Extended pleurectomy and decortication: Video atlas of operative steps Article Swipe

Central MessageThe operative steps for an extended pleurectomy and decortication are described with a video atlas. An ePD can achieve a macroscopic complete resection for MPM with preservation of the lung.See Commentary on page 331.Feature Editor Note—Video Atlas Articles (VAAs) are peer-reviewed descriptions of an operative procedure distilled into a series of steps, with each step taught to the reader through its own narrated video and short corresponding text. The purpose of the VAA is to provide continuing surgical education in a format that is quality-assured, easily accessible, and high impact. Much of the excitement around our new series of VAAs surrounds robotic and thoracoscopic/laparoscopic procedures. Our field has progressed rapidly into one in which robotic and thoracoscopic surgery have improved clinical outcomes, and we drive much of the innovation in minimally invasive surgical platforms and technique. The ability to record high-resolution video during the routine conduct of robotic and thoracoscopic/laparoscopic surgery has facilitated this opportunity in structured, peer-reviewed, expert instruction of index cases in thoracic surgery and is the bedrock for the VAA initiative. Open surgery, however, has become less frequent in our training programs, and operations that are performed open are now more likely to be complex rather than routine cases. This highlights a gap in surgical training that can be narrowed with novel methods of continuing surgical education. In this VAA, the authors describe an extended pleurectomy/decortication procedure for malignant pleura mesothelioma in a structured and comprehensive series of 12 steps. High-resolutions videos recorded from a surgeon's headlight camera are provided for each step and allow the reader to experience the conduct of each step of this complex, open operation from the surgeon's perspective. This is the first VAA of an open procedure and showcases the potential of this format to advance continuing surgical education for open thoracic surgery.Bryan M. Burt, MDMalignant pleural mesothelioma (MPM) is the most common type of malignant mesothelioma, which arise from the pleural, peritoneum, pericardium, and tunica vaginalis. The incidence of MPM is about 3000 patients per year in the United States. The etiology of the majority of cases is asbestos exposure. Surgery with chemotherapy results in long-term survival in some patients.1Rusch V.W. Giroux D. Kennedy C. Ruffini E. Cangir A.K. Rice D. et al.Initial analysis of the international association for the study of lung cancer mesothelioma database.J Thorac Oncol. 2012; 7: 1631-1639Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar Surgery has a role in the diagnosis, staging, and treatment, with both palliative and curative intents.2Bueno R. Opitz I. Taskforce I.M. Surgery in malignant pleural mesothelioma.J Thorac Oncol. 2018; 13: 1638-1654Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar The National Comprehensive Cancer Network, the European Society for Medical Oncology, and American Society of Clinical Oncology have guidelines that recommend surgery for MPM for both diagnosis and treatment.3Baas P. Fennell D. Kerr K.M. Van Schil P.E. Haas R.L. Peters S. ESMO Guidelines CommitteeMalignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Ann Oncol. 2015; 26: v31-v39Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar, 4Ettinger D.S. Wood D.E. Akerley W. Bazhenova L.A. Borghaei H. Camidge D.R. et al.NCCN guidelines insights: malignant pleural mesothelioma, version 3.2016.J Natl Compr Canc Netw. 2016; 14: 825-836Crossref PubMed Scopus (63) Google Scholar, 5Kindler H.L. Ismaila N. Armato III, S.G. Bueno R. Hesdorffer M. Jahan T. et al.Treatment of malignant pleural mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline.J Clin Oncol. 2018; 36: 1343-1373Crossref PubMed Scopus (231) Google ScholarA macroscopic complete resection is the goal of curative-intent surgery.6Rice D. Rusch V. Pass H. Asamura H. Nakano T. Edwards J. et al.Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the International Association for the study of Lung Cancer International Staging Committee and the International Mesothelioma Interest Group.J Thorac Oncol. 2011; 6: 1304-1312Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar,7Ripley R.T. Extended pleurectomy and decortication for malignant pleural mesothelioma.Thorac Surg Clin. 2020; 30: 451-460Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Negative microscopic margins (R0 resection) are not feasible since MPM covers all surfaces of the thoracic cavity and resection of these structures is not possible. The National Cancer Institute, the International Association for the Study of Lung Cancer, and the Mesothelioma Applied Research Foundation have helped standardize the operations for MPM. To achieve a macroscopic complete resection, either a lung-sparing surgery called an extended pleurectomy/decortication (ePD) or a lung-sacrificing surgery called an extrapleural pneumonectomy is performed.8Friedberg J.S. Culligan M.J. Tsao A.S. Rusch V. Sepesi B. Pass H.I. et al.A proposed system toward standardizing surgical-based treatments for malignant pleural mesothelioma, from the Joint National Cancer Institute-International Association for the Study of Lung Cancer-Mesothelioma Applied Research Foundation taskforce.J Thorac Oncol. 