Malignant pleural mesothelioma is an aggressive tumor of the pleura. Extended pleurectomy and decortication is a lung sparing cytoreductive procedure used in the management of this disease for curative intent.In 2011, the International Association of Society of Lung Cancer (IASLC) and International of Mesothelioma Interest Group (IMIG) described the consensus report of the definition of pleurectomy and decortication as parietal and visceral pleurectomy to remove all gross tumor with resection of the diaphragm and/or pericardium (1).The PatientThis video shows the case of a forty-eight-year-old woman with occupational exposure to asbestos. She had a right VATS pleural biopsy, which confirmed diagnosis of epithelioid malignant pleural mesothelioma. She was also being investigated for a concurrent breast lump. A core biopsy also confirmed invasive ductal carcinoma of the breast. The patient’s other comorbidities included Barret’s esophagus, endometriosis, and a hiatal hernia.A workup for the procedure showed normal hematological investigations and preserved cardiac function (LVEF 57 percent). A multidisciplinary discussion led to the decision to proceed with mesothelioma surgery prior to any intervention for the breast malignancy.The SurgeryTo begin, an epidural catheter, arterial line, central line, urinary catheter, and nasogastric tube were placed. The patient was administered general anesthetic and intubated with a double lumen endotracheal tube. The patient was positioned in the lateral decubitus position, and the skin was prepared with betadine and chlorhexidine antiseptic solutions.An extended fifth intercostal space thoracotomy was then made, and a costotome was used to cut the sixth rib posteriorly. At times, there is a need to perform a second thoracotomy two to three rib spaces inferiorly, but that was not needed in this case.Next, an extrapleural dissection was made to remove the parietal pleura from the chest wall. This was continued anteriorly and posteriorly until the pleural had been fully detached from the chest wall.At times, localized deposits remain on the chest wall that, if not excised, can be harbingers of disease progression. These were excised using monopolar diathermy and later ablated with use of LASER.The lung was inflated to facilitate safely making an incision on the visceral pleura and creating a plane. This was performed along the fissure, and the dissection continued anteriorly and posteriorly. Intermittent CP...