[Technical pitfalls of pleural dissection in extrapleural pneumonectomy].

Because extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) suffers from unsatisfiable risk/benefit ratio, very careful consideration on its indication should be required. EPP is a complicated, multi-step surgery that includes pleural dissection, division of hilum, resection of a block of pleura, lung, diaphragm and pericardium, and reconstruction of diaphragm and pericardium. Therefore establishment of surgical images of whole procedures before starting surgery is essential. Dissection of parietal pleura is a particularly important procedure of EPP, because it determinates operating time, surgical blood loss, surgical morbidity/mortality and curability. Technical difficulty of pleural dissection strikingly differs according to the degree of pleural thickening, pleural adhesion and the severity of pleural invasion of the tumor. Although good surgical view is essential for safety, excessive thoracotomy may lead to postoperative pain and respiratory disorder. Underestimation of clinical stage is rather common in MPM even after vigorous preoperative assessment. Surgeons sometimes encounter T4 (i.e., unresectable) MPM such as diffuse chest wall invasion, vascular invasion, peritoneal invasion, and positive pericardial effusion that have not been detected preoperatively. Therefore, potentially-T4 site should be 1st processed for possible discontinuance of operation.