2019; 14: 1343-1353Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar A visceral and parietal pleurectomy includes the "extended" descriptor when resection of the diaphragm and/or pericardium are performed. Whether a partial diaphragm resection should be included as an ePD is questionable, but despite differences in the operations, the goal of an ePD is to remove all visible, palpable, or viable tumor while sparing the lung.This article outlines the steps to perform an ePD. This approach is surgeon-specific, and alternatives to most aspects of this operation exist. Extensive training is necessary before performing this operation independently.Preoperative EvaluationAn extensive evaluation is necessary to determine whether a patient is an operative candidate. The evaluation includes diagnostic and subtype confirmation, establishment of clinical stage, and assessment of cardiopulmonary status. Patients are evaluated for a treatment plan that may include surgery, chemotherapy, immunotherapy, radiotherapy, palliation, and clinical trial eligibility. Presentation at multidisciplinary tumor board helps finalize recommendations.Video-assisted thoracoscopic surgery (VATS) or computed tomography (CT)-guided biopsies establish the diagnosis. Confirmation of the diagnosis or subtyping requires rebiopsy or review of the pathology once referred to a center specializing in MPM. Repeated VATS biopsies may be required. After diagnosis, positron emission tomography scans, CT scans, and occasionally magnetic resonance imaging help establish clinical staging. The positron emission tomography scan evaluates the thoracic cavity, mediastinal lymph nodes, and potential metastatic sites. Magnetic resonance imaging assists with identifying local invasion but does not contribute significantly more than CT.Staging with mediastinoscopy and diagnostic laparoscopy helps to identify a subset of patients with advanced disease that is not noted on imaging.9Rice D.C. Erasmus J.J. Stevens C.W. Vaporciyan A.A. Wu J.S. Tsao A.S. et al.Extended surgical staging for potentially resectable malignant pleural mesothelioma.Ann Thorac Surg. 2005; 80 (discussion 92-3): 1988-1992Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar,10Ripley R.T. Palivela N. Groth S.S. Choi E.A. Cornwell L.D. Carrott P.W. et al.Diagnostic laparoscopy improves staging of malignant pleural mesothelioma with routine PET imaging.Ann Thorac Surg. December 1, 2020; ([Epub ahead of print])Abstract Full Text PDF Google Scholar Diagnostic laparoscopy reveals disease in 17% of patients. Mediastinoscopy may exclude marginal operative candidates, but it does not fully evaluate lymph node metastases because pleural disease can spread to nodes other than the peritracheal nodes. Repeated VATS biopsies, mediastinoscopy, and diagnostic laparoscopy can be performed during the same operation.Assessment of cardiopulmonary status is necessary to lower perioperative risk. Pulmonary function tests and ventilation/perfusion nuclear scans are performed. Postoperative predicted pulmonary volumes are calculated to determine eligibility for an extrapleural pneumonectomy even when an ePD is planned. The diffusion-limited carbon monoxide is important to identify restricted pulmonary diffusion that occurs with asbestosis. An absolute threshold for pulmonary function tests or ventilation/perfusion values in which an ePD should not be performed is debatable; however, when the numbers are particularly low, the lung will likely not regain significant function. An echocardiogram and an electrocardiogram are performed. Right heart catheterization may be necessary, given that echocardiogram does not adequately estimate right heart pressure; however, cardiology consultation is advisable for most patients especially with comorbidities.Operative ApproachPreoperative Planning and PositioningAn epidural catheter, arterial line, central venous catheters, nasogastric tube, and urinary catheter are placed. A pulmonary artery catheter is rarely necessary. A central venous catheter is inserted in the internal jugular vein; however, femoral vein access is an acceptable alternative. Blood loss is normally 300 to 500 mL. Injury to vessels such as the superior vena cava may result in larger-volume blood loss, and femoral access may be helpful for rapid resuscitation. Epidural catheters may be eliminated and regional anesthetic agents used, which may prevent exacerbation of hypotension from unilateral sympathectomy. A flexible bronchoscopy is unnecessary; therefore, a double-lumen endotracheal tube is placed to start. Two-lung ventilation is maintained as long as possible to decrease barotrauma, including during the initial pleurectomy. After the operation, the double-lumen tube is changed to a single-lumen tube and a therapeutic flexible bronchoscopy is performed to remove secretions. The operation is performed in standard lateral decubitus position with slight anterior rotation of the hip.Operative StepsStep 1Video 1 and 2: Incision and development