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

Althoughthe 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 therapeuticoption. The most challenging passage is diaphragmatic resection andreconstruction since standard fifth intercostal space thoracotomy is unable toassure a comfortable view of the surgical field although a second thoracotomyis usually performed. Lower door (LD) thoracotomy implies the section of theanterior costal arches from the sixth to ninth costal cartilage and thedivision of the oblique abdominal muscles below the costal arch. In thisfashion thorax is anteriorly opened like a door. This approach providesexcellent visibility and exposure of the costophrenic and cardio-phrenicangles. Consequently, diaphragmatic resection/reconstruction and en blocresection of lung, parietal pleura, pericardium and diaphragm, can be performedradically, accurately and safely.