used for the only port with no sealing during the procedure. Pneumoperitoneum with a pressure of 8 cm H 2 O was used in the TP-VATS procedures. After confirmation the location of the target tumor, the dissections of the anterior mediastinum were separated and sectioned progressively. After the operation, the main chest tube (22-Fr) was inserted and connected to an underwater sealed bottle for postoperative drainage. The criteria for tube removal were no air leakage and a drainage volume of less than 200 mL per day. Color of the drainage fluid must be within tolerance interval. Complications were all treated with appropriate medication when necessary. Patients were discharged only if the patients’ well-being achieved the criteria assessed by senior doctors. Statistical analysis Clinical information of all selected patients was gathered by the authors from the database of the Second Affiliated Hospital of Zhejiang University. A one-to-one propensity score matching analysis was used for the comparison of the uniportal and three-portal video-assisted thoracoscopic (UP-VATS and TP-VATS) thymectomy. A multinomial logistic regression model was applied based on age, sex, smoking history, body mass index, tumor diameter and location, and pathologic style. A 1:1 match was achieved using the nearest neighbor-matching algorithm with a caliper definition of 0.02. In order to ensure that the final outcome could produce stable results, matching was repeated several times. Variables are presented as proportions, means, or medians where appropriate. Data were compared using Student’s t test, χ 2 test, one-way ANOVA or the Mann-Whitney U test where appropriate. All statistical analyses were performed with SPSS version 23.0 (International Business Machines Corporation, Armonk, NY, USA). Significant differences were defined with p value below 0.05. Results Clinical baseline The surgical location for (UP-VATS and TP-VATS) thymectomy groups was shown in the Fig. 1. From January 2013 to December 2022, 363 patients with thymoma were enrolled for analysis in this study (Fig. 2). The first 20 cases in the uniportal and three-portal video-assisted thoracoscopic (UP-VATS and TP-VATS) thymectomy groups were excluded to account for the learning curve effect. Among the 323 patients, 115 underwent the uniportal video-assisted thoracoscopic (UP-VATS) thymectomy, and 208 accepted the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy. After propensity score matching analysis, a total of 230 closely matched patients were picked up in the end. The baseline demographic parameters and clinical characteristics of the study cohort before and after matching are listed in Table 1. As shown in Table 1, the demographic and clinical characteristics of the two groups were well balanced. There was no significant difference between patients in these groups in terms of demographic parameters and clinical characteristics. Perioperative outcomes between the two groups. The perioperative comparisons are presented in Table 2. During the procedure, intraoperative frozen sections were routinely obtained. TP-VATS procedure took shorter operative time (96.7±2.1 min vs 117.2±5.3 ml, p < 0.001), resulted in less volume of drainage (76.1±1.3 ml vs 86.2±1.7 ml, p =0.078) than the UP-VATS procedure. Additionally, the main chest tube (22-Fr) could be removed on postoperative day (POD) 1 from patients in the UP-VATS group, which was similar with the TP-VATS group (1.1±0.03 vs. 1.2±0.03, p = 0.054). The estimated volume of blood loss (54.9±7.1 vs. 57.3±3.7, p = 0.092), the conversion (6.1% vs. 4.3%, p = 0.553), length of hospital stay (6.0±0.3 vs. 6.5±0.3, p = 0.631), the complication rate (14.8% vs. 12.2%, p = 0.562) were comparable between the two groups with no significant differences. Intraoperatively, there were 7 patients in the UP-VATS group who were converted to thoracotomy, while 5 patients in the TP-VATS group were converted to thoracotomy, due to uncontrolled bleeding (injury to the innominate vein) and severe adhesion in the thoracic cavity. There were 3 cases of blood transfusion in the UP-VATS group and 2 cases in the TP-VATS group during the operation for uncontrolled bleeding (2.6% vs. 1.7%, p = 0.596) (injury to the innominate vein and the estimated volume of blood loss≥300ml). Major complications included chylothorax, atelectasis, empyema, pulmonary infection and pleural effusion. There was no intraoperative mortality and postoperative 30-day mortality between approaches. Perioperative outcomes in the TP-VATS thymectomy group. Whether the perioperative outcomes in the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy group varied with the preoperative variables (age, sex, tumor location, tumor size and pathological type), the TP-VATS thymectomy group was divided into subgroups for perioperative outcomes analysis. The comparison results are presented in Table 3. Subgroups procedure of tumor location(left), tumor size(≥3cm) took longer operative time than subgroups procedure of tumor location(right), tumor size(≤3cm). (101.3±2.3 min vs 79.2±2.5 min, p < 0.001) (107.3±3.3 min vs 88.7±2.3 min, p =0.024) (Table 3). Subgroups procedure of tumor size(＜3cm) was associated with less volume of blood loss than subgroups procedure of tumor size(≥3cm). (28.8±4.0 min vs 53.3±4.2 min, p=0.01). Discussion Accounting for nearly 20% to 40% of all types of mediastinal tumors in adults, thymoma is the most common mediastinal tumor. Thymectomy is indicated in various diseases, including thymoma, thymic cysts, and thymus carcinoma, and thymectomy is also a therapeutic option. The surgical approach to thymectomy remains controversial, and a variety of different techniques have been introduced in recent decades, each with its advantages and disadvantages. Complete thymectomy by open sternotomy is the traditional standard treatment for both benign and malignant thymomas(8, 9). Proponents of open approaches to thymectomy discuss excellent visualization of the thymus and its surrounding structures as well as the ease of resection and reconstruction of involved structures. Recently, there has been considerable interest in expanding minimally invasive approaches for the surgical treatment of thymic resection for both thymoma and myasthenia gravis. On account of the variety of approaches and techniques used for thymectomy, the International Thymic Malignancy Interest Group defined minimally invasive thymectomy as ‘‘any approach as long as no sternotomy (including partial sternotomy) or thoracotomy with rib spreading is involved and in which a complete resection of the tumor is intended.’’ As a minimally invasive surgery, VATS is relatively easy to be adopted. The use of VATS thymectomy in patients was described over two decades ago(10). Proponents of MIT endorse improved visualization of the thymus gland and surrounding structures over open thymectomy (OT), and shorter recovery following surgery. A number of studies on thymectomy have demonstrated favorable short-term advantages of MIT by comparing with sternotomy. The potential benefits include a smaller incision away from the midline, less trauma to the chest wall, faster healing, earlier return to normal activities and work, decreased post-operative length of stay, decreased cytokines, complete remission and no difference in outcomes. Less trauma and faster healing times also permit earlier administration of adjuvant chemo-radiation treatment in advanced cases. An increasing number of studies have shown that minimally invasive thoracoscopic surgery has significant advantages in different patients and types for mediastinal tumors, including anterior mediastinal tumor with myasthenia gravis.