of the extrapleural plane. An extended posterolateral thoracotomy is performed with the incorporation of previous VATS port sites if feasible. The latissimus dorsi and serratus anterior are mobilized and spared. The sixth rib is removed with a subperiosteal dissection to spare the intercostal muscles, which are approximated during closing. The extrapleural space is developed circumferentially from the resected rib. The incision is extended once lack of chest wall invasion is determined. Hemostasis is continually obtained with packing areas while working elsewhere and coagulation with Aquamantys Bipolar Sealers (Medtronic, Minneapolis, Minn) or argon plasma coagulation (instrument list: Table 1 and Table E1).Table 1Unique instrumentation for extended pleurectomy and decorticationInstrumentCompanyMatson Rib Double Ended Elevator and Stripper RaspatoryNovo Surgical IncStille-Luer-Type D/A 10MM Curved JawsCen-Med Enterprises IncAlexander Periosteotome- SharpNovo Surgical IncDoyen Coastal Elevator: Cobb, Right, and Left Blade, Heavy Duty Round HandleSuperior InstrumentsCobb ElevatorNovo Surgical IncHandpiece Interpulse w/Coaxial High FlowStrykerAquamantys 6.0 Bipolar SealerMedtronicArgon Beam CoagulatorValleylab Inc.ProTack 5-mm Fixation DeviceMedtronicLIGACLIP Endoscopic Rotating Multiple Clip ApplierJohnson & JohnsonCarter-Tomason Suture PasserCooperSurgicalGore-Tex Dual Mesh 20 cm × 30 cm × 1.0 mmW. L. Gore & AssociatesEndo GIA Ultra Universal StaplerCovidien Open table in a new tab Step 2Video 3: Anterior extrapleural dissection. The anterior pleural dissection removes the parietal pleural from the chest wall into the pericardiosternal recess. Internal mammary and pericardial fat pad nodes are removed. When the dissection reaches the pericardium, the pleura is peeled off the fibrous pericardium to the pulmonary veins if the disease does not invade the pericardium. If the disease invades the pericardium, separation of the fibrous and serous pericardium may complete the dissection. Alternatively, the anterior dissection is stopped and the pericardium is resected later in the operation.Step 3Video 4: Apical extrapleural dissection. The apical pleural dissection removes the disease from the chest wall and apex. Dissection is continued along the mediastinal pleura by pushing the structures into the mediastinum to avoid traction injuries to the recurrent laryngeal nerves, the lymphatics, vessels, and airways. Once the azygous vein (aortic arch/left side) is identified, this dissection is completed. The apical dissection will connect to the anterior dissection at the superior vena cava.Step 4Video 5: Posterior extrapleural dissection. The posterior pleural dissection is developed from the chest wall over the azygous and the esophagus to posterior hilum. During left-sided operations, the pleurectomy continues over the aorta; avoiding a dissection behind the aorta is critical to prevent injury to the segmental branches. Sharp dissection of fibrous adhesions is required to mobilize the parietal pleura to the visceral pleura; complete mobilization facilitates the visceral dissection later. Below the inferior pulmonary vein, the posterior dissection continues to the diaphragm along the inferior mediastinum. The lymph node dissections from levels 7, 8, and 9 are performed.Step 5Video 6: Lymph node dissection. The level 7 lymph node dissection is completed. Although not shown, lymph node dissections include levels 3, 4R, 5, 6, 8, 9, 10, 11, 12, and internal mammary nodes depending on the side of the operation. These are performed during dissections in the respective areas. Lymph nodes within the intercostal muscles are also retrieved.Step 6Video 7: Diaphragm resection. Preservation of portions of the diaphragm is feasible depending on extent of disease. Anteriorly, removal of the diaphragmatic disease exposes the angle between the diaphragm and pericardium and, posteriorly, the disease is peeled off above the esophagus on the right and the aorta on the left. Often, resection of the diaphragm is easier from the abdominal side; therefore, the diaphragm is opened at the most lateral point and this opening is extended to the mediastinum while preserving as much muscle as possible. The peritoneum at the base of the diaphragm is scored about 1 to 2 cm lateral to the mediastinum. The diaphragm medial to this line becomes a cuff to attach the diaphragm patch to prevent herniation.Step 7Video 8: Pericardial resection. During the anterior parietal dissection at the point in which the pleura cannot be peeled off the pericardium, it is opened. The pericardiectomy is extended superiorly to the great vessels, inferiorly to the diaphragm, posteriorly to the pulmonary veins, and anteriorly to the pleura of the contralateral lung. Complete transection is easier from an intrapericardial approach. Stay sutures are placed to prevent retraction of the pericardium to the contralateral side with subsequent hemodynamic instability.Step 8Video 9: Visceral decortication. The operative lung is inflated and an incision is performed through the pleura; often both the visceral and parietal pleura with the thickened disease are fused. With one hand that provides retraction, the lung is separated from