Anatomy of a Successful Pleurectomy-Decortication
Preparing for surgery
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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." For good karma, Donna's wearing the Lance Armstrong and
the MARF wristbands.
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Donna administers the good luck kiss.
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Dr. Cameron and resident Dr. Dawn
removing
tumor from chest wall.
The gameplan is 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
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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. Inthe 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!
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Clearly visible tumor nodules formed
a thick
and tough rind. The lung is hidden inside
the clutch of tumor.
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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.
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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.
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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.
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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.
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After closing up the chest incision, Dr. Cameron
inspects the beast, which was estimated to weigh over 4
pounds.
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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.
Photos and notes by Roger G. Worthington, all rights reserved, 9/15/05
** POSTED SEPTEMBER 14, 2005 **