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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3715_Библиотеки_им_академика_М_И_Перельмана
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Chapter 13
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Radical Pericardiectomy via Modied Left
Anterolateral Thoracotomy Without
Cardiopulmonary Bypass (UKC’s
Modication): Criteria
forDecision- Making andSelection
oftheOptimal Surgical Approach
13.1 Theoretical Basis
The hemodynamic hallmark of chronic constrictive pericarditis is impaired diastolic
lling of the left ventricle due to a chronically brosed, rigid non-calcic or calcic
pericardial sac. The diseased, brotic pericardial cavity causes myocardial dysfunction by limiting ventricular diastolic lling resulting in decreased cardiac output.
Therefore, surgical excision of the thickened pericardium including the epicardium
remains the only denitive treatment for this disease [1–3, 5–24, 26–34].
It is logical therefore, that the aim of surgery would be to release the encased
ventricles to improve cardiac performance. The employment of different surgical
approaches for pericardial excision is widely accepted [2, 3, 23, 24, 26–36].
A variety of surgical approaches have been documented in the published literature namely conventional left anterolateral thoracotomy, bilateral anterolateral thoracotomy, and median sternotomy [1, 6–10, 12, 14, 17–19, 35].
In 1946, Sellors pointed out that pericardial resection should be primarily aimed
at removal of the ventricular epicardium which will allow maximal expansion of the
ventricles [27]. He further stressed on the importance of pericardial excision posterior to the phrenic nerves on either side [27].
In an attempt to provide a functional anatomical perspective for postoperative
cardiac performance and recovery, Lachman and colleagues in a necropsy study
demonstrated that the anterior portion of the pericardium in between the phrenic
nerves constitute only 58% of the total area of the pericardium. Secondly, the total
pericardium accessible over the left ventricle from midline was only 26%, while the
total area of the left ventricular pericardium accessible through left anterolateral
thoracotomy was 37% [25].
From a physiological perspective, postoperative cardiac performance is primarily dependent on release of the left ventricular chamber. According to Sterling’s law,
the lengthening of the sarcomere is proportionately associated with increased force
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_13
231© The Author(s), under exclusive license to Springer Nature Singapore Pte
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13 Radical Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
of myocardial contraction upto a certain point. Less force is generated with overstretching of the myocardium [4, 22, 27, 35].
It is therefore of paramount importance to release the left ventricular chamber
during pericardiectomy and avoid overstretching in the postoperative period with
excessive volume infusion and autotransfusion [16].
As enunciated in previous chapters, the median sternotomy approach with or without cardiopulmonary bypass may be specically suited for constrictive pericarditis
with calcic pericardial patches, reoperations, pericardial masses, calcic pericardial
“cocoon” and for those with predominant right-sided and annular involvement.
In our previous series of investigations on 395 patients undergoing pericardiectomy, we demonstrated that total pericardiectomy was associated with lower perioperative mortality (p = 0.02), less postoperative low cardiac output syndrome
(p<0.001), shorter hospitalization (p<0.001) and superior long-term survival than
partial pericardiectomy (p=0.004). Overall, the risk of death was 4.5 times higher
in patients undergoing partial pericardiectomy as compared with total pericardiectomy. In patients with CP, total pericardiectomy is more easily accomplished
through median sternotomy [7, 12].
It is pertinent to point out that despite total pericardiectomy, the operative mortality was 7.6% in our series and 6% to 19% in several surgical studies published
after 1985 [1, 2, 5–16, 23, 35, 36]. The incidence of postoperative low cardiac output syndrome continued to remain between 69% and 86% [1, 2, 5–16, 23, 35, 36].
Although the median sternotomy approach allowed adequate excision of the
pericardium overlying the right atrium including the superior and inferior cavoatrial
junctions, these areas are of little hemodynamic signicance in the great majority of
patients. Additionally, it is impossible to excise the pericardium posterior to the
phrenic nerves using this approach.
In an effort to further decrease the perioperative mortality and postoperative low
cardiac output syndrome, the author proceeded to perform several technical modications of the conventional left anterolateral thoracotomy to achieve further excision of the pericardium posterior to the phrenic nerves and diaphragmatic
pericardium without employing cardiopulmonary bypass. Thus, there were seven
forces driving our decision-making towards improvement of results following pericardiectomy via modied left anterolateral thoracotomy [7, 12].
(i) the desire to maintain oxygenation and hemodynamic stability by placing an
intercostal drain on the right side in cases of signicant pleural effusion,
(ii) the desire to keep both groins prepared while positioning and preparing the
patient for emergent institution of cardiopulmonary bypass in cases of inad-
vertent injury to the cardiac chambers and/or great vessels,
(iii) the desire to excise the pericardium posterior to the phrenic nerves,
(iv) the desire to achieve adequate excision of pericardium overlying the right ventricu-
lar outow tract and right atrium by developing a new dissection plane between the
anterior surface of the pericardium and posterior surface of the sternum,
(v) the desire to excise the diaphragmatic pericardium, thus freeing the diaphrag-
matic surface of the right ventricle,
(vi) the desire to minimize cardiac manipulation during pericardial excision by
dividing the anterior and posterior pericardial aps in two halves, and,
a
13.1 Theoretical Basis
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233
(vii) the desire to minimize perioperative autotransfusion by inserting a peritoneal
dialysis catheter before thoracotomy and placing it on controlled gravity
drainage during surgery.
