9．胸膜外肺全摘術における横隔膜・心膜の切除・再建

Resection and Reconstruction of the Diaphragm and the Pericardium in Extrapleural Pneumonectomy

胸膜外肺全摘術は，主に悪性胸膜中皮腫に対して実施されている．悪性胸膜中皮腫は難治性で予後が厳しいが，胸膜外肺全摘術と放射線療法，抗癌剤療法による集学的治療の有効性が報告されている1～3）．当施設において，2011年以後の上皮型悪性胸膜中皮腫29例に対する胸膜外肺全摘術を含む集学的治療の成績は，生存期間中央値59ヵ月，5年生存率43％であった．進行例や縦隔リンパ節転移例も含まれているので，明らかに治療成績が改善している．長期予後のために重要な点は，質の高い胸膜外肺全摘術と術後管理である．適切な放射線療法と抗癌剤療法を実施するためにも，患者の状態を良好に保つ高いレベルの胸膜外肺全摘術を実施しなければならない．本稿では，胸膜外肺全摘術における横隔膜と心膜の切除・再建について述べる．筆者の術式，手術適応や術後管理について，過去の報告4，5）も参考にしていただきたい．

The diaphragm dissection should be started from anterior, because the portion is just under the thoracotomy incision. The diaphragmatic muscle was cut by an electric knife along the line of 1 to 2 cm from the chest wall from anterior and lateral to posterior. The diaphragm including the tendon center is dissected from the peritoneum. The peritoneum should be preserved. If the peritoneum is opened, it should be repaired by sutures. The pericardium is opened at the apex. The pericardium incision is extended from the apex to cranial side. And then, it is cut from the apex to posterior with the diaphragm. And next, the incision of the cranial side edge is extended to posterior. The lower pulmonary vein, upper pulmonary vein, and pulmonary artery are exposed. They are encircled and divided in the pericardium by autosutures. A Goretex sheet with 1 mm thickness is used to reconstruct the diaphragm. Nine sutures were placed in advance for the Goretex, and pulled out from the chest cavity through upper and lower sides of the 10th or 9th rib. The sutures were tied outside the rib cage. For mediastinal side, the Goretex was sutured to the residual diaphragm. A Goretex sheet with 0.1 mm thickness is used to reconstruct the pericardium by interrupted sutures. Because the contralateral lung is overinflated, the reconstruction should not be tight. Slits for the Goretex are made to prevent regional tamponade.