This stage of surgical intervention is important, and sometimes crucial, in determining not only the tactics of surgical intervention, but also the treatment of the patient as a whole. No matter how thoroughly a preoperative examination was carried out, it is only possible to judge the extent of the tumor process, in a number of cases, only during surgery. In advanced stages of lung cancer, the implementation of this phase of surgery always requires high technical skill and extensive professional experience from the surgeon.

The main tasks solved at this stage of the operation are: final clarification of the scope and nature of the local spread of lung cancer and the determination of oncologically reasonable technical possibilities for the removal of a tumor.

The best conditions for solving these problems are created after the complete separation of the lung. In this case, it is possible to inspect and palpate the lung parenchyma, determine the size and nature of tumor growth, the degree of involvement in the blastomatous process of the extrapulmonary formations and organs of the thoracic cavity, the condition of the lung root and lymph nodes of the mediastinum, and through the diaphragm, assess the state of the adjacent abdominal organs. In the absence of adhesions and free pleural cavity, the most favorable conditions for intraoperative diagnosis are formed. But such a situation with advanced stages of lung cancer is the exception rather than the rule. A significant number of patients, as a rule, have dense total adhesions of the visceral and parietal pleura.Detailed examination of the affected lung is also hampered by pronounced rigidity of the pulmonary parenchyma associated with paracancrosis inflammation or with the development of obstructive pulmonary emphysema.

Full release of the lung before making a final decision on the possibility of its removal is fraught with the development of massive, difficult to stop bleeding from pleural adhesions, lung parenchyma, and sometimes from large vessels that are germinated by the tumor, leads to damage to the lung tissue and contributes to the development of severe postoperative complications. In case of cases, when a tumor grows through large extrapulmonary vascular trunks, the chest wall in the area of ​​its aperture, it is dangerous or technically impossible to completely excrete the lung before processing the elements of its root. Due to these circumstances, intraoperative diagnosis and the allocation of the lung should be carried out in parallel, in order to clarify the extent of the lesion and develop a sound surgical solution.

It is most advisable to perform the selection of the lung in the intrapleural plane . . However, already during thoracotomy, in some cases, difficulties arise when entering the pleural cavity. Most often, they are caused by the presence of dense pleural adhesions, and sometimes by the tumor penetration of the chest wall in the projection of the thoracotomy wound or by the location in the immediate vicinity of the lung tissue destruction cavities associated with the disintegration of the tumor or paracancrosis inflammation. The second group of circumstances can and should be foreseen in advance on the basis of a pre-operative examination and when choosing an online access be guided by the data obtained. In cases of extensive and dense pleural fusions, it is preferable to start excretion of the lung extrapleurally. Attempts by the surgeon to enter the pleural cavity before diluting the thoracotomy wound are dangerous and can be accompanied by extensive damage to the pulmonary parenchyma,the development of massive bleeding, impeding accurate orientation in the anatomical layer. Then further actions will be forced. In an effort to stop the bleeding as quickly as possible, the surgeon begins vigorous discharge of the lung, while still further damaging the lung tissue and intensifying the bleeding. Large

in such circumstances, danger may be a forced dilution of the edges of the thoracotomic wound by the expander with insufficient lung secretion.The lung tissue fixed in this area at dilution of the wound is stretched and easily broken. Such damages are especially dangerous in the presence of cavities of destruction of the lung, involvement of large vessels of the lung and chest cavity into the tumor or paracancrosis inflammation. Given the fact that with advanced stages of lung cancer, the ability to perform even palliative resection in some cases is problematic, a very difficult and terrible situation may arise. Performing thoracotomy, lung discharge and intraoperative diagnosis should be done very carefully, with full control of the situation by the surgeon and the ability to quickly complete the surgical intervention in case of inoperability of the patient.

Extrapleural secretion of the lung begins at the level of thoracotomy and is carried out 2 to 2 ribs above and below it and wide enough so that the retractor can be applied and without injury to the lung tissue to dissolve the wound edges. Even in the presence of dense pleural adhesions, the separation of the parietal pleura from the intrathoracic fascia is quite easy. After dilution of the edges of the thoracotomic wound, it is possible to perform a further phased selection of the lung under visual control, with careful hemostasis. In the presence of loose pleural adhesions go to the intrapleural plane of the lung, depending on the circumstances of combining them at different stages. When extrapleural allocation of the lung requires particularly careful hemostasis, becauseat the same time there is a risk of delayed postoperative bleeding on the second day after surgery, which must be remembered in the postoperative period.

A mandatory element of intraoperative diagnosis in advanced stages of lung cancer is revision of various anatomical structures of the lung root, mediastinum, performed, depending on the specific situation, in stages and at different levels: in the pleural cavity, in the pericardium, in the pericardial cavity, intracardiac. The survey becomes possible only with careful preparation and selection of these entities. This approach makes it possible to accurately and thoroughly assess the boundaries of tumor growth, the degree of paracancrosis changes, plan the sequence, the ability to perform and features of resection within the most rational, oncologically reasonable limits.