The following surgical maneuvers (Figs.13.1a–f, 13.2a–f, 13.3a, b, 13.4a, b, 13.5a, b,
13.6, 13.7, 13.8a, b, 13.9a, b, 13.10a, b, c, 13.11a, b, c) facilitated performing radi-
cal pericardiectomy via modied left anterolateral thoracotomy without utilizing
cardiopulmonary bypass.
b
c
d
e
Fig. 13.1 (a) Intraoperative view of the steps of radical pericardiectomy via modied left anterolateral thoracotomy. The chest was entered through the left fourth intercostal space. (b) A large wet
sponge was used to retract the left lung posteriorly. The left phrenic neurovascular pedicle was
identied. (c, d) A dissection plane was created using cautery between the anterior surface of the
pericardium and the posterior surface of the sternum, dividing the sterno-pericardial ligaments. (e)
Using a long cautery pencil, the dissection plane was extended posterior to the sternum to identify
the right phrenic neurovascular pedicle. (f) A new cleavage plane was created using cautery dissection between the diaphragm and diaphragmatic pericardium
f
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a
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13 Radical Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
b
c
d
e
Fig. 13.2 (a) The left phrenic neurovascular pedicle was identied and two full-length parallel
incisions were made 1cm anterior and posterior to the phrenic pedicle till the pulmonary trunk
superiorly and diaphragm inferiorly. (b, c) A plane was developed posterior to the left phrenic
pedicle to expose the posterolateral surface of the left ventricle (LV) and left atrial appendage
(LAA). The posterior pericardial ap (PPF) thus raised was divided into two halves in the centre
and was excised. (d, e) The pericardial ap anterior to the left phrenic pedicle was dissected from
the left and right ventricles, and main pulmonary trunk, avoiding injury to the coronary arteries.
The anterior pericardial ap (APF) was divided in two halves to facilitate dissection without compromising hemodynamics. The ap was excised 1cm anterior to the right phreno-vascular pedicle
till the pulmonary trunk superiorly and inferior cavoatrial junction inferiorly. (f) The pericardium
overlying the diaphragmatic pericardium was dissected from the diaphragmatic muscle without
injury and excised
f
n
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235
Fig. 13.3 (a, b) Step-bystep pictorial depiction of
radical pericardiectomy via
left anterolateral
thoracotomy. The chest
was entered through the
left fourth intercostal space
a
Extension of
thoracotomy
Alternative incision
in midline
b
Thoracotomy in 4th
intercostal space
(i) development of a new cleavage plane between the anterior surface of the peri-
cardium and posterior surface of the sternum using a long cautery tip and a
right-angled deep blade sternal retractor,
(ii) extension of the dissection plane beyond the midline to the right phrenic
pedicle,
(iii) development of a dissection plane between the diaphragmatic muscles and
diaphragm,
(iv) development of a posterior pericardial ap posterior to the left phrenic neuro-
vascular pedicle and dividing it into two halves, and
Lung prior to deflatio
Pericardium &
left phrenic n.
236
a
icardial flap
ventricle
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Fig. 13.4 (a, b) Two
full-length parallel
incisions were made
1.0cm anterior and
posterior to the left phrenic
neurovascular pedicle from
the level of the main
pulmonary trunk superiorly
and diaphragmatic
reection inferiorly. The
incised pericardial edges
were held up using
multiple silk stay sutures
13 Radical Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
Location of 1st
pericardial incisions
Left phrenic n.
b
(v) development of an anterior pericardial ap, division of the anterior ap in two
halves and excision of the pericardium 1cm away from the right phrenovascular pedicle.
Although a modied left anterolateral thoracotomy approach as described above
provides adequate exposure of the left ventricle as well as right ventricle without
cardiac compression and avoids the requirement of cardiopulmonary bypass in the
majority of cases, it is important to consider the negative effects of thoracotomy on
oxygenation and hemodynamic stability during surgery. Although preoperative
assessment of patient’s respiratory function is essential to decide on the optimal
surgical approach, several investigators including ourselves believe that this
approach should ideally be offered to patients with satisfactory respiratory function.
Posterior per
raised from left ventricle
Left phrenic n.
Anterior pericardial flap
developed over right
d
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a
Phrenic n.
Anterior flap
Posterior flap develope
caudally
Left ventricle
Left atrial
appendage
Left
pulmonary
veins
b
Fig. 13.5 (a, b) Pictorial depiction and intraoperative view showing development of a dissection
plane posterior to the phrenovascular pedicle. The posterior pericardium was gently dissected from
the posterolateral surface of the left ventricle (LV) and left atrial appendage (LAA). The dissected
posterior pericardial ap was divided in two halves in the centre till the levels of left pulmonary
veins and was excised
Secondly, in patients with previous cardiac operation, this approach avoids the risks
of dissection through adhesions [4, 7, 12]. Thirdly, in patients with signicant right
pleural effusion, it has been the author’s practice to insert a right pleural intercostal
drain prior to pericardiectomy to avoid intraoperative haemodynamic and respiratory decompensation.
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Fig. 13.6 The pericardial ap anterior to the left phrenic pedicle was dissected from the left ventricle, anterolateral surface of the right ventricle, right ventricular outow tract, and main pulmonary trunk avoiding injury to the right ventricular outow tract and the underlying structures. The
anterior pericardial ap was divided in two halves in between stay sutures to facilitate dissection
without compromising the hemodynamics
13 Radical Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
Pulmonary
trunk
Right
ventricle
Anterior flap lifted toward right
Left phrenic n.
13.1 Theoretical Basis
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Undermining pericardium
& phrenic bundle
Fig. 13.7 The left phrenic neurovascular pedicle was gently dissected from the underlying left
ventricle and two elastomer vascular loops were passed around the pedicle to facilitate atraumatic
traction
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13 Radical Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
a
Sternopericardial reflection
divided with cautery
b
Fig. 13.8 (a, b) Pictorial depiction and intraoperative view demonstrating development of a
cautery- induced dissection plane between the anterior surface of the pericardium and posterior
surface of the sternum to identify the right phrenic neurovascular pedicle and extend the area of
pericardial excision
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