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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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Fig. 14.6 A plane was
developed between the
diaphragmatic pericardium
and diaphragm in between
stay sutures
Fig. 14.7 The pericardium
is divided in two halves
and dissected off the
diaphragm
14 The Operation: Total Pericardiectomy via Median Sternotomy Without…
dissection without compromising haemodynamics. The right-sided ap was
divided 1cm anterior to the right phrenic pedicle, freeing the superior and inferior cavoatrial junctions (Figs.14.8a–d).
• After securing haemostasis, the pericardial and pleural cavities were irrigated
using dilute 1% betadine solution and warm normal saline.
• Two ventricular pacing wires were placed as a routine. Two intercostal drains
were placed, and the wound was closed in layers.
• Dopamine at a dose of 5μg/kg/min was electively started on completion of the
pericardiectomy. There was immediate reduction of median right atrial pressure
from 28mmHg (preoperative) to 4–5mmHg postoperatively, after completion of
mobilization.
• The right-sided pericardial ap was divided into two halves and excised, freeing
the superior and inferior cavoatrial junctions. The surgeon should be more cautious on the right side due to thinness and dilation of the right atrium.
14.1 Total Pericardiectomy for Chronic Constrictive Pericarditis Via Median…
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253
Fig. 14.8 (a, b) The right
phrenic neurovascular
pedicle was identied and a
full length incision was
made 1cm anterior to the
right phrenic nerve till the
superior cavo-atrial junction
superiorly and inferior
cavo-atrial junction
inferiorly. (c, d)
Intraoperative pictures of the
decorticated heart and the
excised pericardium
a
b
c
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14 The Operation: Total Pericardiectomy via Median Sternotomy Without…
Fig. 14.8 (continued)
d
References
1. Chowdhury UK, Subramaniam G, Kumar AS, Airan B, Singh R, Talwar S, etal. Pericardiectomy
for constrictive pericarditis: clinical, echocardiographic and haemodynamic evaluation of two
surgical techniques. Ann Thorac Surg. 2006;81:522–30.
2. 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.
3. 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)
4. Harrington SW.Chronic constrictive pericarditis. Partial pericardiectomy and epicardiolysis in
twenty-four cases. Ann Surg. 1944;120:468–85.
Chapter 15
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The Operation: Radical Pericardiectomy
via Modied Left Anterolateral
Thoracotomy Without Cardiopulmonary
Bypass (UKC’s Modication)
15.1 Technical Details toFacilitate Radical Pericardiectomy
Via Anterolateral Thoracotomy [1–5]
15.1.1 The Operation
15.1.1.1 Step I: Operative Approach
• The approach is by left anterolateral thoracotomy with the patient titled slightly
to the right. Both the groins are positioned and draped for emergency exposure
of the femoral vessels and institution of cardiopulmonary bypass if required.
• The slightly curved subpulmonary incision by way of the fourth or fth intercos-
tal space gives excellent access to the left ventricle, left atrium and right ventricle. Transxation and division of the left internal thoracic artery is required in
most patients. In our experience, we do not transect the sternum to gain exposure
to right ventricle and right atrium across the midline but employ several maneuvres as described below to facilitate exposure to the right-sided cardiac chambers
with certainty and safety. It is important to divide the intercostal muscles posteriorly almost till the angle of the ribs, to facilitate opening of the retractor blade
without causing any rib fractures.
• A scapular or right angled deep-bladed retractor is used to facilitate retraction of
the muscles of the lateral thoracic wall to facilitate undercutting of the intercostal
muscles (Fig.15.1).
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_15
255© The Author(s), under exclusive license to Springer Nature Singapore Pte
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Fig. 15.1 Intraoperative
view of the steps of radical
pericardiectomy via
modied left anterolateral
thoracotomy. The chest is
entered through the left
fourth intercostal space
Fig. 15.2 A large wet
sponge is used to retract
the left lung posteriorly.
The left phrenic
neurovascular pedicle is
identied and the excessive
fat overlying the apex of
the left ventricle is
removed
15 The Operation: Radical Pericardiectomy via Modied Left Anterolateral…
15.1.1.2 Step II: Excision oftheThymus andExcessive Fat Overlying
theLeft Phrenovascular Pedicle andApex oftheLeft Ventricle
• A large wet sponge is used to retract the left lung posteriorly to facilitate expo-
sure of the heart.
• It is important to excise the large amount of fat overlying the apex of the left
ventricle in close proximity of the left phrenic neurovascular pedicle.
• The thymus is gently dissected off the pericardium and excised subtotally trans-
xing its superior pole to facilitate exposure of the pericardium overlying the
ascending aorta and main pulmonary trunk (Fig.15.2)
15.1 Technical Details to Facilitate Radical Pericardiectomy Via Anterolateral…
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257
15.1.1.3 Step III: Development ofaNew Cleavage Plane Between
theAnterior Surface ofthePericardium andPosterior Surface
oftheSternum
• After retracting the posterior table of the sternum using a deep bladed right-
angled retractor, a new cleavage plane is developed between the anterior surface
of the pericardium and sternum using a long handled cautery pencil (Fig.15.3a, b).
