Uniportal video-assisted thoracic surgery resection of pericardial cysts: a retrospective single-center study

Introduction

Background

Pericardial cysts are rare congenital anomalies, with an estimated incidence of 1 in 100,000 individuals. They account for approximately 33% of all mediastinal cysts and 7% of mediastinal masses (1). While the majority of pericardial cysts are asymptomatic, about 75% are discovered incidentally during imaging for unrelated conditions (2). Statistically, the right cardiophrenic angle is the most common location, with cysts reported in this region in 51% to 70% of cases, while the left cardiophrenic angle is involved in 22% to 38% cases (3). Histopathologically, pericardial cysts are characterized by a relatively simple fibrous tissue wall lined by simple cuboidal mesothelial cells, lacking specialized epithelium or smooth muscle cells (4). When symptomatic, these cysts may present with non-specific symptoms such as chronic cough, chest pain, dyspnea, and retrosternal pressure. Additionally, large cysts may cause recurrent pulmonary infections due to chronic compression of the adjacent lung parenchyma (5). In rare instances, they may lead to more severe and potentially life-threatening complications such as arrhythmias, syncope, or even pericardial tamponade (6). Currently, the standard diagnostic modality for pericardial cysts is chest computed tomography (CT), as it provides a detailed view of the pericardial anatomy and helps delineate cyst characteristics. While many cysts are asymptomatic and require no intervention, surgical treatment may be necessary for symptomatic or enlarging cysts (6).

Rationale and knowledge gap

The optimal management approach remains a subject of debate, particularly with regard to surgical indications and the efficacy of minimally invasive technique like uniportal video-assisted thoracic surgery (U-VATS). While numerous studies have described the clinical presentation and diagnosis of pericardial cysts, a consensus on the best surgical approach is lacking.

Since the early 1990s, video-assisted thoracic surgery (VATS) has progressively replaced open thoracotomy for the resection of benign mediastinal lesions, including pericardial cysts. The first procedures were performed using triportal VATS, which provided excellent visualization and safety but involved multiple intercostal incisions. Subsequent refinements led to biportal and, more recently, U-VATS approaches. This progressive evolution reflects the broader shift in thoracic surgery toward less invasive, function-preserving techniques.

Despite these advantages, evidence regarding the optimal surgical approach for pericardial cysts remain limited. Published reports are often confined to small case series or technical notes. Some studies suggest that minimally invasive techniques like U-VATS offer several advantages including shorter recovery times, reduced postoperative pain, and fewer complications compared to traditional open surgery (7). Recent studies, including the report by Koçak et al. (8), have explored the feasibility of U-VATS for mediastinal cysts but often included heterogeneous lesion types or limited outcome reporting. The present study focuses exclusively on pericardial cysts and provides comprehensive clinical, surgical, and follow up data from a consecutive series of patients managed entirely with the U-VATS approach. This focused analysis provides additional evidence supporting the safety, feasibility, and applicability of U-VATS for the management of benign pericardial lesions.

Nevertheless, the effectiveness of U-VATS for pericardial cyst resection has not been conclusively established, particularly in the context of larger or more anatomically complex cysts.

Objective

The aim of this study is to evaluate the safety and efficacy of the U-VATS technique for the resection of pericardial cysts, particularly in cases of varying sizes and anatomical complexities. We present this article in accordance with the STROBE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-34/rc).

Methods

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was reviewed by the Institutional Review Board (IRB) of Catholic University of Sacred Heart, which confirmed that, as a retrospective review conducted for service evaluation within a departmental audit approved by the Department of General Thoracic Surgery, no additional formal IRB approval was required. No experimental interventions or modifications of patients’ care were introduced as part of this research. Written informed consent was obtained from all patients before the surgical operation for the publication of this article and accompanying anonymous images.

