A left paravertebral catheter was established at the T5 to T6 level without difficulty. The patient underwent selective double-lumen endotracheal intubation, and a radial arterial line and central venous access were established. He was placed in a full right lateral decubitus position, and an extended left posterolateral thoracotomy was performed. There was significant difficulty establishing the lateral extrapleural plane, and the tumor extensively involved the posterior periaortic plane. A clear line of separation between the aorta and the tumor could, however, be established. The extrapleural pneumonectomy otherwise went without incident and involved en bloc resection of the lung, mediastinal lymph nodes, left hemidiaphragm, and ipsilateral aspect of the pericardium. Suture ligation and electrocautery control of the ipsilateral upper thoracic segmental arteries was required from the T3 to T6 level. No bleeding from the neural canals at the associated segmental levels was noted. The diaphragm and pericardium were reconstructed with 2-mm polytetrafluoroethylene patches (GORE-TEX; W. L. Gore & Associates, Inc). Hemostasis was assured. Total blood loss was estimated at 1,300 mL, and 5 units of packed RBCs were transfused. He was transferred to the ICU with a low-dose, 0.5 mcg/kg/min phenylephrine infusion for BP support.