Fig. 15.3 (a, b) A new
cleavage plane is created
using cautery dissection
between the anterior
surface of the pericardium
and the posterior surface of
the sternum
a
b
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15 The Operation: Radical Pericardiectomy via Modied Left Anterolateral…
15.1.1.4 Step IV: Extension oftheDissection Plane beyond theMid
Sternum totheRight Phrenic Neurovascular Pedicle
• Three to four tissue forceps or No.1 silk sutures are atraumatically placed over
the anterior surface of the pericardium to facilitate traction in order to extend the
dissection plane beyond the midline towards the right phrenovascular pedicle
(Fig.15.4).
15.1.1.5 Step V: Dissection oftheDiaphragmatic Pericardium
andDevelopment ofaNew Cleavage Plane Between
theDiaphragm andDiaphragmatic Pericardium
• Using a long-handled cautery, a new dissection plane is created between the
diaphragm and diaphragmatic pericardium. Care is taken to avoid injury to the
diaphragmatic muscle bres and perioperative hypotension (Fig.15.5).
15.1.1.6 Step VI: Isolation andMobilization oftheLeft Phrenic
Neuromuscular Pedicle
• Following exposure of the pericardium, two full- length parallel incisions are
made using low voltage (around 8–10mV) cautery 1cm anterior and posterior to
the left phrenic neurovascular pedicle and extended until the level of the pulmonary artery superiorly and the diaphragm inferiorly. Multiple silk stay sutures are
placed on the incised pericardial edges anteriorly and posteriorly to achieve
exposure, and the left phrenic pedicle is thereafter isolated using two elastomer
vessel loops (Fig.15.6).
Fig. 15.4 The retrosternal
dissection plane is further
extended beyond the
midline to the right
phrenovascular pedicle
using long handled cautery
pencil
15.1 Technical Details to Facilitate Radical Pericardiectomy Via Anterolateral…
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Fig. 15.5 A new
dissection plane is created
using cautery dissection
between the diaphragm
and diaphragmatic
pericardium
Fig. 15.6 After identifying
the left phrenovascular
pedicle, two full length
parallel incisions are made
1cm anterior and posterior
to the phrenic pedicle till
the pulmonary trunk
superiorly and diaphragm
inferiorly. Two elastomer
vessel loops are passed
around the phrenic pedicle
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15.1.1.7 Step VII: Pericardial Dissection Posterior totheLeft Phrenic
Neurovascular Pedicle
• The pericardium is gently dissected off the posterolateral surface of the left atrial
appendage and left ventricle. The midportion of the posterior pericardial ap is
subsequently divided in two halves, to facilitate adequate mobilization until the
level of left-sided pulmonary veins, and excised (Fig.15.7a, b).
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15 The Operation: Radical Pericardiectomy via Modied Left Anterolateral…
Fig. 15.7 A plane was
developed (a) posterior to
the left phrenovascular
pedicle to expose the
posterolateral surface of
the left ventricle and left
atrial appendage. The
mid-portion of the
posterior pericardial ap
was divided in two halves
at the center (b) and was
excised
a
b
15.1.1.8 Step VIII: Creation oftheAnterior Pericardial Flap
• The pericardial ap anterior to the left phrenovascular pedicle is dissected and
raised from the right ventricle and main pulmonary trunk using low voltage cautery at 8 to 10 mv.
• The anterior pericardial ap (APF) is subsequently divided in between silk stay
sutures to minimize cardiac compression, thus avoiding unstable
hemodynamics.
• Anteriorly, the pericardial dissection is continued till approximately 1cm ante-
rior to the right phrenovascular pedicle and subsequently excised from the level
of pulmonary trunk till the inferior cavoatrial junction (Fig.15.8a, b).
15.1 Technical Details to Facilitate Radical Pericardiectomy Via Anterolateral…
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261
Fig. 15.8 (a, b): The
anterior pericardial ap
(APF) is dissected from the
left and RV and pulmonary
trunk avoiding injury to the
coronary vessels. The ap
is divided in two halves at
the center in between stay
sutures to minimize cardiac
compression and unstable
hemodynamics. The
anterior ap is excised 1
cm anterior to the right
phrenovascular pedicle till
the pulmonary trunk
superiorly and the inferior
cavoatrial junction
inferiorly
a
b
15.1.1.9 Step IX: Development ofaNew Dissection Plane Between
theDiaphragm andDiaphragmatic Pericardium
• Inferiorly a dissection plane is developed between the diaphragm and thickened
pericardium avoiding injury to the diaphragmatic muscle bres. Loculated pus
cavities, if encountered are unroofed at this stage. The apex of the left ventricle
and the diaphragmatic surface of the right ventricle and freed of the underlying
adhesions maintaining stable haemodynamics.
• Three to four silk stay sutures are placed as the incised edge of the diaphragmatic
pericardium, divided in two halves and are subsequently excised taking special
precautions near the inferior cavoatrial junction.
• All constricting epicardial layers are peeled of the cardiac chambers and great
vessels avoiding injury to the coronary vessels.
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