Study design

This study is a retrospective, single-center analysis conducted between 2021 and 2024 at the Department of General Thoracic Surgery, Catholic University of the Sacred Heart (our center). It includes 12 consecutive patients who underwent surgical resection of pericardial cysts using the U-VATS technique, with no exclusion criteria applied. Data collected included patient demographics, cyst characteristics (size, location, and complexity), perioperative outcomes, length of hospital stay, postoperative complications, and follow-up results. Surgical indication was established after multidisciplinary evaluation. Surgery was offered to patients who were symptomatic or whose cysts demonstrated progressive enlargement, atypical radiologic features, or uncertain differential diagnosis on imaging. In selected asymptomatic patients, particularly those with an oncologic history or inconclusive imaging, surgical excision was indicated to achieve definitive diagnosis and to exclude alternative mediastinal pathologies. The decision was individualized based on clinical presentation, imaging findings, and patient preference. All procedures were performed by a single surgical team to maintain consistency in technique and care.

Surgical technique

At our center, the U-VATS approach is employed for nearly all oncological and non-oncological procedures, whenever feasible (9). All procedures in this study were performed under general anesthesia. The anesthesia team used double-lumen endotracheal intubation to ensure proper lung isolation and to facilitate lung deflation during the procedure (10). Patients were positioned in lateral decubitus using a vacuum mattress, with both arms flexed and extended towards the head (11). In the standard U-VATS approach, a single incision, typically 3–4 cm in length, is made in the fourth or fifth intercostal spaces along the mid-axillary line. This incision serves as the access point for the entire procedure. For pericardial cyst removal, the incision was made along the anterior axillary line, offering better access and optimal visualization of the cyst. A 10-mm, 30° thoracoscope was introduced through the same incision, protected by a wound retractor, to allow high-definition visualization of the thoracic cavity. In addition to the thoracoscope, specific endoscopic instruments were also introduced through the same incision. Once the pericardial cyst was identified, it was carefully dissected and excised using endoscopic instruments, ensuring minimal trauma to surrounding tissues. In selected cases of large or tense cysts, controlled aspiration of the cystic content was performed to facilitate safer dissection and improve visualization. This step was undertaken only after intraoperative assessment confirmed benign macroscopic features, based on the judgment of the senior surgeon. The entire cyst wall was subsequently removed and sent for histopathological examination, ensuring definitive diagnosis and minimizing the risk of recurrence. However, these decisions are inherently subjective and may differ across centers.

At the end of the procedure, a 24- or 28-Fr chest tube was placed through the same incision to evacuate residual air or fluid and ensure proper lung re-expansion. The chest tube was generally removed once proper lung re-expansion was confirmed and there were no signs of complications, such as pneumothorax or pleural effusion.

Primary and secondary outcomes

The primary outcome was the safety and effectiveness of the U-VATS approach, evaluated through the occurrence of intraoperative or postoperative complications, the need for conversion, and completeness of cyst resection. The secondary outcomes included the duration of chest drain, length of hospital stay, and the presence of symptom resolution during follow-up.

Statistical analysis

Data were analyzed using descriptive statistics to summarize patient demographics, cyst characteristics, and surgical outcomes. Continuous variables, such as age and cyst size, were reported as means with standard deviations (SDs) or medians with interquartile ranges (IQRs) for non-normally distributed variables, while categorical variables, including symptom status and postoperative complications, were expressed as frequencies and percentages. Statistical analysis was performed using SPSS 25.0 (SPSS Inc., Chicago, IL, USA).

Results

A total of 12 patients underwent surgical resection of pericardial cysts using the U-VATS technique at our center. The cohort consisted predominantly of male patients (58%), with a mean age of 59.6±21.3 years. The cysts were primarily located on the right side of the chest (58%). Cyst size varied significantly, with an average size of 5.6±3.8 cm. Four of the cysts (33.3%) exhibited complex morphology, including internal septations, irregular contours, and extensive intrathoracic extension, requiring meticulous dissection to avoid injury to adjacent structures. Table 1 summarizes the main clinical characteristics, surgical approach, and postoperative outcomes of the 12 cases.

Regarding symptom presentation, 7 patients (58%) were symptomatic, with persistent cough being the most common complaint, followed by dyspnea and chest pain. The remaining patients were asymptomatic, with cysts discovered incidentally during radiological examinations for unrelated medical conditions or during follow-up for other diseases.

