Surgical technique of pleurectomy/decortication

Malignant pleural mesothelioma (MPM) is an aggressive and fatal thoracic malignancy associated with exposure to asbestos. Although there is no strong evidence to support how surgery can improve prognosis, multimodal therapy, including curative intent surgery, has been utilized in patients with resectable MPM. Two different approaches exist for curative intent surgery. Extrapleural pneumonectomy (EPP) is the well-established approach in which the lung is sacrificed with en bloc resection of the parietal pleura, ipsilateral lung, diaphragm, and pericardium. Pleurectomy/decortication (P/D) is the lung sparing surgery that involves the resection of parietal and visceral pleura. As neither EPP nor P/D obtain microscopic complete resection because of anatomical aspects, the goal of curative intent surgery for MPM is defined as macroscopic complete resection. This article describes the current status of P/D along with our observations. Regarding the surgical technique, which still remains considerably varied, our approach consists mainly of blunt dissection especially with cotton gloves or swabs. P/D is still a highly invasive surgery, though less so than EPP. Further reduction of invasiveness in the surgical approach is required to achieve better survival and postoperative quality of life.