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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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13.1 Theoretical Basis
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a
Anterior flap divided
horizontally & peeled
up to right atrium
241
b
Fig. 13.9 (a, b) Using a long cautery pencil, the anterior pericardial ap (APF) was divided in two
halves in between stay sutures to facilitate dissection without compromising hemodynamics and
was excised approximately 1cm anterior to the right phrenic pedicle
242
diaphragmatic dissection
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13 Radical Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
Fig. 13.10 (a, b, c) Using
a long cautery pencil, a
new cleavage plane is
made to develop between
the diaphragm and
diaphragmatic pericardium,
along its length. The
diaphragmatic pericardium
was freed from the
diaphragmatic surface of
the right ventricle and the
apex of the left ventricle
and was excised from the
pericardio-diaphragmatic
reection. APF Anterior
pericardial ap, D
Diaphragm, DP
Diaphragmatic
pericardium, RV right
ventricle
a
b
Continuation of
around to left side
c
Dissection of diaphragmatic
pericardium from inferior
aspect of right ventricle
a
13.1 Theoretical Basis
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Fig. 13.11 (a, b, c)
Pictorial depiction and
intraoperative view of the
decorticated heart with an
intact left phrenovascular
pedicle. LAA left atrial
appendage, LV left
ventricle
243
Right ventricle
Cut edge of anterior pericardiodiaphragmatic reflectin
Phrenic n.
Left
ventricle
Cut edge of posterior
pericardiodiaphragmatic
reflection
b
Left pulmonary veins
Left atrium
Left phrenic n.
Left ventricle
Cut edge of posterior
pericardiodiaphragmatic
reflection
c
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13 Radical Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
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timing and techniques of radical pericardiectomy via modied left anterolateral thoracotomy
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constrictive pericarditis. World J Ped Cong Heart Surg. 2020;11(4):NP203–6.
14. Chowdhury UK, Narang R, Malhotra P, Choudhury M, Choudhury A, Singh SP.Indications,
timing and techniques of radical pericardiectomy via modied left anterolateral thoracotomy
(UKC’s modication) and total pericardiectomy via median sternotomy (Holman and Willett)
without cardiopulmonary bypass. J Prac Cardiovasc Sci. 2016;2:17–27.
15. Chowdhury UK, Patel K, Kumari L, Seth S, Avneesh S, Mishra AK, Kalaivani M, Hasija
S.Tissue Doppler imaging-derived mitral and tricuspid annular velocities: non-predictors of
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left anterolateral thoracotomy (UKC’s modication): a video presentation. Int Med. 2019;1(4)
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18. Chowdhury UK, George N, Kumari LS, Singh S, Chauhan AS. Total pericardiectomy via
median sternotomy (Holman and Willett): a video presentation. Int Med. 2019;1(4)
19. Chowdhury UK, George N, Sankhyan LK, Singh S, Chauhan A, Gupta A, Chowdhury
P.Radical Pericardiectomy via left anterolateral thoracotomy (UKC’s modication): a video
presentation. J Clinical Cardiology and Cardiovascular Interventions. 2020;3(13):01–4.
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pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation. 1999;100:1380–6.
25. Lachman N, Vanker EA, Christensen KN, Satyapal KS, Fennell WM.Pericardiectomy: a functional anatomical perspective for the choice of left anterolateral thoracotomy. J Card Surg.
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26. Reinmuller R, Gurgan M, Erdmann E, Kemkes BM, Kreutzer E, Weinhold C.CT and MR
evaluation of pericardial constriction: a new diagnostic and therapeutic concept. J Thorac
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30. Spodick DH.Constrictive pericarditis. In: Spodick DH, editor. The pericardium: a comprehensive textbook. 1st ed. NewYork: Marcel Dekker, Inc; 1997. p.214–59.
31. Spodick DH. The pericardium. A comprehensive textbook, vol. 233. New York, NY:
M.Dekker; 1997. p.464.
32. Spodick DH.Tuberculous pericarditis. Arch Intern Med. 1956;98:737–49.
33. Spodick DH. Pericardial diseases. In: Braunwald E, Zipes DP, Libby P, editors. Heart disease: a textbook of cardiovascular medicine, vol. 6. Philadelphia, PA: WB Saunders Co; 2001.
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36. Tokuda Y, Miyata H, Motomura N, Araki Y, Oshima H, et al. Outcome of pericardiectomy for constrictive pericarditis in Japan: a nationwide outcome study. Ann Thorac Surg.
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245
Chapter 14
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The Operation: Total Pericardiectomy via
Median Sternotomy Without
Cardiopulmonary Bypass (Holman
andWillett’s Approach)
14.1 Total Pericardiectomy forChronic Constrictive
Pericarditis Via Median Sternotomy: Surgical
Steps [1–4]
14.1.1 The Operation
14.1.1.1 Step I: Median Sternotomy, Subtotal Thymectomy, Mobilization
ofthePleural Reection
• Both groins were electively prepared for immediate institution of cardiopulmo-
nary bypass, if required, in case of advertent injury to cardiac chambers or great
vessels.
• The chest was opened through the mid-sternotomy incision. The thymus was
subtotally excised to expose the pericardium overlying the aorta and pulmonary
artery. Subsequently, pleural reections were mobilised laterally to obtain a wide
width of pericardium to be excised (Fig.14.1).
14.1.1.2 Step II: Identication ofRight andLeft Phrenic Pedicles
• Both pleural spaces were electively opened to visualize both phrenic pedicles
and decompress pleural effusion if present. It is important to identify and remove
the large amount of fat which usually overlies the left ventricular apex in close
proximity to the left phrenic nerve (Fig.14.2).
