Surgical approaches for extrapleural pneumonectomy for mesothelioma: The lower door thoracotomy

Although the optimal treatment for patients affected by malignant pleural mesothelioma (MPM) is subject of dispute and a surgical standard has not been yet established, extrapleural pneumonectomy (EPP) is still considered a suitable therapeutic option. The most challenging passage is diaphragmatic resection and reconstruction since standard fifth intercostal space thoracotomy is unable to assure a comfortable view of the surgical field although a second thoracotomy is usually performed. Lower door (LD) thoracotomy implies the section of the anterior costal arches from the sixth to ninth costal cartilage and the division of the oblique abdominal muscles below the costal arch. In this fashion thorax is anteriorly opened like a door. This approach provides excellent visibility and exposure of the costophrenic and cardio-phrenic angles. Consequently, diaphragmatic resection/reconstruction and en bloc resection of lung, parietal pleura, pericardium and diaphragm, can be performed radically, accurately and safely.