All the resections were performed using the U-VATS approach. The surgical procedures were well tolerated. The mean hospital stay was 2.3±1.4 days (range, 1–5 days). The chest drain was removed after an average of 2±1.0 days (range, 1–5 days).

One patient (Case 6) experienced significant bleeding during the procedure due to the highly vascularized adhesions of the cyst to surrounding structures, which required a second revision surgery for hemostasis. This procedure was successfully performed through the same uniportal access without further complications. According to the Clavien-Dindo classification, the only postoperative event observed—a case of bleeding requiring revision through the same uniportal access—was graded as a minor (grade II) complication. No Grade III or higher complications occurred in this series. No other patient experienced significant postoperative complications.

The size of the cysts varied, with the largest being 17 cm (Case 10) (Figure 1), while the smallest was 2.2 cm (Case 2). Interestingly, despite the smaller size of the cyst, one of the most complex resections was performed for Case 5, where a cyst measuring 9.4 cm craniocaudally presented extensive anatomical relationships with surrounding structures such as the trachea, thyroid gland, and epiaortic vessels. Nonetheless, the cyst was completely excised without leaving residual tissue or leading to complications.

Figure 1 Intraoperative view of pericardial cyst resection using U-VATS approach. (A) Intraoperative view of a large pericardial cyst exhibiting a tense and translucent wall, while occupying the entire operative field and pushing on the diaphragm. (B) Final step of the resection procedure, performed after intentional rupture of the cyst to allow safer mobilization and complete removal of its adherent wall. U-VATS, uniportal video-assisted thoracic surgery.

Histological examination was consistently performed after pericardial cyst removal. In all twelve cases, the diagnosis was a serous pericardial cyst, characterized by a flat, single-layered epithelial lining without atypia, confirming the benign nature of the cysts.

Postoperative follow-up was conducted over a median period of 18 months. Both clinical and radiological evaluations showed no evidence of recurrences during this period. Symptomatic patients reported complete resolution of their preoperative symptoms, including resolution of cough and dyspnea. Postoperative pain was minimal or absent, and no patients experienced paresthesia or other neurological complications. Aesthetic outcomes were also satisfactory, with no complaints regarding surgical scar, as shown in Figure 2.

Figure 2 Uniportal access site at the end of the procedure. A single incision of approximately 3 cm is visible in the anterior axillary line, through which a chest tube has been placed.

Discussion

Key findings

To the best of our knowledge, this study represents the largest single-center series to date reporting the surgical resection of pericardial cysts using the U-VATS approach. In our cohort, all procedures were completed successfully without conversion. Only one patient experienced minor bleeding after surgery, which was effectively managed through the same uniportal access. The mean hospital stay was relatively short, reflecting the minimally invasive nature and favorable postoperative recovery associated with this approach. No other major postoperative complications or recurrences were observed during follow-up. These results reinforce that U-VATS is safe, reliable, and effective technique for the management of pericardial cysts of varying sizes and anatomical complexities. Our findings are consistent with and expand upon those of Koçak et al. (8), who published the first series of four pericardial cysts treated by the U-VATS approach, with excellent results in terms of post-operative and clinical outcomes.

Strengths and limitations

This study has several important strengths as it provides valuable insights into the application of the U-VATS approach for the management of pericardial cysts. All procedures were performed by a single experienced surgical team using a standardized technique in our center, ensuring uniformity in perioperative management, technical execution, and postoperative care. Notably, no conversions to open surgery or multi-port approaches occurred, and no recurrences were observed during a median 18-month follow-up, indicating excellent long-term surgical outcomes.

Importantly, the cohort included complex and anatomically challenging cysts, such as lesions adjacent to critical mediastinal structures, all of which were successfully resected, reinforcing the feasibility and safety of the U-VATS technique in both routine and demanding scenarios.

