A thoracic epidural catheter is placed preoperatively for intraoperative management and postoperative analgesia. Standard monitoring with telemetry, continuous pulse oximetry, central venous access, and urinary Foley catheterization are routinely used. After anesthetic induction, a left-sided double-lumen endotracheal tube is placed for single-lung ventilation, and the patient is positioned in the left lateral decubitus position for an extended right posterolateral thoracotomy. A nasogastric tube is placed, which facilitates identification of the esophagus during extrapleural dissection. It is left in place postoperatively to decompress the stomach and to prevent aspiration.
EPP is performed in the following order: (1) incision and exposure of the parietal pleura; (2) extrapleural dissection to separate the tumor from the chest wall; (3) en bloc resection of the lung, pleura, pericardium, and diaphragm with division of the hilar structures; (4) radical lymph node dissection; and (5) reconstruction of the diaphragm and pericardium.2,6,7
When there is preoperative radiologic evidence suggesting intra-abdominal disease, a limited subcostal incision is made along the line of the thoracotomy incision before proceeding with definitive resection. The diaphragm and peritoneal cavity are inspected for transdiaphragmatic involvement. Laparoscopic evaluation may be used as an alternative approach to an open subcostal incision. If there is evidence of intra-abdominal disease, histologic diagnosis is confirmed by biopsy, and the resection is aborted.
In the absence of intra-abdominal spread, an extended right posterolateral thoracotomy is performed (Fig. 122-1). The incision is started midway between the posterior scapular tip and the spine (inset) and extended along the sixth rib to the costochondral junction.6 The latissimus dorsi and serratus anterior muscles are both divided. The sixth rib is resected. The posterior periosteum in the bed of the sixth rib is incised, exposing the extrapleural plane.
Incision and exposure for a right posterolateral thoracotomy.
Extrapleural dissection is performed with the use of blunt and sharp dissections initially in the anterolateral aspect followed by dissection to the apex. Anteriorly, the internal mammary vessels should be identified to prevent avulsion. If extensive chest wall invasion is discovered obliterating the extrapleural plane, surgical resection is precluded. In the absence of chest wall invasion, the extrapleural plane is extended, and previously dissected areas are packed with surgical pads for hemostasis. Along the thoracotomy, two chest retractors are positioned anteriorly and posteriorly to optimize exposure (Fig. 122-2). At the apex, care should be taken to avoid injury to the subclavian vessels (Fig. 122-3). The dissection is advanced over the apex of the lung, and the tumor is brought down from the posterior and superior mediastinum, where care should be attended to the azygos vein and superior vena cava (Fig. 122-4). After adequate exposure is obtained anterolaterally, posterior dissection is performed, with careful attention to the esophagus. If unexpected invasion of vital mediastinal structures (e.g., aorta, vena cava, esophagus, epicardium, or trachea) is identified, the operation is aborted.
Two chest retractors are placed, one anterior and one posterior, to increase the exposure.
Care is taken to avoid the subclavian vessels while dissecting the pleura at the lung apex.
After advancing over the apex, the pleural dissection proceeds inferiorly, with attention to the azygos vein and superior vena cava.
The extrapleural dissection is continued until the right upper lobe and right mainstem bronchus are exposed. Resectability is assessed by direct palpation posteriorly for aortic and esophageal invasion. The esophagus is dissected away from the tumor, facilitated by palpation of the nasogastric tube to avoid injury (Fig. 122-5). The pericardium is opened anteriorly, and the pericardial space is palpated to assess for myocardial invasion (Fig. 122-6). In the absence of mediastinal extension, diaphragmatic resection is initiated.
A nasogastric tube in the esophagus aids in palpating the esophagus while dissecting the pleura from the esophagus.
The pericardium is opened anteriorly, and the pericardial space is palpated to assess for myocardial invasion.
The diaphragm is incised first at its lateral margin, followed by a circumferential resection anteriorly and posteriorly (Fig. 122-7). The diaphragmatic muscle attachments to the chest wall are cauterized or bluntly avulsed (Fig. 122-8). The peritoneum is bluntly dissected off the diaphragm (Fig. 122-9). Dissection is performed at the inferior vena cava and esophageal hiatus with caution (Fig. 122-10). The pericardial incision is extended. The junction of the pericardium and diaphragm and the medial aspect of the diaphragm are divided. With release of the diaphragmatic attachments medially and posteriorly, the esophagus is dissected away from the specimen.
The diaphragm is incised circumferentially.
The diaphragm is separated bluntly or by avulsion from the chest wall muscular attachments.
The diaphragm is dissected bluntly from the underlying peritoneum.
Dissection around the esophageal hiatus and inferior vena cava.
The anterior pericardial incision is extended to the level of the hilum. The main right pulmonary artery is dissected intrapericardially (Fig. 122-11). A soft-flanged catheter (endoleader) is passed around the pulmonary artery to guide the safe passage of the endovascular stapler (United States Surgical, Norwalk, CT), which facilitates division of the pulmonary artery (Fig. 122-12). The superior and inferior pulmonary veins are divided intrapericardially in the same fashion. After division of the hilar vessels, the posterior pericardium is incised, completing the pericardial resection (Fig. 122-13).
