Technical aspects of extrapleural pneumonectomy

Malignant pleural mesothelioma (MPM) is an extremely aggressive disease for which single modality therapy alone is largely ineffective thus requiring multimodality approach to optimize oncological results. The main target of surgery is to obtain a macroscopic radical resection that—in case of extrapleural pneumonectomy (EPP)—means en-bloc resection of lung, pleura, pericardium, and diaphragm with radical lymphadenectomy, followed by reconstruction of diaphragm and pericardium. Although progress and improvements made during the last 40 years, EPP still remains an extremely challenging procedure—both from the technical and the clinical point of view—and it should therefore only be performed at high volume centers by experienced surgeons and anesthesiologists.