Key Points

• Preoperative evaluation includes computed tomographic (CT) scanning of the chest and upper abdomen, positron emission tomography (PET)-CT scanning, pulmonary function tests, quantitative ventilation/perfusion scanning and cardiac evaluation.
• Thoracotomy is performed via an extended S-shaped posterolateral incision with resection of the sixth rib.
• The pleural tumor is mobilized away from the chest wall and mediastinum with careful attention to hemostasis.
• The diaphragm is partially or completely resected. Depending on the extent of the tumor, pericardial resection may or may not be required.
• After subcarinal node dissection, the main stem bronchus then the hilar vessels are ligated or divided.
• The diaphragmatic reconstruction should be placed at the same level as the native diaphragm. Pericardial defects should also be reconstructed.
• Postoperative care should emphasize meticulous pulmonary toilet and fluid management with transfusion as required and prophylaxis of supraventricular arrhythmias.