Interactive Cardiovascular and Thoracic Surgery 3:201-203(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Work in progress report - Thoracic general |
Extended posterolateral–subcostal thoracotomy for extrapleural pneumonectomy: a surgical approach for radical operation of pleural mesothelioma
Kotaro Kameyama,
Cheng-long Huang,
Eiichi Hayashi and
Hiroyasu Yokomise*
Second Department of Surgery, Kagawa Medical University, 1750-1, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
* Corresponding author. Tel.: +81-87-891-2191; fax: +81-87-891-2192
yokomise{at}kms.ac.jp
Received June 12, 2003;
received in revised form October 7, 2003;
accepted November 11, 2003
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Abstract
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Extrapleural pneumonectomy is an essential procedure in multimodality therapy of malignant pleural mesothelioma. However, radical resection may be difficult in a standard posterolateral thoracotomy because the edge of the diaphragm is located in the dead angle of the pleural cavity. We have tried a subcostal thoracotomy following a posterolateral thoracotomy (extended posterolateral–subcostal thoracotomy) for extrapleural pneumonectomy. With extended posterolateral–subcostal thoracotomy, ideal surgical resection, with en bloc removal of the lung, parietal pleura, pericardium and diaphragm, can be performed radically, but safely, without a second thoracotomy. We conclude that extended posterolateral–subcostal thoracotomy is an effective approach for extrapleural pneumonectomy.
Key Words: Thoracotomy; Pleural cavity; Mesothelioma; Pleural disease; Diaphragm
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1. Introduction
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Wide exposure of the pleural cavity is required in some cases in thoracic surgery. Extrapleural pneumonectomy is an essential procedure in multimodality therapy of malignant pleural mesothelioma [1,2]. A radical resection should be performed to obtain tumor-free resection margins [3]. However, this may be difficult in a standard posterolateral thoracotomy because the edge of the diaphragm is located in the dead angle of the pleural cavity. Sometimes, a second thoracotomy is required. Therefore, we attempted a subcostal thoracotomy following a posterolateral thoracotomy (extended posterolateral–subcostal thoracotomy) for an extrapleural pneumonectomy requiring adequate exposure of the diaphragm.
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2. Surgical technique
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A standard posterolateral incision is extended along the anterior costal arch (Fig. 1). A blunt dissection is begun extrapleurally at the fifth intercostal space, and the parietal pleura is stripped off the chest wall. The sixth and seventh costal cartilages are transected after the dissection reaches the anterior chest wall. The rectus abdominis, external abdominal oblique, internal abdominal oblique, and transversus abdominis muscles are dissected from the costal arch and the peritoneum is exposed. A blunt dissection divides the peritoneum from the diaphragmatic muscle. Subsequent procedures follow the technique proposed by Sugarbaker and colleagues [1]. Radical surgical resection is performed, with en bloc removal of the lung, parietal pleura, pericardium and diaphragm. Reconstruction of the diaphragm and pericardium is carried out with prosthetic impermeable patches. The transected sixth and seventh costal cartilages are closed with a heavy stainless steel wire suture.
Extrapleural pneumonectomy was performed using extended posterolateral–subcostal thoracotomy in four patients (right side 3, left side 1) with malignant pleural mesothelioma. This approach provided wide and continuous exposure of the pleural cavity from the diaphragm to the apex in all patients (Fig. 2A). A blunt dissection easily divided the diaphragm to preserve the underlying peritoneum while providing adequate exposure of the diaphragmatic edge (Fig. 2B). There were no postoperative complications that were directly attributable to the extended posterolateral–subcostal thoracotomy. Postoperative pains, sufficiently controlled with epidural anesthesia, were at the same level as pain from a standard posterolateral thoracotomy.
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Fig. 2 (A) The right pleural cavity after extrapleural pneumonectomy. (B) The right costophrenic angle after extrapleural pneumonectomy. White arrows indicate the head side. A black arrow indicates the retroperitoneal fat pad under the diaphragm. CC, costal cartilages; Eso, esophagus; ICV, inferior caval vein; Peri, peritoneum; RA, right atrium; RMB, right main bronchus; SCV, superior caval vein; Ver, vertebra.
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3. Discussion
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Extrapleural pneumonectomy is an essential procedure in multimodality therapy of malignant pleural mesothelioma [1,2]. Some reports have described extrapleural pneumonectomy for selected cases of malignant disease, such as advanced lung cancer and thymic malignancies [4,5]. Although the operative mortality of extrapleural pneumonectomy has been decreasing, it is still one of the most invasive thoracic surgeries [2]. In extrapleural pneumonectomy, radical resection should be performed to obtain tumor-free resection margins [3]. However, radical resection may be difficult in a standard posterolateral thoracotomy. We feel that resection is quite difficult because the edge of the diaphragm is located in the dead angle of the pleural cavity. Indeed some reports state that a second thoracotomy in the ninth or tenth intercostal space is available in such cases [6], but the second thoracotomy does not provide continuous exposure, and the view from the thoracotomy is narrow. The extended posterolateral–subcostal thoracotomy was designed to provide wide and continuous exposure of the pleural cavity from the diaphragm to the apex. With this thoracotomy, ideal surgical resection, with en bloc removal of the lung, parietal pleura, pericardium and diaphragm, can be performed radically, but safely. Because this approach provides adequate exposure of the diaphragmatic edge, a blunt dissection easily divides the diaphragm to preserve the underlying peritoneum. This thoracotomy can also be extended from a standard posterolateral thoracotomy. We conclude that extended posterolateral–subcostal thoracotomy is an effective approach for extrapleural pneumonectomy.
doi:10.1016/j.icvts.2003.11.001
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References
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Abstract
1. Introduction