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Mature mediastinal teratomas are benign germ cell tumours that rarely present with extensive involvement of intrathoracic structures. We report the case of a patient with an 11 × 10 × 10 cm heterogeneous anterior mediastinal mature teratoma compressing the right atrium, right ventricle, superior vena cava and aorta with perforation into the right pleural cavity and associated hemidiaphragm elevation. Given the density of adhesions, a median sternotomy was indicated. Extensive intrapericardial adhesiolysis, dissection of tumour and adhesions off the right lung, hemidiaphragm and heart, as well as the great vessels was performed, along with right lung decortication . The mass was ultimately resected as completely as possible en bloc with the involved right pericardium and phrenic nerve. The resected specimen contained hair, fat and calcifications.