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_14
247© The Author(s), under exclusive license to Springer Nature Singapore Pte
248
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Fig. 14.1 Intraoperative
views of steps of total
pericardiectomy via
median sternotomy. The
chest was opened through
the mid-sternotomy
incision
Fig. 14.2 Pleural spaces
were entered to visualize
both phrenic pedicles and
decompress the pleural
effusion
14 The Operation: Total Pericardiectomy via Median Sternotomy Without…
14.1.1.3 Step III: I-Shaped Midline Incision over thePericardium
• The pericardium was inspected and palpated to determine a soft and uncalcied
area. An I-shaped incision was made in the midline over the pericardium upto the
level of the pulmonary artery superiorly and diaphragm inferiorly (Fig.14.3).
14.1.1.4 Step IV: Development ofaDissection Plane Between
thePericardium andtheHeart
• The thickened pericardium was incised using cautery until the parietal pericar-
dium and underlying epicardial fat. When done properly, there is clear visualization of the epicardial fat and coronary arteries. This plane is typically avascular
and supercial to the visceral pericardium. Inability to visualize the coronaries
indicates that the dissection plane is not deep enough, i.e. the epicardial peel of
Harrington is intact [4].
• It is important to set the cautery between 8 and 10mV during the process of dis-
section, to avoid cautery-induced ventricular brillation. Multiple silk stay
sutures were placed on the cut edges of the incised pericardium. The pericardium
14.1 Total Pericardiectomy for Chronic Constrictive Pericarditis Via Median…
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Fig. 14.3 An I-shaped
incision is made in the
midline over the
pericardium upto the level
of the pulmonary artery
superiorly and diaphragm
inferiorly
Fig. 14.4 The pericardium
overlying the anterior
surface of the right
ventricle and left
ventricular apex was
dissected off the heart
along with its serous layer
with clear visualisation of
the epicardial fat and
coronary arteries. The
pericardium was initially
divided close to the
diaphragmatic reection
249
was initially divided close to diaphragmatic reection over the right ventricle,
and the lateral pericardial ap was raised superiorly and laterally. If calcied
plaques or spicules penetrating the epicardium are present, these are left behind
at this stage with islands of calcied pericardium, making numerous scores over
the patch. Circumferential patches of calcied pericardium are crushed with a
thick haemostat and/or bone cutter and removed, avoiding injury to underlying
vascular structures, coronaries and phrenic nerves. We have been able to successfully remove all islands of calcic patches/spicules at the end of dissection. We
have not used a cavitational ultrasonic surgical aspiration system (CUSA) for
removal of calcium, or a nerve stimulator for identication of the phrenic nerve
(Fig.14.4).
• Multiple silk stay sutures were used for holding the edges for traction; a Kocher
or Alice Clamp can also be used. The heart was retracted with the left hand using
a wet sponge on the heart by the operating surgeon, or a sponge forceps held by
the assistant.
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14 The Operation: Total Pericardiectomy via Median Sternotomy Without…
14.1.1.5 Step V: Creation ofAnterior Pericardial Flap ontheLeft Side
andIts Division inTwo Halves
• The process of pericardial mobilization was started at the caudal end of the “I”
incision on the left side and progressed superiorly towards the aorta and pulmonary artery till the inferior border of the brachiocephalic vein, creating a ap of
about 1cm width.
• Multiple silk stay sutures were placed on the incised pericardial edges to facili-
tate dissection. Subsequently, the ap was divided in the mid-portion to facilitate
mobilization and dissection with minimal compression of the cardiac chambers
and great vessels, maintaining stable haemodynamics as much as possible.
• The lateral limit of the dissection on the left side was 1cm anterior to the phrenic
nerve over the left atrial appendage, freeing the apex of the left ventricle.
• It is important to remember that left phrenic pedicle frequently has a more ante-
rior course than expected. Although some centres periodically stimulate the left
phrenic nerve with a nerve stimulator, we have not used one. The left anterior
interventricular coronary artery should be well visualized in the operative eld
(Figs.14.5a–c).
14.1.1.6 Step VI: Mobilisation ofDiaphragmatic Pericardium
andRelease ofLeft Ventricular Apex
• A new plane was developed between the diaphragmatic pericardium and dia-
phragm. Three to four silk stay sutures were placed on the edges of the diaphragmatic pericardium, dividing it in two halves.
• The pericardium was dissected off the posterolateral left ventricular wall and the
inferior walls of the left and right ventricles. Posterolaterally, the pericardium
posterior to the left phrenic nerve down to the left-sided pulmonary veins was
dissected and excised. Generally, there is a greater haemodynamic compromise
while removing the diaphragmatic pericardium (Fig.14.6).
14.1.1.7 Step VII: Excision ofDiaphragmatic Pericardium
• Finally, the diaphragmatic pericardium on the right side was dissected off the
diaphragm, avoiding injury to a dilated and thinned inferior caval vein. The
edges of the incised pericardium were gently cauterized to obtain haemostasis
(Fig.14.7).
14.1 Total Pericardiectomy for Chronic Constrictive Pericarditis Via Median…
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251
Fig. 14.5 (a–c) The
anterior pericardial ap
(APF) was divided into
two halves in the middle,
which facilitated
mobilisation with minimal
intermittent cardiac
compression. The left
phrenic neurovascular
pedicle was identied, and
a full-length incision was
made 1cm anterior to the
pedicle, dening the
posterior extent of
pericardial excision
a
b
c
14.1.1.8 Step VIII: Creation ofPericardial Flap onRight Side,
andDivision inTwo Halves
• The right side of the pericardial ap was subsequently developed taking care not
to injure the right atrium, superior caval vein and inferior caval vein. Due to the
thinness and dilation, these structures are more vulnerable to injury during dissection. The right-sided ap was also divided in the midportion to facilitate
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