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Chapter 22
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Total Pericardiectomy via Median
Sternotomy Without Cardiopulmonary
Bypass (Holman andWillett): AVideo
Presentation
22.1 The Operation (Video 22.1) [1, 2]
22.1.1 Median Sternotomy, Subtotal Thymectomy,
Mobilization ofPleural Reection
• Both groins are electively prepared for immediate institution of cardiopulmonary
bypass, if required, in case of inadvertent injury to cardiac chambers or great
vessels.
• Following median sternotomy, the thymus is subtotally excised to expose the
pericardium overlying the aorta and pulmonary artery. Precautions are taken not
to expose the brachiocephalic vein. The pleural reections are mobilized laterally to obtain a wide width of pericardium to be excised.
22.2 Exposure ofRight andLeft Phrenic Pedicles
• Both pleural cavities are electively opened to visualize the phrenic pedicles and
to drain the pleural uid. A large amount of fat is identied overlying the apex of
the left ventricle in close proximity to the left phrenic nerve.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 981- 99- 5808- 5_22.
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_22
381© The Author(s), under exclusive license to Springer Nature Singapore Pte
382
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22 Total Pericardiectomy via Median Sternotomy Without Cardiopulmonary Bypass…
22.3 I-Shaped Midline Incision over thePericardium
• The pericardium is inspected and palpated to determine a soft and uncalcied
area. Using cautery at 8–10mV, an ‘I’-shaped incision is made in the midline
over the pericardium up to the level of the pulmonary artery superiorly and diaphragm inferiorly.
22.4 Development ofaDissection Plane Between
Pericardium andHeart
• The pericardial incision is deepened using low voltage cautery until the epicar-
dial fat and coronary arteries are visualized. Precautions are taken to develop the
plane of dissection between the epicardial peel of Harrington and epicardial fat.
22.5 Development ofPericardial Flap onLeft Side
• Pericardial mobilization is started at the caudal end of the ‘I’ incision on left side
and progresses 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 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.
• 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.
Placement of multiple silk sutures deep inside the pericardial ap facilitate the
process of dissection.
22.6 Mobilization ofDiaphragmatic Pericardium
andRelease ofLeft Ventricular Apex
• A new cleavage plane is developed between the diaphragmatic pericardium and
diaphragm. Three to four silk stay sutures are placed on the edges of the diaphragmatic pericardium, dividing it in two halves.
• The pericardium overlying the inferior surface of the heart is subsequently dis-
sected and excised, thus freeing the diaphragmatic surface of the right ventricle
and apex of left ventricle with minimal compromise on haemodynamics.
References
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383
22.7 Creation ofPericardial Flap onRight Side
• The right side of the pericardial ap is subsequently developed taking care not to
injure the right atrium, superior caval vein and inferior caval vein. Due to the
thinness and dilatation these structures are more vulnerable to injury during dissection. The right-sided ap is also divided in midportion to facilitate dissection
without compromising haemodynamics. The right-sided ap is divided 1cm
anterior to the right phrenic pedicle, freeing the superior and inferior cavoatrial
junctions.
• After securing haemostasis, the pericardial and pleural cavities are irrigated
using dilute 1% betadine solution and warm normal saline.
Two ventricular pacing wires are placed as a routine. Two intercostal drains are
placed, and the wound is closed in layers.
Dopamine at a dose of 5μg/kg/min is electively started on completion of the
pericardiectomy. There is immediate reduction of median right atrial pressure from
29 mmHg (preoperative) to 10–11 mmHg postoperatively, after completion of
mobilization.
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2. Chowdhury UK, George N, Sankhyan LK, Goja S, Choudhury A, Gupta S, Malik V, Pandey
NN.Total Pericardiectomy for calcic constrictive pericarditis with extracardiac intrapericar-
dial caseating mass via median sternotomy (Holman and Willett’s Approach): a video presenta-
tion. J Clin Cardiol Cardiovasc Interv. 5(2) https://doi.org/10.31579/2641- 0419/240.
Chapter 23
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Total Pericardiectomy via Modied Left
Anterolateral Thoracotomy Without
Cardiopulmonary Bypass (UKC’s
Modication): AVideo Presentation
23.1 Surgical Steps (Video 23.1) [1–3]
23.1.1 Step I: Patient Positioning andIncision
• The patient is positioned for a left anterolateral thoracotomy and is slightly inclined
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 chest is accessed through the fourth intercostal space. The left internal
thoracic artery is transxed. A scapular/deep bladed retractor is used to retract
the muscles of the lateral thoracic wall to facilitate undercutting of the inter-
costal muscles. In order to avoid rib fractures posteriorly during opening of the
retractor blade, the intercostal muscles are divided almost upto the angle of
the ribs.
23.1.2 Step II: Dissection oftheThymus andRemoval
ofExcessive Fat Overlying theLeft Phrenovascular
Pedicle andLeft Ventricular Apex
• The thymus is dissected to facilitate exposure of the pericardium over the ascend-
ing aorta and pulmonary trunk. The thymus is excised subtotally, transxing the
superior pole of the thymic gland.
• A large wet sponge is placed over the left lung and retracted posteriorly to facili-
tate exposure.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 981- 99- 5808- 5_23.
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_23
385© The Author(s), under exclusive license to Springer Nature Singapore Pte
386
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• Special precautions are taken not to injure the left phrenovascular pedicle since
23 Total Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
it is retracted in an anterior position due to pericardial inammation and smoul-
dering brosis.
23.1.3 Step III: Developing aNew Dissection Plane Between
Anterior Surface ofPericardium andSternum
• After retracting the posterior table of the sternum with a right angled deep blade
retractor, a new dissection plane is developed between the anterior pericardial
surface and sternum using cautery.
23.1.4 Step IV: Extension ofDissection Plane beyond
Midsternum toRight Phrenovascular Pedicle
• The anterior portion of the pericardium is held in traction, thereby extending the
newly developed dissection plane beyond midsternum to the right phrenovascu-
lar pedicle.
23.1.5 Step V: Mobilization andIsolation ofLeft
Phrenovascular Pedicle
• After exposing the pericardium, two full-length parallel incisions are made using
low-voltage cautery (around 8–10mV), 1cm anterior and posterior to the left
phrenic neurovascular pedicle, and extended until the level of the pulmonary
trunk superiorly and diaphragm inferiorly. Multiple silk stay sutures are placed
on the incised pericardial edges anteriorly and posteriorly to achieve exposure;
the left phrenovascular pedicle is thereafter isolated using two vessel loops.
23.1.6 Step VI: Dissection ofPericardium Posterior toLeft
Phrenovascular Pedicle andDivision ofthePosterior
Pericardium inTwo Halves
• Posteriorly, the pericardium is dissected from posterolateral surface of the left
ventricle and left atrial appendage. The midportion of the posterior pericardial
ap is subsequently divided into two halves to facilitate adequate mobilization
until the levels of left-sided pulmonary veins, and excised.
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