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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. 17.2 (a–e) Step-bystep demonstration of
excision of the calcic
pericardium. A vertical
incision is made over the
midportion of pericardium
using a low voltage cautery
upto the level of the
pulmonary artery superiorly
and diaphragm inferiorly.
The calcic patches are
fragmented using heavy
artery forceps
a
b
c
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17 The Operation: Total Pericardiectomy for Calcic Constrictive Pericarditis…
Fig. 17.2 (continued)
d
e
minimal compression/manipulation of the cardiac chambers/great vessels,
thereby maintaining haemodynamic stability. Thus, the process of decalcication is continued laterally.
• Multiple silk stay sutures are placed on the incised pericardial edges to facilitate dissection. Subsequently, the ap is divided in mid-portion to facilitate
mobilization and dissection with minimal compression of the cardiac chambers and great vessels, maintaining stable haemodynamics as much as possible (Fig.17.5a–e).
Step VI: Excision of the left superior half of the calcic pericardium using a
bone cutter
• Following mobilization of the left upper half of the calcic pericardium till
the level of left atrial appendage and the inferior border of left brachiocephalic vein, the superior half of the calcic pericardium is divided initially
using a bone cutter followed by a heavy scissor and cautery. Precautions are
taken not to injure the left atrial appendage, left phrenic nerve, and pericardiophrenic vessels (Fig.17.6a–d).
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285
Fig. 17.3 (a–d) The calcic
fragments are removed from
the myocardium with the
help of DeBakey’s forceps
and a dissection plane is
being developed between the
epicardial peel of Harrington
and epicardial fat
a
b
c
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17 The Operation: Total Pericardiectomy for Calcic Constrictive Pericarditis…
Fig. 17.3 (continued)
d
• Whenever possible, our target is to develop a plane of cleavage above and
below the calcied plaque. The circumferential patch of calcied pericardium
is crushed with a thick hemostat and/or bone cutter as required and is removed
piecemeal, avoiding injury to the underlying cardiac chambers, vascular
structures, coronaries and phrenic nerves. Special precautions need to be
exercised while removing calcied pericardial patches over the right atrium,
pulmonary artery and right ventricle.
• Using the above precautions, we have been able to remove almost all calcic
patches overlying the cardiac chambers, including cases with calcied spurs/
spicules penetrating the epicardium. During last 15 years we have not left
behind any calcied patches over the cardiac chambers. 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, on any
patient in this study.
• Although some surgeons grasp the edges of the incised pericardium with a
Kocher or Allis Clamp, we use multiple silk stay sutures for holding the edges
for traction. Retraction of the heart can be done with the left hand using a wet
sponge on the heart by the operating surgeon, or a sponge forceps held by an
assistant.
• Although the posterior extent of the dissection line is approximately 1cm
anterior to the left phrenic nerve, precautions are taken to not leave behind
sharp divided calcied pericardial edges.
• It is most often possible to peel off the calcied pericardium from the phrenic
pedicle, and the portion of pericardium posterior to the phrenic nerve. Extreme
precautions need to be exercised not to injure the pulmonary veins during the
process of dissection.
• It is important to remember that the left phrenic pedicle frequently has a more
anterior course than expected. Although some centres periodically stimulate
the left phrenic nerve with a nerve stimulator, we have not used such tech-
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287
Fig. 17.4 (a–e) Pericardial
mobilisation is started at
the caudal end of the “I”
shaped incision on the left
side. The calcic fragments
are being removed using
DeBakey’s forceps
a
b
c
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17 The Operation: Total Pericardiectomy for Calcic Constrictive Pericarditis…
Fig. 17.4 (continued)
d
e
niques. The left anterior interventricular coronary artery should be well visualized in the operative eld.
Step VII: Mobilization of the diaphragmatic pericardium and excision of the
left inferior half of the calcic pericardium using a bone cutter
• A new cleavage plane is developed between the diaphragmatic pericardium
and diaphragm. Multiple stay sutures are placed deep inside the pericardial
edges to facilitate mobilization of the lateral wall and apex of the left ventricle. The lateral limit of dissection on the left side is 1 cm anterior to the
phrenic pedicle over the left atrial appendage, freeing the apex of the left
ventricle.
• The pericardium overlying the apex is subsequently divided using a bone cutter and heavy scissor and excised avoiding injury to the left phrenic nerve and
apex of the left ventricle (Fig.17.7a–f).
Step VIII: Mobilisation of the diaphragmatic pericardium and release of left
ventricular apex.
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289
Fig. 17.5 (a-e) The
pericardial ap on the left
side is divided in two
halves and multiple stay
sutures are placed on the
pericardial edges to
facilitate dissection
without compromising
hemodynamics. The
calcic fragments are
being removed from the
pericardium using a No.15
scalpel blade and hemostat
a
b
c
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17 The Operation: Total Pericardiectomy for Calcic Constrictive Pericarditis…
Fig. 17.5 (continued)
d
e
• Dissection is done between the pericardium and posterolateral left ventricular
wall, and along 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 is dissected and excised. Generally, there is an increased haemodynamic compromise while removing the diaphragmatic pericardium
(Fig.17.8a, b).
• Between the diaphragm and inferior surface of right ventricle, there are pockets of caseation and patchy calcication in many patients. These blind recesses
are responsible for the collection of pockets of caseation, and asymmetric
distribution of calcication.
Step IX: Creation of the pericardial ap on the right side and division in
two halves.
• Next, the dissection proceeds laterally on the right side exactly as we have
done on the left side. It is important to divide the right pericardial ap in the
midportion; the surgeon should be very careful to avoid injury to the right
atrium, the superior caval vein, or the inferior caval vein/inferior cavoatrial
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junction. Due to their thinness and dilation, these structures are very vulnerable to injury during dissection. The pericardial reection overlying the intraand extra-pericardial junction of the superior caval vein is incised as a routine.
The posterior extent of the dissection line is approximately 1cm anterior to
291
Fig. 17.6 (a–d) The
superior half of the
mobilized calcic
pericardial patch is being
divided using a bone cutter,
a heavy scissor, and
cautery
a
b
c
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17 The Operation: Total Pericardiectomy for Calcic Constrictive Pericarditis…
Fig. 17.6 (continued)
d
the right phrenic nerve. Use of a No.15 scalpel blade is extremely helpful in
dissection of the diseased, thickened, calcied pericardium away from the
right atrial chamber (Fig.17.9a–d).
Step X: Excision of the inferior portion of the diaphragmatic pericardium
• Finally, the diaphragmatic pericardium on the right side is dissected off the
diaphragm, avoiding injury to the dilated and thinned inferior caval vein. The
edges of the incised pericardium are treated gently with electrocautery to
obtain haemostasis (Fig.17.10a, b).
Step XI: Irrigation of the pericardial cavity and placement of the pacing wires
• After securing haemostasis, the pericardial and pleural cavities are irrigated
using dilute 1% betadine solution and warm normal saline (Fig.17.11a, b, c).
• Two ventricular pacing wires are placed as a routine. Two intercostal drains
are placed, and the wound is closed in layers.
• Note the decorticated heart and the excised calcic pericardium.
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