The features of the anatomical structure and location of the right pulmonary artery allow its resection with very extensive tumor lesions. The main difficulties in the diagnosis of such lesions occurs when the posterior wall of the vessel is involved in the process, which is observed when the right main bronchus grows into it, trachea bifurcation and metastases into bifurcation and right tracheobronchial lymph nodes. The excretion of the pulmonary artery in the pleural cavity begins with the intersection of the pericardial-arterial ligament — a fibrous cord that extends from the pericardium and attaches to the area of ​​the right pulmonary artery bifurcation. This allows you to widely expose the front wall of the artery and create a comfortable environment for its selection. If there are metastases on the anterior wall of the artery that impede its secretion or grow into the pericardium, as well as in cases when germination of the posterior wall of the vessel is suspected, it is advisable to conduct further revision intrapericardially.

Intrapericardial discharge and ligation of the right pulmonary artery lateral to the superior vena cava gives few advantages compared with pleural access to it after crossing the pericardial-arterial ligament, since produced at the same level. Intrapericardial vascular discharge in this place is performed in cases where the main obstacle to its excretion is by the pleural route.

metastases in the lymph nodes located on the front wall of the pulmonary artery. After the provisional ligature is brought under the pulmonary artery, the pericardium is dissected along the vessel and the vessel is dissected in the distal direction to a length that enables its further processing.

With extensive tumor lesions of the pulmonary artery

In case of extensive tumor lesions of the pulmonary artery, the key point to answer the question about the possibility of ligation is intrapericardial secretion of the artery medial to the superior vena cava, in the aorto-caval cavity. The main danger in performing this critical operative reception is damage to the posterior wall of the pulmonary artery during its tumor lesion and the wall of the left atrium, directly adjacent to the lower-back surface of the artery.

The selection of the right pulmonary artery in the inter-aorto-caval cavity is performed after dilution of the aorta and superior vena cava. A vertical incision is made to open the posterior leaf of the pericardium: in this case, the incision is started from the upper edge of the pulmonary artery and, gradually peeling it from top to bottom, the upper and anterior surfaces of the vessel are separated. The selection of the lower surface of the pulmonary artery is made under visual control, which avoids injury to the left atrium. The most dangerous moment is the release of the posterior semicircle of the vessel, which can be germinated by tumor metastases into bifurcation lymph nodes or with a tumor of the right main bronchus and trachea bifurcation. Manipulation is actually done blindly, focusing mainly on tactile sensations. If it is not possible to circumvent the pulmonary artery freely,it is necessary to refuse to perform pneumonectomy.

Damage to the posterior wall of the pulmonary artery germinated by tumor tissue at this level is extremely dangerous. When a vessel is injured, any rough manipulations lead to an increase in the size of the defect and its spread to the pulmonary artery stem. To cope with this complication is very difficult. Attempting to roughly impose a clamp on the vessel during the germination of its posterior wall is not very promising.

When performing surgery from the anteroposterior approach, it is possible, by means of transverse sternotomy, to isolate the pulmonary artery stem and, after crossing the arterial ligament and posterior pericardiotomy, try to tie the right pulmonary artery at its mouth.

Involvement of the esophageal wall into the tumor process, as a rule, is caused by the germination of tumor by its metastases in paraesophageal lymph nodes. Often they form large conglomerates that compress the lumen of the esophagus, which may clinically manifest symptoms of partial dysphagia. Preoperative X-ray examination, stating the fact of damage to the esophagus, can not always answer the question about the operability of the patient. We consider only a complete germination of the esophageal mucosa by the tumor, which is recognized by endoscopic examination, as a contraindication to surgery. In all other cases, the question of the operability of the patient should be resolved during thoracotomy. Dissection of the esophagus wall is performed simultaneously with the mediastinal lymphadenectomy, from its unaffected portions. For better identification of the esophagus, its secretion is safer to perform after the introduction of the gastric probe.This technique makes it possible to precisely control the position of the esophagus in the tumor conglomerate and to avoid opening its lumen. By detailed preparation it is possible to clarify the true limits of germination of the esophagus wall and assess the possibilities of performing its resection. At the same time full mobilization of the affected part of the esophagus can not produce. In the presence of germination of tumor tissue in the muscular layer of the esophagus, the latter is opened at a distance of at least 1.5 – cm from the borders of the tumor growth and the mucous membrane is gently peeled off, assessing its condition. We consider as contraindications to the resection of a section of the esophagus wall: the complete germination of the tumor into the lumen of the esophagus and the germination of the muscular layer, with a length of more than 7 cm and more than half of its circumference.By detailed preparation it is possible to clarify the true limits of germination of the esophagus wall and assess the possibilities of performing its resection. At the same time full mobilization of the affected part of the esophagus can not produce. In the presence of germination of tumor tissue in the muscular layer of the esophagus, the latter is opened at a distance of at least 1.5 – cm from the borders of the tumor growth and the mucous membrane is gently peeled off, assessing its condition. We consider as contraindications to the resection of a section of the esophagus wall: the complete germination of the tumor into the lumen of the esophagus and the germination of the muscular layer, with a length of more than 7 cm and more than half of its circumference.By detailed preparation it is possible to clarify the true limits of germination of the esophagus wall and assess the possibilities of performing its resection. At the same time full mobilization of the affected part of the esophagus can not produce. In the presence of germination of tumor tissue in the muscular layer of the esophagus, the latter is opened at a distance of at least 1.5 – cm from the borders of the tumor growth and the mucous membrane is gently peeled off, assessing its condition. We consider as contraindications to the resection of a section of the esophagus wall: the complete germination of the tumor into the lumen of the esophagus and the germination of the muscular layer, with a length of more than 7 cm and more than half of its circumference.In the presence of germination of tumor tissue in the muscular layer of the esophagus, the latter is opened at a distance of at least 1.5 – cm from the borders of the tumor growth and the mucous membrane is gently peeled off, assessing its condition. We consider as contraindications to the resection of a section of the esophagus wall: the complete germination of the tumor into the lumen of the esophagus and the germination of the muscular layer, a length of more than 7 cm and more than half of its circumference.In the presence of germination of tumor tissue in the muscular layer of the esophagus, the latter is opened at a distance of at least 1.5 – cm from the borders of the tumor growth and the mucous membrane is gently peeled off, assessing its condition. We consider as contraindications to the resection of a section of the esophagus wall: the complete germination of the tumor into the lumen of the esophagus and the germination of the muscular layer, with a length of more than 7 cm and more than half of its circumference.

To assess the prevalence of swelling along the bronchus and tracheal wall, in cases of a massive conglomerate of enlarged lymph nodes in the mediastinum, impeding palpation of the lung root, a wide mediastinotomy is performed with ligation and intersection of the unpaired vein, which makes it possible to isolate the tracheobronchial angle. Gradually highlighting the posterior surface of the distal trachea and the mouths of the main bronchi, determine the nature and extent of the tumor process. Comparing data from bronchoscopic examination and intraoperative revisions, decide on the possibility of performing surgery and its volume, based on the need to perform the intersection of the wall of the bronchus or trachea, receding at least 1.5-2 cm from the visible boundaries of tumor growth. Sometimes it is possible to definitively determine the prevalence of a tumor according to the bronchus only after treating the vessels of the lung and performing lymphadenectomy.

The most difficult issues in determining the operability of a patient with left-sided thoracotomy is the diagnosis of anatomical lesions of the aortic window, the descending aorta, pulmonary veins, as well as during right-side operations of the esophagus.