Clamshell thoracotomy for mediastinal mass resection: technical refinements and short-term outcomes in the largest single-center cohort

BACKGROUND: The clamshell thoracotomy remains controversial for mediastinal mass resection because of its extensive exposure but significant injuries. This study evaluated its modern indications, technical refinements, and short-term outcomes at a high-volume center. METHODS: A single-center, single-arm prospective investigation was conducted on 78 patients who underwent clamshell thoracotomy for mediastinal masses. Two CT-based radiological parameters were developed to quantify anatomical complexity. Short-term outcomes were presented and analyzed. RESULTS: The cohort (median age 51 years; 71.8% male) included 68 primary tumors and 10 recurrent/metastatic tumors. The median operative time was 275 minutes, with a blood loss of 500 mL. Pulmonary resections (79.5%) and vascular reconstructions (65.4%) were frequently required. The postoperative 90-day mortality rate was 5.1%. The radiological classification was proposed as four types: A (bulky), B (hilar), C (deep-tricky), and D (mixed). Modified incisions might reduce tissue trauma without compromising exposure. CONCLUSIONS: Clamshell thoracotomy was essential for addressing giant or deep mediastinal tumors, particularly when vascular control or multiplanar dissection was necessary. The CT-based radiological parameters and the classification might improve preoperative planning. All these reflected a single center's experience and criteria.