Anatomy of a Pleurectomy/Decortication

Dr. Robert Cameron, UCLA Medical Center. September 13, 2005

Preparing for surgery

Bill and Donna in pre-op, waiting for a"go."

Bill thanks Dr. Cameron in advance. "Get this damn tumor out of me! I want to get back on my tractor."

Entering the chest

Dr. Cameron and resident Dr. Dawn removing tumor from chest wall.

The gameplan is to remove the bulky tumor that is adhering to the chest wall, pericardium and diaphragm, and then decorticate or remove the thickened tumor from around the two lung lobes. The outer lining (abutting the chest wall) is the parietal pleura. The membrane abutting the lung is the visceral pleura. The tumor is growing in between the membranes. We hope the tumor has not obliterated the membranes and invaded the lung and elsewhere. The goal of the surgery is to preserve the lung and leave clean, tumor free surgical margins

Roger G. Worthington observes

The tumor flap hanging over the side. Dr. Cameron took about 2.5 hours taking the tumor off the walls, pericardium and diaphgram before cutting through the thick, leathery tumor to find the collapsed lung inside.

The tumor was big. It looked like tendons or gristle. A thick sheath covered the lung. Small oatmeal-sized globules of white tumor were pervasive. In places, the tumor was two inches thick. Fortunately, the tumor did not invade the chest wall or pericardium, nor did it intertwine with the aorta or esophagus. Note: Bill has a Lance Armstrong sized aorta -- the better for pumping large volumes of blood. The doctors were extraordinarily careful to avoid nicking the large blood vessels, for obvious reasons.

Dr. Cameron helped devise a retractor instrument that helps keep the ribs apart so he has clear access to the open chest cavity. In the past, he would make two incisions, and remove two ribs. The more incisions, the more chance for malignant cells to spread. Now, by making only one incision, Dr. Cameron reduces the chance for the tumor to spread and fewer incisions helps speed up the patient's recovery. Progress!

Removing the Tumor

Clearly visible tumor nodules formed a thick and tough rind. The lung is hidden inside the clutch of tumor.

The lung is encased inside the bulging, yellowish white tumor. The tumor grew in a contiguous sheet with a clear boundary, making it easier to separate the festering invader from the healthy body parts.

The tumor adhered to the diaphragm. Dr. Cameron and Dr. Dawn painstakingly cauterized the embedded tumor from the muscle.

To repair the diaphragm, the doctors stitched a bovine patch onto the muscle. A small section of diaphragm tissue bonded like cement to the tumor. In an EPP, the doctors would remove the entire diaphragm, which could open the door for tumor to trespass into the peritoneum.

Preparing to remove the tumor "straightjacket" from the buried, collapsed but (we hope) otherwise healthy lung.

After removing the tumor from the pericardium, chest wall and diaphragm, the doctors inflated the lung and began to cut through the tumor. The doctors knew they hit the lung when they saw bubbles push up through the tumor. Life busting through. The P/D aims to preserve the lung, which unless invaded is a perfectly healthy (and we all know vital) organ. Notice that the thickness of the tumor around the lung varied, from less than one- half centimeter to two centimeters.

A pivotal issue in surgery is whether it's possible to remove all the visible tumor that wedges between the interlobar fissures dividing the upper and lower lung lobes. EPP proponents contend that the visceral pleura will obliterate, allowing the tumors to invade the lung, which then would justify total lung amputation. However, Dr. Cameron used a very fancy tool to dig into the space and pull the tumor away from the fissure -- his index finger! Amazingly, the tumor peeled away without a fight. No knives, not burners, no scrapes, no nicks. Clean.

Dr. Cameron burning the tumor away from the diaphragm.

Four hours after he opened Bill's chest, Dr. Cameron prepares to pull the neatly dissected tumor rind out of the chest. You know the satisfaction of peeling an orange in one spiral piece? Multiply that times a billion.
After closing up the chest incision, Dr. Cameron inspects the beast, which was estimated to weigh over 4 pounds

Good riddance and don't come back! The tumor was significantly bigger and thicker than suggested by the CT scan.

All Smiles! Dr. Cameron gives the good news to Donna and Lori that the surgery went very smoothly, that all of the visible tumor was removed, and that the tumor did not invade the chest wall, pericardium, lung or diaphragm. Caught in the nick of time. Next, recovery, radiation, and low dose interferon. May the survival curve move upward and to the right! And may Bill return to his beloved tractor and boat as happy and hearty as ever.