Enter the chest in the fourth or fifth intercostal space using a standard posterolateral thoracotomy incision. Examine the mediastinum and hilum to confirm that the diseased area does not extend into the mediastinum, chest wall, or apex and is thus resectable. Retract the lung inferiorly to reveal the superior hilum. Inferior to the azygos vein, dissect the pleura carefully at the apex with Metzenbaum scissors or electrocautery.

Identify and mobilize the main pulmonary artery by careful blunt dissection with a “peanut” dissector. Pass a large right-angled clamp carefully around the artery in preparation for double ligation. For security, first tie the proximal pulmonary artery with heavy silk (usually number 1). Place a transfixion suture ligature (usually one size smaller than the freehand tie) just distal to the freehand tie. Control the distal end of the artery (specimen side) with a freehand tie and divide the pulmonary artery. Alternatively, a linear stapler with vascular staples is an expedient way to secure the proximal side of this large, fragile vessel.

Review the location of mediastinal structures and the relationships of major structures in the root of the lung before surgery.
Mediastinal structures of concern include the azygos vein, superior vena cava, phrenic and vagus nerves, and esophagus. The unpaired azygos vein provides a reliable landmark, for the superior aspect of the right hilum. This vein, lying on the side of the thoracic vertebral bodies, drains the right intercostal spaces and receives the termination of the hemiazygos vein on the left, then arches anteriorly to enter the superior vena cava immediately superior to the hilum of the lung. The right bronchial vein, which drains the lung parenchyma, also empties into the azygos vein. Division of the azygos vein, if necessary, is permissible owing to the abundant collateral venous return of the chest wall.