TECHNIQUE OF PLEURAL PNEUMONECTOMY IN

DIFFUSE MESOTHELIOMA

GENERAL THORACIC SURGERY

CHAPTER 66

Extrapleural pneumonectomy

• Improvement in operative mortality since 1970 （ 30% to 6% ） .

• Patient selection, preoperative preparation, intraoperative management, postoperative care with this extremely complex disease.

Staging

• Use the Butchart staging system— Surgical resection only appropriate for stage I disease.

• Brigham stage I and II as potentially respectable. Table 66-2.

Patient selection

• Karnofsky performance status higher than 70. • Normal liver and liver function, • ABG – Room air PCO2 less than 45 mmHg, PO2

more than 65 mmHg. • Lung function and ventilation–perfusion scan

normal. • Echocardiography, CT and MRI– For determine

the presence of transdiaphragmatic extention or mediastinal invasion.

Technique of right side extrapleural pneumonectomy

• Before thoracotomy, limited subcostal incision– Explore the possible transdiaphragmatic involvement. (May laparoscopic exploration). If peritoneal invasion, the thoracotomy should be terminated.

• Left lateral decubitus position, extended right posterolateral thoracotomy,

• N.G. tube.

Technique of right side extrapleural pneumonectomy

• Sixth ribs is excised. • Widely based extrapleural blunt and sharp

dissection. • Superiorly toward the apex and anterior

component. • Posterior latterly after adequate exposure of

anterior side which can provide safe view of mediastinal structure.

Technique of right side extrapleural pneumonectomy

• Brachial triangle is exposed carefully– To avoid avulsion of subclavian artery and vein

• Protected internal mammary artery.

• Open pericardium with resection posterior to hilum.

• Diaphragm is dissected off the peritoneum by blunt dissection using sponge stick.

Technique of right side extrapleural pneumonectomy

• Ligated the right main pulmonary artery, superior and interior pulmonary vein, right main stem bronchus.

• Pericardial fat-pad– Cover the cutting end of bronchus.

• Radical lymph node dissection. • Right side pericardium is reconstructed by

prothetic patch to prevent cardiac herniation. • Diaphragm reconstructed by prosthetic

impermeable patch.

Technique of left side extrapleural pneumonectomy

• Dissection is less difficult. • Dissection the posteromedial aspect – Should

entering correct plane in preaortic region – To prevent avulsion intercostals vessels.

• Assessment of aorta is critical step on left side pleuropneumonectomy.

• Protect esophagus. • Pericardium is NOT routinely reconstructed–

Because of risk of cardiac herniation is low.

Technique of extrapleural pneumonectomy

• Hemostasis— Intra-operative blood loss 750 for right side and 500 for left side.

• Use argon beam coagulator and electrocautery for the numerous small vessels in extrapleural plane.

Postoperative management

• Control pain.

• Minimize intravascular volume change （ 1-L, 24hour fluid restriction for 3-5 days ） .

• DVT prophylaxis.

• Bed rest 48 hours– To facilitate mediastinal stability.

Result

• Mortality 3.8% （ 1999 ） .

• 2-year survival – 38%.

• 5-year survival – 15%.