(11-15) There are some studies reporting the advantages in surgical outcomes of VATS for thymectomy. According to these reports, VATS thymectomy demonstrated a superior outcome in terms of hospital stay, intraoperative blood loss, and cosmetic satisfaction when compared with open access surgery(5, 16). This minimally invasive thymectomy (MIT) have gained popularity for patients due to its favorable surgical treatment outcomes. In our institution, video-assisted thoracoscopic surgery (VATS) was employed in different ways, mainly including the uniportal video-assisted thoracoscopic (UP-VATS) thymectomy and the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy. Because the effectiveness of these two minimally invasive thymectomy (MIT) is unknown, we utilized our institutional dataset to determine whether UP-VATS thymectomy is equivalent with TP-VATS thymectomy. In this retrospective study, the TP-VATS thymectomy had a potential advantage compared with the UP-VATS thymectomy. The operative time in the TP-VATS group were significantly lower than those in the UP-VATS group. This significant difference between the two groups could be caused by attribution of CO2 insufflation. CO2 insufflation through a complete portal approach opens up the confined anterior mediastinum space and allows for bilateral phrenic nerve visualization and bilateral thymic horn dissection. Postoperative drainage and chest tube removal were not significantly different. Additionally, no significant differences in other perioperative outcomes were exist between the two groups. The VATS thymectomy is superior to the open procedures in regard to post-operative pain. However, the pain difference between the UP-VATS group and TP-VATS was not analysed in our study in consideration of subjectivity nature of the visual analog pain score (VAS) score and distinction in the control for pain management after the operation among patients. In our study, there was no difference in morbidity between the two groups, and also there was no difference in the incidence of complications. The overall morbidities were 14.8% an 12.2% in the UP-VATS group and the TP-VATS group respectively. Additionally, there was no death case in both groups, no significant difference in mortality was exist between the two groups. In our study, Postoperative length of hospital, postoperative drainage and duration of chest tube drainage in our analysis were similar between the two groups. our perioperative data showed that the difference between the two groups regarding operative time and perioperative blood loss was not statistically significant. In this study, there was no difference in blood transfusion during the operation and length of hospital stay between the two groups. The length of hospital stay was 6.5±0.3d in the TP-VATS, compared with 6.0±0.3 d in the UP-VATS. Intraoperatively, there were 7 patients in the UP-VATS group who were converted to thoracotomy, while 5 patients in the TP-VATS group were converted to thoracotomy, due to uncontrolled bleeding (injury to the innominate vein) and severe adhesion in the thoracic cavity. There were 2 cases of blood transfusion during the operation in TP-VATS group for uncontrolled bleeding，with 3 cases in UP-VATS group (injury to the innominate vein and the estimated volume of blood loss≥300ml). No significant differences were exist between two groups. Tumor location and size is a major concern before considering VATS thymectomy. Girard and colleagues (17) stated that VATS was contraindicated for large tumors, whereas Youssef and colleagues(18) suggested that VATS thymectomy was more appropriate in tumors smaller than 3 cm in diameter，more advantageous in tumors located in the right side .In the subgroups analysis, our results indicated that the tumor size bigger than 3 cm in diameter, the tumor location in the left anterior mediastinum would significantly take more operation time, compared with the corresponding subgroups. Meanwhile, subgroups analysis results indicated that the tumor size bigger than 3 cm in diameter, would significantly cause more blood loss during the procedure, compared with the corresponding subgroups. There are several limitations to this study. First, the major limitation is the retrospective single center design with its observational nature. Second, the surgical procedure performed and the decision to convert to open surgery were at the discretion of the surgeon, which might have resulted in potential bias. Third, our center had a limited number of cases. More cases series should be investigated to establish the validity of our procedure result. Conclusion In conclusion, this propensity score-matched study suggests that the uniportal video-assisted thoracoscopic (UP-VATS) thymectomy and the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy are associated with similar perioperative period outcomes for thymoma. Additionally, three-portal video-assisted thoracoscopic (TP-VATS) thymectomy provides an alternative for the thymoma treatment, depending on the surgeon preference and mastery. Abbreviations video-assisted thoracoscopic surgery (VATS) postoperative day (POD) open thymectomy (OT) uniportal video-assisted thoracoscopic thymectomy (UP-VATS) three-portal video-assisted thoracoscopic thymectomy (TP-VATS) Declarations Acknowledgements We acknowledge all members of Department of Thoracic Surgery, 2 nd Affiliated Hospital, Zhejiang University, Hangzhou, China for their support. Funding Not applicable. Competing interests The authors declare that they have no competing interests Authors’ contributions ZPY and GFZ participated in all aspects of the experiment, ZPY and GS drafted the article. All authors read and approved the final manuscript. Availability of data and materials The datasets used and analysed in the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University. The research involved no more than minimal risk to the participants. This study was retrospective data analysis of previously collected medical records. References Rascoe PA, Kucharczuk JC, Cooper JD. Surgery of the mediastinum: historical notes. Thorac Surg Clin 2009;19:1-5. Heilmann C, Stahl R, Schneider C, Sukhodolya T, Siepe M, Olschewski M, Beyersdorf F. Wound complications after median sternotomy: a single-centre study. Interact Cardiovasc Thorac Surg 2013;16:643-648. Burt BM, Yao X, Shrager J, Antonicelli A, Padda S, Reiss J, Wakelee H, et al. Determinants of Complete Resection of Thymoma by Minimally Invasive and Open Thymectomy: Analysis of an International Registry. J Thorac Oncol 2017;12:129-136. Jurado J, Javidfar J, Newmark A, Lavelle M, Bacchetta M, Gorenstein L, D'Ovidio F, et al. Minimally invasive thymectomy and open thymectomy: outcome analysis of 263 patients. Ann Thorac Surg 2012;94:974-981; discussion 981-972. Meyer DM, Herbert MA, Sobhani NC, Tavakolian P, Duncan A, Bruns M, Korngut K, et al. Comparative clinical outcomes of thymectomy for myasthenia gravis performed by extended transsternal and minimally invasive approaches. Ann Thorac Surg 2009;87:385-390; discussion 390-381. Bachmann K, Burkhardt D, Schreiter I, Kaifi J, Busch C, Thayssen G, Izbicki JR, et al. Long-term outcome and quality of life after open and thoracoscopic thymectomy for myasthenia gravis: analysis of 131 patients. Surg Endosc 2008;22:2470-2477. Whitson BA, Andrade RS, Mitiek MO, D'Cunha J, Maddaus MA. Thoracoscopic thymectomy: technical pearls to a 21st century approach. J Thorac Dis 2013;5:129-134. Maniscalco P, Tamburini N, Quarantotto F, Grossi W, Garelli E, Cavallesco G. Long-term outcome for early stage thymoma: comparison between thoracoscopic and open approaches. Thorac Cardiovasc Surg 2015;63:201-205. Blalock A, Mason MF, Morgan HJ, Riven SS. MYASTHENIA GRAVIS AND TUMORS OF THE THYMIC REGION: REPORT OF A CASE IN WHICH THE TUMOR WAS REMOVED. Ann Surg 1939;110:544-561. Sugarbaker DJ. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653-656. Jiao J, Yu J, Chen C, Chen T, Zheng T, He L, Zeng Q. Thoracoscopic approach for massive thymic hyperplasia in an infant: Case report and literature review. Front Pediatr 2023;11:1144384. Gu Z, Hao X, Liu Y, Xu N, Zhang X, Li B, Mao T, et al. Minimally Invasive Thymectomy Could Be Attempted for Locally Advanced Thymic Malignancies: A Real-World Study With Propensity Score-Matched Analysis. J Thorac Oncol 2023;18:640-649. Alvarez A, Moreno P. Minimally invasive thymectomy: the best option for early and locally advanced epithelial thymomas. Eur J Cardiothorac Surg 2022;62. Raja SM, Guptill JT, McConnell A, Al-Khalidi HR, Hartwig MG, Klapper JA. Perioperative Outcomes of Thymectomy in Myasthenia Gravis: A Thoracic Surgery Database Analysis. Ann Thorac Surg 2022;113:904-910. Jung Y, Hong JI, Han KN, Kim HK. Thoracoscopic anterior mediastinal mass removal using an articulating laparoscopic instrument. Interact Cardiovasc Thorac Surg 2021;33:498. Zahid I, Sharif S, Routledge T, Scarci M. Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis? Interact Cardiovasc Thorac Surg 2011;12:40-46. Girard N, Mornex F, Van Houtte P, Cordier JF, van Schil P. Thymoma: a focus on current therapeutic management. J Thorac Oncol 2009;4:119-126. Youssef SJ, Louie BE, Farivar AS, Blitz M, Aye RW, Vallières E. Comparison of open and minimally invasive thymectomies at a single institution. Am J Surg 2010;199:589-593. Tables Table 1 Baseline demographics and characteristics of patients before and after matching. All patients P value Propensity-matched patients P value Single-port（n=115） Three-port（n=208） Single-port（n=115） Three-port（n=115） Age（year） 54.63±0.94 55.5±0.72 0.684 54.63±0.94 55.39±0.99 0.812 Sex 0.732 0.509 Male (%) 53（46.1） 100（48.1） 53（46.1） 58（50.4） Female (%) 62（53.9） 108（51.9） 62（53.9） 57（49.6） Smoking history 0.617 0.890 Yes (%) 41（35.7） 80（38.5） 41（35.7） 40（34.8） No (%) 74（64.3） 128（61.5） 74（64.3） 75（65.2） BMI (kg/m2) 23.70±0.24 23.62±0.18 0.834 23.7±0.24 23.3±0.25 0.597 Pathologic stage 0.600 0.086 ≤ B1 (%) 54(47.0) 104（50.0） 54(47.0) 67(58.3) ＞B1 (%) 61（53.0） 104（50.0） 61（53.0） 48（41.7） Tumor size（cm） 4.20±0.17 4.27±0.12 0.972 4.20±0.17 4.16±0.15 0.540 Location 0.743 0.690 Left (%) 52（45.2） 98（47.1） 52（45.2） 49（42.6） Right (%) 63（54.8） 110（52.9） 63（54.8） 66（57.4） Table 2 perioperative outcomes of patients in both groups. Single-port（n=115） Three-port（n=115） P value Operative time（min） 117.2±5.3 96.7±2.1 <0.001 Blood loss（ml） 54.9±7.1 57.3±3.7 0.092 Conversion (%) 7（6.1%） 5（4.3%） 0.553 Chest tube removal(day) 1.1±0.03 1.2±0.03 0.054 Blood transfusion (%) 3（2.6%） 2（1.7%） 0.596 postoperative drainage（ml） 86.2±1.7 76.1±1.3 0.078 Length of stay（days） 6.0±0.3 6.5±0.3 0.631 Major complications Atelectasis (%) 2（1.7%） 3（2.6%） 0.651 Poor wound healing (%) 3（2.6%） 4（3.5%） 0.701 Pneumonia (%) 12（10.4%） 7（6.1%） 0.231 Total (%) 17（14.8%） 14（12.2%） 0.562 Mortally (%) 0 0 - Table 3 Comparison of clinical variables and perioperative outcomes of three-port surgery (n =115) Variable n operative time（min） Blood loss（ml） length of stay（day） age(year) ＜60 76 94.9±2.6 51.6±4.8 8.2±0.3 ≥60 39 100.0±3.6 41.5±4.5 9.0±0.5 p value 0.837 0.163 0.107 sex male 58 96.0±2.9 45.2±4.2 8.7±0.4 female 57 97.3±3.0 51.2±5.7 8.2±0.4 p value 0.854 0.856 0.124 tumor size（cm) ≥3 24 101.3±2.3 53.3±4.2 8.8±0.3 ＜3 91 79.2±2.5 28.8±4.0 7.2±0.4 p value <0.001 0.01 0.089 location left 49 107.3±3.3 44.9±6.0 8.0±0.3 right 66 88.7±2.3 50.6±4.3 8.8±0.4 p value 0.024 0.561 0.341 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5312029","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370337832,"identity":"21e785da-ce10-4420-bd87-f1cc04a1c509","order_by":0,"name":"Zipu Yu","email":"","orcid":"","institution":"second affiliated hospital of Zhejiang university","correspondingAuthor":false,"prefix":"","firstName":"Zipu","middleName":"","lastName":"Yu","suffix":""},{"id":370337833,"identity":"57ac5758-2d35-4245-8196-519d29d0bcc2","order_by":1,"name":"Guofei Zhang","email":"","orcid":"","institution":"second affiliated hospital of Zhejiang university","correspondingAuthor":false,"prefix":"","firstName":"Guofei","middleName":"","lastName":"Zhang","suffix":""},{"id":370337834,"identity":"27817848-129d-4217-86a9-0b1fcc1d1ca6","order_by":2,"name":"Gang Shen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIie3RvQrCMBDA8SsnmU66pgj6CpFCFwVfJSLYSdBFHCuCLj5AxMFnEF+gJeBUdHVwKPgCji5+1cmpxk0w/+3gfhwkADbbD+YiJpkcNasA8XNkBsSbsY44p13fnIg9Bd5iqtvRazQhoMn3iWG4GqcCzkMN7jIqFs6EDU5ErDeOUuGonQZ+jIsJIm584tSbQCqwPNUguCwmDCGokOAhy8nVhBCWAk9JISknjgnhmD9yLOsKtv1kvguJHz6Q1l4nWft2r9WUXmeXYaPqqg/k7V78+kwy3X/mRl8s22w221/1AIeRQSH9asi4AAAAAElFTkSuQmCC","orcid":"","institution":"second affiliated hospital of Zhejiang university","correspondingAuthor":true,"prefix":"","firstName":"Gang","middleName":"","lastName":"Shen","suffix":""}],"badges":[],"createdAt":"2024-10-22 13:08:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5312029/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5312029/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69077055,"identity":"b9680705-04d0-4c19-9fc0-47b614265abd","added_by":"auto","created_at":"2024-11-15 11:19:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":957545,"visible":true,"origin":"","legend":"\u003cp\u003eUniportal and three-portal video-assisted thoracoscopic thymoma resection for the treatment of thymoma.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5312029/v1/646ad36c94ad699920ad8960.png"},{"id":69078134,"identity":"75027017-7632-48ae-970f-de0ab6ed3e80","added_by":"auto","created_at":"2024-11-15 11:27:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":373178,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart summarizing patient enrolment in this study\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5312029/v1/8f4de6e3d5d6b01e34a07675.png"},{"id":81178655,"identity":"0debbcf2-26a3-4d2d-a77e-54e6e5efe359","added_by":"auto","created_at":"2025-04-23 06:53:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2654231,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5312029/v1/1001df32-95eb-4a50-8798-233238d5be05.