the visceral pleura by both blunt and sharp dissections. The disease may be too adherent for decortication. The lingula or right middle lobe may require resection and wedge resections often facilitate pleurectomy at difficult angles. The fissure is approached by performing the visceral pleural dissection from each lobe to the base of the fissure. With complete fissures, this dissection may require dissection off the pulmonary arteries. Completion of the visceral pleurectomy is obtained when this dissection connects to the parietal pleural dissection.Step 9A: Video 10: Diaphragm reconstruction (part I). A nonabsorbable, 1- to 2-mm patch is placed in the native position at the eighth intercostal space (ICS) anteriorly, ninth ICS laterally, and ICS Alternatively, reconstruction with a such as an may decrease by 2 sutures are through the chest into diaphragm patch as a with the into the chest cavity, and through the chest wall one A may to the muscles are Video Diaphragm reconstruction (part Once the lateral diaphragm patch is the and of the patch are on the sutures along the mediastinum. Anteriorly, a of the diaphragm is between the chest wall and pericardium which is to the anterior of the patch with the patch is to the base of the pericardium, which provides more to the reconstruction with the anterior The medial of the patch is from the pericardium to the cuff of the The reconstruction is over the with a 5-mm Video Pericardial reconstruction (part I). The pericardial reconstruction and The pericardium is with a patch that is with Alternatively, or pericardium is used, which may decrease the great vessels, the pericardium does not to be The pericardium is with sutures in the anterior pericardium that are into the Video 13: Pericardial reconstruction (part The inferior pericardial patch is to the of the diaphragm and pericardium through diaphragm of the inferior vena cava is critical during this The patch is to the posterior pericardium along the inferior pulmonary vein and superior pulmonary The of these sutures will determine the of the given that the anterior sutures are in if the patch is too may The patch is to prevent 14: are that may decrease is to the cavity complete resection and reconstruction of diaphragm and pericardium with from and L. E. P. D. J. et pleural with by chemotherapy in patients with malignant pleural mesothelioma.J Thorac Oncol. 2011; 6: Full Text Full Text PDF PubMed Scopus Google Scholar include chemotherapy, and argon has or over for the of of with incision and chest with to for in and with for of with with High to for in incision and chest with to for in and with for for Open table in a new tab Step of the of the thoracic cavity latissimus dorsi and the serratus anterior can be mobilized If space in the chest results in an or these muscles are as muscle This approach requires to avoid In if the muscle does not the chest the space can with the thoracic sixth rib is removed in a plane. When the chest resection of this the intercostal sutures not the to help decrease The intercostal are and the muscle are into the incision to prevent through the chest Alternatively, the rib may be removed for of the the rib is chest wall invasion is during the initial pleurectomy to determine wall with rapid assessment can help determine whether chest wall invasion is for of the pleura off and is performed by pushing the mediastinum off the pleura rather than the pleura off the mediastinum to decrease traction the and performing the pleurectomy from the posterior pleura the vein to the pericardium anteriorly will help identify the diaphragm to a cuff for the of the parietal pleural the vessels the pulmonary will facilitated of the visceral the visceral decortication can be performed before of the parietal pleurectomy. This will facilitate the approach to the mediastinum and especially between the and the visceral pleura of the pleura is acceptable if the visceral pleura cannot be adequately the diaphragm, in the peritoneum are or the diaphragm and it from the is often than resection of the diaphragm from the thoracic cavity to the pleural of a cuff of diaphragm along the mediastinum over the aorta and esophagus helps the diaphragm patch and prevent If disease is this can be and on the vein is critical to avoid because this vein can the inferior vena cava and into the reconstruction of the pericardium, the patch and have to prevent and chest are placed in diaphragm, and posterior on the may result in significant loss of to pleurectomy and decortication can achieve a macroscopic complete resection of malignant pleural mesothelioma with the preservation of the lung. are the steps to perform this operation. The operative steps for an extended pleurectomy and decortication are described with a video atlas. An ePD can achieve a macroscopic complete resection for MPM with preservation of the lung. The operative steps for an extended pleurectomy and decortication are described with a video atlas. An ePD can achieve a macroscopic complete resection for MPM with preservation of the lung. Commentary on page Commentary on page Editor Note—Video Atlas Articles (VAAs) are peer-reviewed descriptions of an operative procedure distilled into a series of steps, with