1. Use of the Posterior Pericardium to Cover the Bronchial Stump After Right Extrapleural Pneumonectomy 
Marc de Perrot, MD, MSc 
The Annals of Thoracic Surgery 
Volume 96, Issue 2, Pages (August 2013)
DOI: /j.athoracsur
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
The anatomy of the pericardium and its reflection along the posterior wall of the pericardial sac is shown in an anterior view after removing the heart. The number 1 represents the pericardial reflection between the inferior vena cava (IVC) and the right inferior pulmonary vein (RPV). This reflection is generally freed to complete the EPP and remove the right sided part of the pericardium with the tumor. Numbers 2 and 3 represent the right pulmonary vein recess and the postcaval recess, respectively. In order to obtain adequate length and mobility from the posterior pericardium to cover the right bronchial stump, the pericardial reflection has to be dissected in these recesses from the right pulmonary veins (RPV), the right pulmonary artery, and the superior vena cava (SVC). Additional pericardial mobility can then be gained by freeing the reflection separating the transverse sinus from the oblique sinus (number 4) toward the left pulmonary veins (LPV).
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A) Exposure of the right hilum obtained through a right posterolateral thoracotomy after completing the EPP. The right main bronchus (RMB) is stapled. The pericardial reflection is dissected off the right pulmonary veins (RPV), the right pulmonary artery (RPA), and the superior vena cava. The edge of the posterior pericardium (PP) is then exposed up to the transverse sinus in front of the esophagus (Eso). After freeing the pericardial reflection between the transverse sinus and the oblique sinus (number 4), the posterior pericardium gains length and mobility to cover the right bronchial stump (#). The number 4 correlates with the identification given in Figure 1.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
The bronchial stump is entirely covered and mediastinalized. The pericardial mesh is fixed to the anterior and posterior edges of the pericardium in a standard fashion because no additional pericardium is removed or raised to create a flap.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2013 The Society of Thoracic Surgeons Terms and Conditions