Surgical Methods Of Resection Of Malignant Pleural Mesothelioma

Pleurectomy and Decortication

Pleurectomy and decortication were introduced in the 1950s for the treatment of trapped lungs associated with tuberculous empyema. 

This treatment was then adopted for malignant pleura mesothelioma. Surgery is provided for elderly patients, with comorbidity, and is not suitable for pneumonectomy.

The treatment was then adopted for Malin Pleural Mesothelioma. Surgery is reserved for patients who are old, with comorbidities and are not suitable for pneumonectomy.

Two thin layers of the pleura envelop the pleural space: 

  1. The visceral pleura covers the surface of the lung and 
  2. The parietal pleura lines the inside of the chest wall. 

The former is attached to the lung surface firmly and the latter is attached to the chest wall somewhat loosely. 

The space between the pleurae is the pleural space where dangerous cells can be found with mesothelioma. 

The surgery cal procedure of pleurectomy and decortication entails two different components.  Decortication is defined as the separation of visceral pleura from underlying lung parenchyma. 

A cut is made in cancer, and a plane is laid out between the instinctive pleura and lung parenchyma.  Growth attack in instinctive pleura stretches out into various gap planes and can cause loss of lung development.


Therefore, decortication should separate the fissures to allow the lung re-expansion. The challenge of this procedure is to remove as much of the tumor as possible without causing injury to the underlying lung. 

Pleurectomy involves dissection of the parietal pleura of the chest wall, pericardium, and diaphragm. This is usually achieved with blunt and sharp dissection. Extreme care is taken when dissecting at the apex and around the pericardium to avoid injury to vascular structures. Inferiorly, the pleurectomy may involve peeling or removing the tumor of the diaphragm (Rice 2012).

Peeling of the pleura leaves a raw surface on the chest wall and lung parenchyma that can lead to significant blood loss. Hemostasis can be achieved with high-power electrocautery and packing. 

The elimination of visceral pleural leaving the exposed pulmonary parenchyma, which can cause air leakage. The majority of air leak seals within 72 hours with good drainage and full lung expansion. Drainage tubes are left behind to allow blood and air to flee.

In the healing process, the lungs will go and form adhesion to the chest wall which will remove the space where the liquid usually accumulates. Sometimes chemical agents such as talc or povidone-iodine are used to help the scar tissue process. 


It is not uncommon that the tumor involves the surface of the diaphragm that cannot be peeled and requires partial or total removal. 

Diaphragm reconstruction may be needed if the most diaphragm is removed. In addition, in some patients, the pericardium involved was selected. Both diaphragm and often pericardium require reconstruction.

If the diaphragm is resected and reconstructed, this is termed extended pleurectomy/decortication (EPD). Most surgeons use GoreTex prosthesis for this purpose, but a bioprosthesis can be used particularly if there is a concern for infection or in a patient who had a long-standing drainage tube to control pleural effusion before definitive surgery.

Source

Mary Hesdorffer, Gleneara E. Bates-Pappas - Caring for Patients with Mesothelioma_ Principles and Guidelines-Springer International Publishing (2019)

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