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of uniportal and three-portal video-assisted thoracoscopic thymectomy for thymoma: a propensity score-matched study.","fulltext":[{"header":"Background","content":"\u003cp\u003eFor over a century, median sternotomy has been considered as the standard approach for the anterior mediastinum tumor(1). However, thoracic surgeons are striving to explore the other less invasive approaches because of the significant morbidity associated with median sternotomy approach(2). On account of endeavor for the past decades, there has been a significant increase in the adoption of minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS).\u003c/p\u003e\n\u003cp\u003eMinimally invasive surgical approaches for thymectomy have gained popularity for patients. A variety of studies suggested that video-assisted thoracoscopic surgery (VATS) has improved surgical treatment outcomes. Video-assisted thoracoscopic surgery (VATS) has many advantages by comparison with the traditional thymectomy. VATS thymectomy has been associated with shorter hospital stay, less operative blood loss and decreased postoperative pain (3-7).\u003c/p\u003e\n\u003cp\u003eTo investigate the efficacy of the minimally invasive thymectomy, a retrospective comparison of perioperative outcomes for patients was conducted between the uniportal and three-portal video-assisted thoracoscopic (UP-VATS and TP-VATS) thymectomy. We retrospectively compared clinical data from patients who underwent the UP-VATS thymectomy or the TP-VATS thymectomy technique.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFrom January 2013 to December 2022, patients were admitted for surgical assessment in the Department of Thoracic Surgery of the Second Affiliated Hospital of Zhejiang University. This study was authorized by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University (2021-0696). The operability evaluation included a panel of oncological assessments (including respiratory function tests, computed tomography scanning of the chest or magnetic resonance imaging chest, brain magnetic resonance imaging), and standard pulmonary and cardiac function tests. Based on the results of assessments, the surgical treatment regimen was decided by senior consultant surgeons.\u003c/p\u003e\n\u003cp\u003eClinical and demographic data (including age, sex, smoking history, body mass index, tumor diameter and location and pathologic style) were recorded. The operative time, estimated volume of blood loss, blood transfusion during the operation, conversion to the traditional thoracotomy, length of hospital stay, chest tube removal, complications, volume of postoperative drainage, mortality within 30 days\u0026nbsp;were collected. The first TP-VATS thymectomy was performed in our department in 2013. The UP-VATS thymectomy technique was employed in 2015, whereas some surgeons still performed TP-VATS thymectomy for individual preference. The first 20 cases in each group were excluded to account for the learning curve effect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneral anesthesia and double-lumen endotracheal intubation were routinely used. All patients were in the horizontal position with the surgery side elevating upward. The surgeon and assistant stood on the surgery sides of the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the uniportal video-assisted thoracoscopic\u0026nbsp;(UP-VATS) thymectomy, a\u003c/p\u003e\n\u003cp\u003e4 cm incision was made between the midaxillary and anterior axillary line \u0026nbsp; in the fourth intercostal space (in the fifth intercostal space for women). For the three-portal video-assisted thoracoscopic\u0026nbsp;(TP-VATS) thymectomy, a 1cm incision was made at the anterior axillary line in the third intercostal space as the assistant utility port. \u0026nbsp;Another 1cm incision was made at the midaxillary line in the fifth intercostal space as the observation port. A 3 cm mini-thoracotomy was made at the fifth intercostal space between the midclavicular line and anterior axillary line in the fifth intercostal space as the major utility port. In the TP-VATS, the major utility port was sealed with a plastic protective jacket. In the UP-VATS, a plastic protective jacket was used for the only port with no sealing during the procedure. Pneumoperitoneum with a pressure of 8 cm H\u003csub\u003e2\u003c/sub\u003eO was used in the TP-VATS procedures. After confirmation the location of the target tumor, the dissections of the anterior mediastinum were separated and sectioned progressively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter the operation, the main chest tube (22-Fr) was inserted and connected to an underwater sealed bottle for postoperative drainage. The criteria for tube removal were no air leakage and a drainage volume of less than 200 mL per day. Color of the drainage fluid must be within tolerance interval. Complications were all treated with appropriate medication when necessary. Patients were discharged only if the patients\u0026rsquo; well-being achieved the criteria assessed by senior doctors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical information of all selected patients was gathered by the authors from the database of the Second Affiliated Hospital of Zhejiang University. A one-to-one propensity score matching analysis was used for the comparison of the uniportal and three-portal video-assisted thoracoscopic\u0026nbsp;(UP-VATS and TP-VATS) thymectomy. A multinomial logistic regression model was applied based on age, sex, smoking history, body mass index, tumor diameter and location, and pathologic style. A 1:1 match was achieved using the nearest neighbor-matching algorithm with a caliper definition of 0.02. In order to ensure that the final outcome could produce stable results, matching was repeated several times.\u003c/p\u003e\n\u003cp\u003eVariables are presented as proportions, means, or medians where appropriate. Data were compared using Student\u0026rsquo;s t test, \u0026chi;\u003csup\u003e2\u003c/sup\u003e test, one-way ANOVA or the Mann-Whitney U test where appropriate. All statistical analyses were performed with SPSS version 23.0 (International Business Machines Corporation, Armonk, NY, USA). Significant differences were defined with p value below 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eClinical baseline\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgical location for (UP-VATS and TP-VATS) thymectomy groups was shown in the Fig. 1. From January 2013 to December 2022, 363 patients with thymoma were enrolled for analysis in this study (Fig. 2). The first 20 cases in the uniportal and three-portal video-assisted thoracoscopic\u0026nbsp;(UP-VATS and TP-VATS) thymectomy groups were excluded to account for the learning curve effect. Among the 323 patients, 115 underwent the uniportal video-assisted thoracoscopic\u0026nbsp;(UP-VATS) thymectomy, and 208 accepted the three-portal video-assisted thoracoscopic\u0026nbsp;(TP-VATS) thymectomy. After propensity score matching analysis, a total of 230 closely matched patients were picked up in the end. The baseline demographic parameters and clinical characteristics of the study cohort before and after matching are listed in Table 1. \u0026nbsp;As shown in Table 1, the demographic and clinical characteristics of the two groups were well balanced. There was no significant difference between patients in these groups in terms of demographic parameters and clinical characteristics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative outcomes between the two groups.