14 After either neurolysis of the C8 and T1 roots or division of the T1 root, the sympathetic chain is next divided, along with some ligation of intercostal veins. Care must also be taken at this point because occasionally the vertebral artery, as it courses toward the cervical spine, can have a downward trajectory and can be injured. The dissection is extended with an apical pleurectomy and dissection of Sibson's fascia as it extends up into the neck. The pleural dissection is also extended onto the anterior portion of the vertebral body to include the prevertebral fascia. Once a clear margin is identified, then the pleura and prevertebral fascia are incised with electrocautery and extended up toward the neck. Often, the longus coli muscle may also be infiltrated and can be dissected high into the neck, as well as from the posterior approach. The lobe and chest wall have now been completely mobilized. At this point, for small apical tumors, the chest wall and tumor can be separated from the lobe with a series of linear (GIA) stapler firings. The specimen can be handed off and can be processed for frozen section analysis by the pathologist while a completion lobectomy and mediastinal lymphadenectomy is performed. Removal of the chest wall at this point minimizes some of the weight of the specimen that could result in a torsional injury to the delicate hilar vessels during the dissection of the hilum. Tumors that extend more centrally cannot be removed before the formal anatomic dissection. At this point, the vertebral bodies are closely examined. If there is any suggestion of involvement of the vertebral body or neural foramina, a spinal surgeon is consulted about performing either a foraminotomy or partial or complete vertebrectomy through this extended posterolateral thoracotomy exposure. Extended resections, including several level vertebral body resections with anterior and posterior stabilization, may be required for complex lesions. Provided no vertebral body work needs to be done, then the chest wall defect is closed by using a double layer of polypropylene mesh anchored to the transverse processes posteriorly and then pulled taut anteriorly and placed into the second, third, and fourth or fifth ribs anteriorly. The patient is positioned in a reverse flection to elevate the legs, and a very taut closure is then performed to the remaining ribs inferiorly. Large chest tubes are placed before the closure. Smaller resections do not require prosthetic closure of the chest wall because the overlying scapula and chest wall musculature are sufficient protection, despite the posteriorly resected ribs. For lesions that extend down to the fourth or fifth ribs, however, the mesh reconstruction is required to avoid scapula tip entrapment postoperatively. If a mesh reconstruction is not used, then a partial scapular tip resection needs to be performed. Patients postoperatively often require 24 to 48 hours of ventilatory support for the larger chest wall resections because the loss of the scalene musculature into these upper ribs accounts for a greater volume loss than would be expected after a routine lobectomy that would be performed without a concomitant chest wall resection. Reconstruction of the chest wall defect may improve some of the chest wall mechanics that can occur from these apical chest wall resections.