Transcript TECHNIQUE OF PLEURAL PNEUMONECTOMY IN DIFFUSE MESOTHELIOMA

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（1L, 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%.