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe perioperative comparisons are presented in Table 2. During the procedure, intraoperative frozen sections were routinely obtained. TP-VATS procedure took shorter operative time (96.7\u0026plusmn;2.1 min vs 117.2\u0026plusmn;5.3 ml, p \u0026lt; 0.001), resulted in less volume of drainage (76.1\u0026plusmn;1.3 ml vs 86.2\u0026plusmn;1.7 ml, p =0.078) than the UP-VATS procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, the main chest tube (22-Fr) could be removed on postoperative day (POD) 1 from patients in the UP-VATS group, which was similar with the TP-VATS group (1.1\u0026plusmn;0.03 vs. 1.2\u0026plusmn;0.03, p = 0.054). The estimated volume of blood loss (54.9\u0026plusmn;7.1 vs. 57.3\u0026plusmn;3.7, p = 0.092), the conversion (6.1% vs. 4.3%, p = 0.553), length of hospital stay (6.0\u0026plusmn;0.3 vs. \u0026nbsp;6.5\u0026plusmn;0.3, p = 0.631), the complication rate (14.8% vs. \u0026nbsp; 12.2%, p = 0.562)\u0026nbsp;were comparable between the two groups with no significant differences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntraoperatively, there were 7\u0026nbsp;patients in the UP-VATS group who were converted to thoracotomy, while 5 patients in the TP-VATS group were converted to thoracotomy, due to uncontrolled bleeding (injury to the innominate vein) and severe adhesion in the thoracic cavity. There were 3 cases of blood transfusion in the UP-VATS group and 2 cases in the TP-VATS group during the operation for uncontrolled bleeding (2.6% vs. 1.7%, p = 0.596) (injury to the innominate vein and the estimated volume of blood loss\u0026ge;300ml). Major complications included chylothorax, atelectasis, empyema, pulmonary infection and pleural effusion. There was no intraoperative mortality and postoperative 30-day mortality between approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative outcomes in the TP-VATS thymectomy group.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhether the perioperative outcomes in the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy group varied with the preoperative variables (age, sex, tumor location, tumor size and pathological type), the TP-VATS thymectomy group was divided into subgroups for perioperative outcomes analysis. The comparison results are presented in Table 3. Subgroups procedure of tumor location(left), tumor size(\u0026ge;3cm) took longer operative time than subgroups procedure of tumor location(right), tumor size(\u0026le;3cm). (101.3\u0026plusmn;2.3 min vs 79.2\u0026plusmn;2.5 min, p \u0026lt; 0.001) (107.3\u0026plusmn;3.3 min vs 88.7\u0026plusmn;2.3 min, p =0.024) (Table 3). Subgroups procedure of tumor size(＜3cm) was associated with less volume of blood loss than subgroups procedure of tumor size(\u0026ge;3cm). (28.8\u0026plusmn;4.0 min vs 53.3\u0026plusmn;4.2 min, p=0.01).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccounting for nearly 20% to 40% of all types of mediastinal tumors in adults, thymoma is the most common mediastinal tumor. Thymectomy is indicated in various diseases, including thymoma, thymic cysts, and thymus carcinoma, and thymectomy is also a therapeutic option. The surgical approach to thymectomy remains controversial, and a variety of different techniques have been introduced in recent decades, each with its advantages and disadvantages. Complete thymectomy by open sternotomy is the traditional standard treatment for both benign and malignant thymomas(8, 9). Proponents of open approaches to thymectomy discuss excellent visualization of the thymus and its surrounding structures as well as the ease of resection and reconstruction of involved structures. Recently, there has been considerable interest in expanding minimally invasive approaches for the surgical treatment of thymic resection for both thymoma and myasthenia gravis. On account of the variety of approaches and techniques used for thymectomy, the International Thymic Malignancy Interest Group defined minimally invasive thymectomy as \u0026lsquo;\u0026lsquo;any approach as long as no sternotomy (including partial sternotomy) or thoracotomy with rib spreading is involved and in which a complete resection of the tumor is intended.\u0026rsquo;\u0026rsquo; As a minimally invasive surgery, VATS is relatively easy to be adopted. The use of VATS thymectomy in patients was described over two decades ago(10). Proponents of MIT endorse improved visualization of the thymus gland and surrounding structures over open thymectomy (OT), and shorter recovery following surgery. A number of studies on thymectomy have demonstrated favorable short-term advantages of MIT by comparing with sternotomy. The potential benefits include a smaller incision away from the midline, less trauma to the chest wall, faster healing, earlier return to normal activities and work, decreased post-operative length of stay, decreased cytokines, complete remission and no difference in outcomes. Less trauma and faster healing times also permit earlier administration of adjuvant chemo-radiation treatment in advanced cases. An increasing number of studies have shown that minimally invasive thoracoscopic surgery has significant advantages in different patients and types for mediastinal tumors, including anterior mediastinal tumor with myasthenia gravis.(11-15) There are some studies reporting the advantages in surgical outcomes of VATS for thymectomy. According to these reports, VATS thymectomy demonstrated a superior outcome in terms of hospital stay, intraoperative blood loss, and cosmetic satisfaction when compared with open access surgery(5, 16).\u003c/p\u003e\n\u003cp\u003eThis minimally invasive thymectomy (MIT) have gained popularity for patients due to its favorable surgical treatment outcomes. In our institution, video-assisted thoracoscopic surgery (VATS) was employed in different ways, mainly including the uniportal video-assisted thoracoscopic (UP-VATS) thymectomy and the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy. Because the effectiveness of these two minimally invasive thymectomy (MIT) is unknown, we utilized our institutional dataset to determine whether UP-VATS thymectomy is equivalent with TP-VATS thymectomy. In this retrospective study, the TP-VATS thymectomy had a potential advantage compared with the UP-VATS thymectomy. The operative time in the TP-VATS group were significantly lower than those in the UP-VATS group. This significant difference between the two groups could be caused by attribution of CO2 insufflation. CO2 insufflation through a complete portal approach opens up the confined anterior mediastinum space and allows for bilateral phrenic nerve visualization and bilateral thymic horn dissection. Postoperative drainage and chest tube removal were not significantly different. Additionally, no significant differences in other perioperative outcomes were exist between the two groups.