Beyond these technical outcomes, the study highlights the practical benefits of U-VATS, including short hospital stay, minimal postoperative discomfort, and favorable aesthetic results, which collectively support its role as a patient-centered minimally invasive strategy.

While the results of this series support the feasibility and safety of U-VATS for pericardial cyst resection, it is important to acknowledge some limitations. First, the retrospective nature of the study and the relatively small cohort size may limit generalizability of the findings. Second, as a descriptive study, it was not designed for direct comparison with other surgical techniques. Additionally, the U-VATS technique may present ergonomic challenges, particularly for less experienced surgeons, due to the limited maneuverability of instruments through a single port. The learning curve for mastering U-VATS should not be underestimated, especially when dealing with large or adherent cysts.

Comparison with similar research

The first documented cases of pericardial cysts date back to the mid-19^th century, when they were identified by pathologists during autopsies (12). Advancements in thoracic surgery led to the first successful resection of a pericardial cyst, performed by Pickhardt et al. (13) from Lenox Hill Hospital in New York in 1931 on a 53-year-old woman. The introduction of VATS marked a pivotal shift toward minimally invasive management of benign mediastinal lesions, including pericardial cysts.

One of the earliest works to document exclusive treatment of this pathology using a minimally invasive VATS approach was by Menconi et al. (14), who described five patients, three of whom had a confirmed radiological diagnosis of pericardial cyst. In the two remaining cases, the differential diagnosis included other thoracic pathologies, making it impossible to establish a definitive diagnosis based solely on radiological images. Three patients were symptomatic. All patients underwent cyst removal via VATS, with no postoperative complications and a short hospital stay. These results suggested that VATS, due to its minimally invasive nature, is a suitable approach both for diagnosis of atypical lesions and therapeutic management of symptomatic cysts.

Since then and the current literature includes several case reports and small case series of pericardial cyst successfully treated using the VATS and robotic-assisted thoracic surgery (RATS) technique (Table 2).

The work published by Poffo et al. (16) documents the first case of a pericardial cyst successfully treated with RATS surgery. RATS has emerged as a promising alternative for the removal of symptomatic pericardial cysts. Compared to traditional VATS, RATS offers several key advantages, making it an appealing option for dealing with pericardial cysts or mediastinal lesions as it provides enhanced dexterity through its robotic arms, which allow greater maneuverability and more intricate movements within confined anatomical spaces, such as the mediastinum. In addition, the robotic arms’ flexibility offers a multi-angle “wrist” feature, which allows to navigate complex areas more easily. The magnified three-dimensional field of view allows for a clear visualization of structures, which can be critical when working around delicate organs and reducing the risk of inadvertent injury to surrounding tissue (19). Despite its advantages, RATS is not without its challenges. The procedure requires the use of more expensive equipment, which increase the overall cost of the procedure, making it less accessible and limiting its use in some centers. Also, the artificial pneumothorax during surgery can sometimes result in small cysts being displaced from their original positions, potentially leading to missed lesions. This is particularly true for small cysts located in the anterior mediastinum, where the magnification of the robotic system can obscure the lesion due to a narrowed field of view (19). In terms of postoperative recovery, RATS generally demonstrates superior outcomes compared to standard VATS. Studies have shown that RATS is associated with shorter operative times, reduced intraoperative bleeding, and quicker postoperative recovery, including a shorter chest drainage time and hospital stay (19). These advantages are especially relevant in the context of pericardial cyst resections, where minimizing trauma to the chest and reducing recovery times are critical for patient outcomes.

VATS, on the other hand, remains an effective and widely accessible technique, especially due to the advancement of U-VATS that has further enhanced the appeal of this technique. Indeed, compared to traditional VATS approach, the use of a single port in U-VATS also simplifies the procedure, reducing the risk of complications such as bleeding or infection associated with multiple incisions. The ability to perform the surgery with a single incision ensures that patients experience a less invasive procedure, with quicker recovery times and fewer complications, resulting in lower levels of postoperative pain and discomfort with better cosmetic outcome, while still achieving the desired surgical outcomes (20).