The posterior pericardium and medial aspect of the diaphragm are divided.
An endoleader is passed around the pulmonary artery to guide the safe passage of the endovascular stapler, and the right pulmonary artery is divided.
The right pulmonary artery is dissected.
The right mainstem bronchus is dissected and encircled as close to the carina as possible with a heavy-gauge wire bronchial stapler (TA-30, Ethicon, Johnson & Johnson, Cincinnati, OH) (Fig. 122-14). Before dividing the bronchus, the contralateral lung is handbag ventilated (Valsalva maneuver by anesthesia) to confirm that the contralateral bronchus is free of encroachment, and the stump is visualized under direct bronchoscopic examination to ensure a short bronchial stump. With division of the bronchus, the en bloc resection (i.e., lung, pleura, pericardium, and diaphragm) is complete, and the specimen is removed from the thorax. A frozen-section analysis of the bronchial margin is performed by pathology.
The right mainstem bronchus is encircled as close to the carina as possible before division with a heavy-gauge wire bronchial stapler.
For complete staging, the paratracheal, subcarinal, paraesophageal, and inferior pulmonary ligament lymph nodes are resected (Fig. 122-15).
Lymph nodes are dissected for clinical staging.
Warm saline is instilled into the chest, and handbag ventilation is performed to 30 mm Hg to check for air leaks along the bronchial staple line. Chest wall hemostasis is achieved with liberal use of the argon beam coagulator (Valleylab, Boulder, Colorado). Any areas of gross tumor are marked with metallic clips to facilitate adjuvant radiation therapy.
The greater omentum is mobilized off the transverse colon, and the vascular supply is contoured from a pedicle off the gastroepiploic arteries along the greater curvature of the stomach (Fig. 122-16). The omental flap is used later to buttress the bronchial stump.
The omental flap is harvested for later use as a bronchial buttress.
The diaphragmatic and pericardial defects are reconstructed with Gore-Tex (W.L. Gore and Associates, Flagstaff, Arizona) patches. The diaphragm is reconstructed using two pieces (20 cm × 30 cm) of 2-mm-thick Gore-Tex dual patch stapled together in a side-by-side fashion with slight overlap at the center (Fig. 122-17). The patch is contoured to the hemithorax. This creates a loose, floppy patch at the center with less tension along the suture line. This dynamic patch is less likely to be complicated by patch dehiscence from the chest wall and abdominal content herniation into the pneumonectomy cavity. The diaphragmatic patch is sutured anteriorly, laterally, and posteriorly to the chest wall with nine Gore-Tex sutures placed through the patch and intercostal space. Each suture is passed through a 14-mm polypropylene button. The sutures are tied down on the button, buttressing the patch to the chest wall (Fig. 122-18). Before completing the diaphragm reconstruction medially, a small opening is created on the medial mid-portion of the diaphragmatic patch to permit transposition of the omental flap into the pneumonectomy space (Fig. 122-19). The patch is sewn medially to the pericardial edge and diaphragmatic crus. This step in prosthetic reconstruction of the pericardium and diaphragm is critical to prevent intra-abdominal viscus organ herniation into the chest.
The diaphragmatic patch is constructed from two pieces of 2-mm-thick Gore-Tex dual mesh.
Polypropylene buttons (14 mm) (A) are used to buttress the (B) suture that secures the patch to the chest wall.
A small opening is made in the midportion of the diaphragmatic patch for the omental flap.
The pericardium is reconstructed to prevent cardiac herniation into an empty right hemithorax, a potentially fatal complication. A 15 cm × 20 cm, 0.1-mm-thick, Gore-Tex pericardial patch is fenestrated to prevent development of a pericardial effusion and cardiac tamponade, and sewn to the pericardial edge with interrupted Gore-Tex sutures placed posteriorly first, followed by anterior placement (Fig. 122-20A). Both patches are sutured to the cut edge of the pericardium and to each other medially (Fig. 122-20B). Tension on the pericardial patch should be avoided to prevent dehiscence along the suture line and restriction on the contracting heart.
A. The pericardial patch is fenestrated and sewn to the pericardial edge. B. Both patches are sutured to the cut edge of the pericardium and to each other medially.
After the pericardial and diaphragmatic reconstruction is completed, the omental flap is sutured to the bronchial stump to provide coverage and separation from the pulmonary artery staple line (Fig. 122-21). Alternatively, an intercostal muscle or pericardial fat pad may be used. However, we have found that the omentum provides a more reliable vascularized buttress to the bronchial stump.
The omental flap is sutured to the bronchial stump.
The thoracotomy is closed in standard fashion. A 12 F red rubber catheter is placed into the pneumonectomy space and brought out on the medial aspect of the incision. The chest wall is closed in multiple layers. The red rubber catheter is connected to a three-way stopcock, and 1000 mL of air in men, or 750 mL in women, is removed, positioning the mediastinum to the midline. After the chest is closed, the patient is placed in the supine position, and flexible bronchoscopy is performed to assess the bronchial stump and to clear secretions. The patient is extubated in the OR.