\u003c/p\u003e\n\u003cp\u003eThe VATS thymectomy is superior to the open procedures in regard to post-operative pain. However, the pain difference between the UP-VATS group and TP-VATS was not analysed in our study in consideration of subjectivity nature of the visual analog pain score (VAS) score and distinction in the control for pain management after the operation among patients. In our study, there was no difference in morbidity between the two groups, and also there was no difference in the incidence of complications. The overall morbidities were 14.8% an 12.2% in the UP-VATS group and the TP-VATS group respectively. Additionally, there was no death case in both groups, no significant difference in mortality was exist between the two groups. \u003c/p\u003e\n\u003cp\u003eIn our study, Postoperative length of hospital, postoperative drainage and duration of chest tube drainage in our analysis were similar between the two groups. our perioperative data showed that the difference between the two groups regarding operative time and perioperative blood loss was not statistically significant. In this study, there was no difference in blood transfusion during the operation and length of hospital stay between the two groups. The length of hospital stay was 6.5\u0026plusmn;0.3d in the TP-VATS, compared with 6.0\u0026plusmn;0.3 d in the UP-VATS. Intraoperatively, there were 7 patients in the UP-VATS group who were converted to thoracotomy, while 5 patients in the TP-VATS group were converted to thoracotomy, due to uncontrolled bleeding (injury to the innominate vein) and severe adhesion in the thoracic cavity. There were 2 cases of blood transfusion during the operation in TP-VATS group for uncontrolled bleeding，with 3 cases in UP-VATS group (injury to the innominate vein and the estimated volume of blood loss\u0026ge;300ml). No significant differences were exist between two groups. \u003c/p\u003e\n\u003cp\u003eTumor location and size is a major concern before considering VATS thymectomy. Girard and colleagues (17) stated that VATS was contraindicated for large tumors, whereas Youssef and colleagues(18) suggested that VATS thymectomy was more appropriate in tumors smaller than 3 cm in diameter，more advantageous in tumors located in the right side .In the subgroups analysis, our results indicated that the tumor size bigger than 3 cm in diameter, the tumor location in the left anterior mediastinum would significantly take more operation time, compared with the corresponding subgroups. Meanwhile, subgroups analysis results indicated that the tumor size bigger than 3 cm in diameter, would significantly cause more blood loss during the procedure, compared with the corresponding subgroups. \u003c/p\u003e\n\u003cp\u003eThere are several limitations to this study. First, the major limitation is the retrospective single center design with its observational nature. Second, the surgical procedure performed and the decision to convert to open surgery were at the discretion of the surgeon, which might have resulted in potential bias. Third, our center had a limited number of cases. More cases series should be investigated to establish the validity of our procedure result.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this propensity score-matched study suggests that the uniportal video-assisted thoracoscopic (UP-VATS) thymectomy and the three-portal video-assisted thoracoscopic (TP-VATS) thymectomy \u0026nbsp; are associated with similar perioperative period outcomes for thymoma. Additionally, three-portal video-assisted thoracoscopic (TP-VATS) thymectomy provides an alternative for the thymoma treatment, depending on the surgeon preference and mastery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003evideo-assisted thoracoscopic surgery (VATS)\u003c/p\u003e\n\u003cp\u003epostoperative day (POD)\u003c/p\u003e\n\u003cp\u003eopen thymectomy (OT)\u003c/p\u003e\n\u003cp\u003euniportal video-assisted thoracoscopic\u0026nbsp;thymectomy (UP-VATS)\u003c/p\u003e\n\u003cp\u003ethree-portal video-assisted thoracoscopic thymectomy (TP-VATS)\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge all members of Department of Thoracic Surgery, 2\u003csup\u003end\u003c/sup\u003e Affiliated Hospital, Zhejiang University, Hangzhou, China for their support. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZPY and GFZ\u0026nbsp;participated in all aspects of the experiment, ZPY and GS drafted the article. All authors read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed in the current study are available from the corresponding author on reasonable request. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University. The research involved no more than minimal risk to the participants. This study was retrospective data analysis of previously collected medical records.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRascoe PA, Kucharczuk JC, Cooper JD. Surgery of the mediastinum: historical notes. Thorac Surg Clin 2009;19:1-5.\u003c/li\u003e\n\u003cli\u003eHeilmann C, Stahl R, Schneider C, Sukhodolya T, Siepe M, Olschewski M, Beyersdorf F. Wound complications after median sternotomy: a single-centre study. Interact Cardiovasc Thorac Surg 2013;16:643-648.\u003c/li\u003e\n\u003cli\u003eBurt BM, Yao X, Shrager J, Antonicelli A, Padda S, Reiss J, Wakelee H, et al. Determinants of Complete Resection of Thymoma by Minimally Invasive and Open Thymectomy: Analysis of an International Registry. J Thorac Oncol 2017;12:129-136.\u003c/li\u003e\n\u003cli\u003eJurado J, Javidfar J, Newmark A, Lavelle M, Bacchetta M, Gorenstein L, D\u0026apos;Ovidio F, et al. Minimally invasive thymectomy and open thymectomy: outcome analysis of 263 patients. Ann Thorac Surg 2012;94:974-981; discussion 981-972.\u003c/li\u003e\n\u003cli\u003eMeyer DM, Herbert MA, Sobhani NC, Tavakolian P, Duncan A, Bruns M, Korngut K, et al. Comparative clinical outcomes of thymectomy for myasthenia gravis performed by extended transsternal and minimally invasive approaches. Ann Thorac Surg 2009;87:385-390; discussion 390-381.\u003c/li\u003e\n\u003cli\u003eBachmann K, Burkhardt D, Schreiter I, Kaifi J, Busch C, Thayssen G, Izbicki JR, et al. Long-term outcome and quality of life after open and thoracoscopic thymectomy for myasthenia gravis: analysis of 131 patients. Surg Endosc 2008;22:2470-2477.\u003c/li\u003e\n\u003cli\u003eWhitson BA, Andrade RS, Mitiek MO, D\u0026apos;Cunha J, Maddaus MA. Thoracoscopic thymectomy: technical pearls to a 21st century approach. J Thorac Dis 2013;5:129-134.\u003c/li\u003e\n\u003cli\u003eManiscalco P, Tamburini N, Quarantotto F, Grossi W, Garelli E, Cavallesco G. Long-term outcome for early stage thymoma: comparison between thoracoscopic and open approaches. Thorac Cardiovasc Surg 2015;63:201-205.\u003c/li\u003e\n\u003cli\u003eBlalock A, Mason MF, Morgan HJ, Riven SS. MYASTHENIA GRAVIS AND TUMORS OF THE THYMIC REGION: REPORT OF A CASE IN WHICH THE TUMOR WAS REMOVED. Ann Surg 1939;110:544-561.\u003c/li\u003e\n\u003cli\u003eSugarbaker DJ. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg 1993;56:653-656.\u003c/li\u003e\n\u003cli\u003eJiao J, Yu J, Chen C, Chen T, Zheng T, He L, Zeng Q. Thoracoscopic approach for massive thymic hyperplasia in an infant: Case report and literature review. Front Pediatr 2023;11:1144384.\u003c/li\u003e\n\u003cli\u003eGu Z, Hao X, Liu Y, Xu N, Zhang X, Li B, Mao T, et al. Minimally Invasive Thymectomy Could Be Attempted for Locally Advanced Thymic Malignancies: A Real-World Study With Propensity Score-Matched Analysis. J Thorac Oncol 2023;18:640-649.