each step taught to the reader through its own narrated video and short corresponding text. The purpose of the VAA is to provide continuing surgical education in a format that is quality-assured, easily accessible, and high impact. Much of the excitement around our new series of VAAs surrounds robotic and thoracoscopic/laparoscopic procedures. Our field has progressed rapidly into one in which robotic and thoracoscopic surgery have improved clinical outcomes, and we drive much of the innovation in minimally invasive surgical platforms and technique. The ability to record high-resolution video during the routine conduct of robotic and thoracoscopic/laparoscopic surgery has facilitated this opportunity in structured, peer-reviewed, expert instruction of index cases in thoracic surgery and is the bedrock for the VAA initiative. Open surgery, however, has become less frequent in our training programs, and operations that are performed open are now more likely to be complex rather than routine cases. This highlights a gap in surgical training that can be narrowed with novel methods of continuing surgical education. In this VAA, the authors describe an extended pleurectomy/decortication procedure for malignant pleura mesothelioma in a structured and comprehensive series of 12 steps. High-resolutions videos recorded from a surgeon's headlight camera are provided for each step and allow the reader to experience the conduct of each step of this complex, open operation from the surgeon's perspective. This is the first VAA of an open procedure and showcases the potential of this format to advance continuing surgical education for open thoracic M. Burt, pleural mesothelioma (MPM) is the most common type of malignant mesothelioma, which arise from the pleural, peritoneum, pericardium, and tunica vaginalis. The incidence of MPM is about 3000 patients per year in the United States. The etiology of the majority of cases is asbestos exposure. Surgery with chemotherapy results in long-term survival in some patients.1Rusch V.W. Giroux D. Kennedy C. Ruffini E. Cangir A.K. Rice D. et al.Initial analysis of the international association for the study of lung cancer mesothelioma database.J Thorac Oncol. 2012; 7: 1631-1639Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar Surgery has a role in the diagnosis, staging, and treatment, with both palliative and curative intents.2Bueno R. Opitz I. Taskforce I.M. Surgery in malignant pleural mesothelioma.J Thorac Oncol. 2018; 13: 1638-1654Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar The National Comprehensive Cancer Network, the European Society for Medical Oncology, and American Society of Clinical Oncology have guidelines that recommend surgery for MPM for both diagnosis and treatment.3Baas P. Fennell D. Kerr K.M. Van Schil P.E. Haas R.L. Peters S. ESMO Guidelines CommitteeMalignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Ann Oncol. 2015; 26: v31-v39Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar, 4Ettinger D.S. Wood D.E. Akerley W. Bazhenova L.A. Borghaei H. Camidge D.R. et al.NCCN guidelines insights: malignant pleural mesothelioma, version 3.2016.J Natl Compr Canc Netw. 2016; 14: 825-836Crossref PubMed Scopus (63) Google Scholar, 5Kindler H.L. Ismaila N. Armato III, S.G. Bueno R. Hesdorffer M. Jahan T. et al.Treatment of malignant pleural mesothelioma: American Society of Clinical Oncology Clinical Practice Guideline.J Clin Oncol. 2018; 36: 1343-1373Crossref PubMed Scopus (231) Google Scholar A macroscopic complete resection is the goal of curative-intent surgery.6Rice D. Rusch V. Pass H. Asamura H. Nakano T. Edwards J. et al.Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the International Association for the study of Lung Cancer International Staging Committee and the International Mesothelioma Interest Group.J Thorac Oncol. 2011; 6: 1304-1312Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar,7Ripley R.T. Extended pleurectomy and decortication for malignant pleural mesothelioma.Thorac Surg Clin. 2020; 30: 451-460Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Negative microscopic margins (R0 resection) are not feasible since MPM covers all surfaces of the thoracic cavity and resection of these structures is not possible. The National Cancer Institute, the International Association for the Study of Lung Cancer, and the Mesothelioma Applied Research Foundation have helped standardize the operations for MPM. To achieve a macroscopic complete resection, either a lung-sparing surgery called an extended pleurectomy/decortication (ePD) or a lung-sacrificing surgery called an extrapleural pneumonectomy is performed.8Friedberg J.S. Culligan M.J. Tsao A.S. Rusch V. Sepesi B. Pass H.I. et al.A proposed system toward standardizing surgical-based treatments for malignant pleural mesothelioma, from the Joint National Cancer Institute-International Association for the Study of Lung Cancer-Mesothelioma Applied Research Foundation taskforce.J Thorac Oncol. 2019; 14: 1343-1353Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar A visceral and parietal pleurectomy includes the "extended" descriptor when resection of the diaphragm and/or pericardium are performed. Whether a partial diaphragm resection