Explanations of findings

The favorable outcomes observed in this study can be attributed to several key factors related to a careful surgical planning, appropriate case selection, and the intrinsic advantages of the U-VATS approach. In nearly all reported cases in the literature, surgical indication was prompted either by the presence of symptoms or by the inability to establish a definitive diagnosis—criteria that were also used at our center. Most individuals with pericardial cysts are asymptomatic, with fewer than 25% showing symptoms related to compression of nearby structures. When present, symptoms are nonspecific and may include persistent cough, chest discomfort, shortness of breath, and retrosternal pressure. Occasionally, patients might experience dysrhythmias, fainting, or pneumonia (5). Extremely rare but serious complications, such as pericardial tamponade, have also been documented in association with pericardial cysts.

Additionally, pericardial cysts are commonly misdiagnosed with several other conditions including bronchial cysts, diaphragmatic cysts, mediastinal tumors, congenital malformations, and inflammatory or infectious lesions such as abscesses or granulomas as reported in the case described by Menconi et al. (14). In our cohort, symptomatic presentation or proximity to vital structures (as seen in Cases 2, 3, and 8) were the main drivers of surgical decision-making. Moreover, Case 9, who had a history of double head and neck carcinoma, underwent surgical intervention and histological examination to achieve a definitive diagnosis, despite not being symptomatic. In Case 3, surgical exploration was justified by the differential diagnosis, which included a diaphragmatic cyst. In all other cases, the choice of surgical intervention was driven by the presence of significant and disabling symptoms in the patients.

The U-VATS approach enabled safe and effective resections even in anatomically challenging cases, where cysts presented with intricate relationships to major mediastinal structures (trachea, thyroid, epiaortic vessels), yet complete resection was achieved without complications. These results highlight the excellent exposure and precision allowed by the uniportal approach.

Moreover, the low morbidity and absence of conversions in our series likely reflect both the experience of the surgical team and careful preoperative planning. The use of a standardized technique, high-definition visualization, and refined dissection strategies contributed to the smooth intraoperative course observed in all but one case.

Finally, the consistent histological confirmation of benign serous pericardial cysts in all patients underscores the importance of surgical excision not only as a therapeutic intervention but also for definitive diagnosis, particularly in cases with atypical imaging features.

Implications and actions needed

The findings of this study reinforce the role of U-VATS as a safe, effective, and minimally invasive surgical option for the treatment of pericardial cysts, including cases with complex anatomy or large size. The absence of conversions, low complication rates, and favorable follow-up outcomes support its broader adoption in clinical practice, particularly in centers with adequate thoracoscopic experience.

The reduced number of incisions, short chest drainage duration, fast recovery, and excellent cosmetic outcomes associated with U-VATS further enhance its appeal in elective surgical settings. These benefits, combined with its accessibility and cost-effectiveness, suggest that U-VATS can be considered as first-line surgical strategy for appropriately selected patients.

Further studies are needed to compare U-VATS and RATS approaches in the treatment of pericardial cysts, to better understand the situations in which each technique is most beneficial. Ultimately, the choice between RATS and U-VATS should also be guided by the surgeon’s expertise and the available resources at the treating institution.

Conclusions

According to our preliminary results, the U-VATS approach seems to be a safe and effective approach for resection of pericardial cysts of varying sizes and complexity. The procedure was associated with shorted recovery times and a low incidence of complications. Additionally, the aesthetic outcomes were favorable. However, further studies, including randomized controlled trials and comparisons with other surgical techniques, are needed to more definitely establish the benefits of U-VATS in the management of pericardial cysts.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-34/rc

Data Sharing Statement: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-34/dss

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-34/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-34/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was reviewed by the Institutional Review Board (IRB) of Catholic University of Sacred Heart, which confirmed that, as a retrospective review conducted for service evaluation within a departmental audit approved by the Department of General Thoracic Surgery, no additional formal IRB approval was required. No experimental interventions or modifications of patients’ care were introduced as part of this research. Written informed consent was obtained from all patients before the surgical operation for the publication of this article and accompanying anonymous images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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