\u003c/li\u003e\n\u003cli\u003eAlvarez A, Moreno P. Minimally invasive thymectomy: the best option for early and locally advanced epithelial thymomas. Eur J Cardiothorac Surg 2022;62.\u003c/li\u003e\n\u003cli\u003eRaja SM, Guptill JT, McConnell A, Al-Khalidi HR, Hartwig MG, Klapper JA. Perioperative Outcomes of Thymectomy in Myasthenia Gravis: A Thoracic Surgery Database Analysis. Ann Thorac Surg 2022;113:904-910.\u003c/li\u003e\n\u003cli\u003eJung Y, Hong JI, Han KN, Kim HK. Thoracoscopic anterior mediastinal mass removal using an articulating laparoscopic instrument. Interact Cardiovasc Thorac Surg 2021;33:498.\u003c/li\u003e\n\u003cli\u003eZahid I, Sharif S, Routledge T, Scarci M. Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis? Interact Cardiovasc Thorac Surg 2011;12:40-46.\u003c/li\u003e\n\u003cli\u003eGirard N, Mornex F, Van Houtte P, Cordier JF, van Schil P. Thymoma: a focus on current therapeutic management. J Thorac Oncol 2009;4:119-126.\u003c/li\u003e\n\u003cli\u003eYoussef SJ, Louie BE, Farivar AS, Blitz M, Aye RW, Valli\u0026egrave;res E. Comparison of open and minimally invasive thymectomies at a single institution. Am J Surg 2010;199:589-593.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Baseline demographics and characteristics of patients before and after matching.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"556\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAll patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePropensity-matched patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eSingle-port（n=115）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eThree-port（n=208）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eSingle-port（n=115）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eThree-port（n=115）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAge（year）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e54.63\u0026plusmn;0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e55.5\u0026plusmn;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e54.63\u0026plusmn;0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e55.39\u0026plusmn;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e0.812\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e0.509\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMale (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e53（46.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e100（48.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e53（46.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e58（50.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eFemale (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e62（53.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e108（51.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e62（53.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e57（49.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSmoking history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eYes (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e41（35.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e80（38.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e41（35.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e40（34.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eNo (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e74（64.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e128（61.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e74（64.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e75（65.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eBMI (kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e23.70\u0026plusmn;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e23.62\u0026plusmn;0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.834\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e23.7\u0026plusmn;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e23.3\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ePathologic stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026le; B1 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e54(47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e104（50.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e54(47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e67(58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e＞B1 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e61（53.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e104（50.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e61（53.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e48（41.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTumor size（cm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e4.20\u0026plusmn;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.27\u0026plusmn;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.972\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.20\u0026plusmn;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e4.16\u0026plusmn;0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eLeft (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e52（45.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e98（47.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e52（45.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e49（42.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eRight (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e63（54.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e110（52.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e63（54.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e66（57.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 perioperative outcomes of patients in both groups.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"553\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003eSingle-port（n=115）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003eThree-port（n=115）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eOperative time（min）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e117.2\u0026plusmn;5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e96.7\u0026plusmn;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(226, 80, 65);\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eBlood loss（ml）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e54.9\u0026plusmn;7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e57.3\u0026plusmn;3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eConversion (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e7（6.1%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e5（4.3%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eChest tube removal(day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e1.1\u0026plusmn;0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e1.2\u0026plusmn;0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eBlood transfusion (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e3（2.6%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e2（1.7%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.596\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003epostoperative\u0026nbsp;drainage（ml）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e86.2\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e76.1\u0026plusmn;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eLength of stay（days）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e6.0\u0026plusmn;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e6.5\u0026plusmn;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.631\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eMajor complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eAtelectasis (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e2（1.7%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e3（2.6%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003ePoor wound healing (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e3（2.6%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e4（3.5%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003ePneumonia (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e12（10.4%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e7（6.1%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eTotal (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e17（14.8%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e14（12.2%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e0.562\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31.2839%;\"\u003e\n \u003cp\u003eMortally (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.1356%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.859%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.7215%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eComparison of clinical variables and perioperative outcomes of three-port surgery (n =115)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"531\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003eoperative time（min）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003eBlood loss（ml）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003elength of stay（day）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003eage(year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003e＜60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e94.9\u0026plusmn;2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e51.6\u0026plusmn;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e8.2\u0026plusmn;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003e\u0026ge;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e100.0\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e41.5\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e9.0\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e0.837\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003esex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e96.0\u0026plusmn;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e45.2\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e8.7\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e97.3\u0026plusmn;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e51.2\u0026plusmn;5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e8.2\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e0.854\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e0.856\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003etumor size（cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e101.3\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e53.3\u0026plusmn;4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e8.8\u0026plusmn;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003e＜3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e79.2\u0026plusmn;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e28.8\u0026plusmn;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e7.2\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(226, 80, 65);\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(226, 80, 65);\"\u003e0.01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003elocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003eleft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e107.3\u0026plusmn;3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e44.9\u0026plusmn;6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e8.0\u0026plusmn;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003eright\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e88.7\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e50.6\u0026plusmn;4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e8.8\u0026plusmn;0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16.855%;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.7702%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 24.812%;\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(226, 80, 65);\"\u003e0.024\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.1203%;\"\u003e\n \u003cp\u003e0.561\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 23.4962%;\"\u003e\n \u003cp\u003e0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Video-assisted thoracoscopic surgery, Thymectomy, Uniportal, Three-portal, Thymoma ","lastPublishedDoi":"10.21203/rs.3.rs-5312029/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5312029/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMinimally invasive thymectomy (MIT) is a surgical approach to thymectomy. To investigate the efficacy of the minimally invasive thymectomy, a retrospective comparison for perioperative outcomes of patients was conducted between uniportal and three-portal video-assisted thoracoscopic thymectomy (UP-VATS and TP-VATS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA detailed database search identified 135 patients treated withUP-VATS thymectomy technique and 228 patients treated via TP-VATS thymectomy technique between January 2013 and December 2022. Propensity score-matched analysis was used to compare the perioperative outcomes between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The first 20 patients were excluded respectively to account for the learning curve effect in both groups. 115 patients in each group were screened after propensity match. There were 14.8% morbidity in the UP-VATS group and 12.2% morbidity in the TP-VATS group, no significant differences were exist between two groups. Furthermore, no significant differences in other perioperative outcomes were exist between two groups. Although the volume of drainage (86.2 vs. 76.1, p = 0.078) were similar between the two groups, the operative time in the UP-VATS group (117.2 vs. 96.7, p \u0026lt; 0.001) was longer than that in the TP-VATS group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSION: \u003c/strong\u003eThymectomy treatment of (TP-VATS) is an advisable procedure for patients with thymoma, while these two minimally invasive thymectomy techniques are both appropriate for thymoma treatment.\u003c/p\u003e","manuscriptTitle":"Comparison of uniportal and three-portal video-assisted thoracoscopic thymectomy for thymoma: a propensity score-matched study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 11:19:38","doi":"10.21203/rs.3.rs-5312029/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb8e1b05-b17f-4a56-9a1c-8b2e7a863e40","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-23T06:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-15 11:19:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5312029","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5312029","identity":"rs-5312029","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}