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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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23.1 Surgical Steps (Video 23.1)
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387
23.1.7 Step VII: Developing aDissection Plane Between
theDiaphragmatic Pericardium andDiaphragm
• Inferiorly, a new dissection plane is developed between the diaphragm and the
thickened pericardium all along its length. A loculated pus pocket surrounded by
brocalcic pericardial tissue is encountered. 100ml of putty-like material is
evacuated from the pocket. Three to four silk stay sutures are placed on the edge
of diaphragmatic pericardium dividing into two halves. Dissection is done
between pericardium and diaphragmatic surface of right ventricle and left ven-
tricle. The apex is completely freed from pericardial adhesions. After the cardiac
chambers are freed off the underlying adhesions, the entire width of the dia-
phragmatic pericardium is excised in toto, taking special precautions near the
inferior cavoatrial junction.
23.1.8 Step VIII: Dissection ofPericardium Anterior
toPhrenovascular Pedicle
• Using cautery at 8–10mV, the anterior pericardial ap is raised from the right
ventricle and pulmonary trunk. Multiple stay sutures on the anterior pericardial
edge are extremely helpful during dissection.
• Further division of the anterior pericardial ap in two halves minimizes intermit-
tent cardiac compression and prevents unstable hemodynamics. Utmost precau-
tions need to be exercised while dissecting the anterior pericardial ap overlying
the dilated and thin -walled inferior cavo atrial junction
• The pericardium is dissected upto 1cm anterior to the right phrenovascular ped-
icle the anterior pericardial ap is thereafter excised till the level of the superior
caval vein superiorly and upto the inferior cavo atrial junction inferiorly.
Two ventricular pacing wires are placed as a routine. An intercostal drain is placed,
and the wound is closed in layers. After securing haemostasis, the pericardial and
pleural cavities are irrigated using dilute 1% betadine solution and warm normal saline.
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
26 mmHg (preoperative) to 4–5 mmHg postoperatively, after completion of
mobilization.
388
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23 Total Pericardiectomy via Modied Left Anterolateral Thoracotomy Without…
References
1. 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. Int Med. 2019;1(4):246.
2. Chowdhury UK, George N, Singh S, Sankhyan LK, Sengupta S, Ray R, Vaswani P, etal.
Total pericardiectomy via modied left anterolateral thoracotomy without cardiopulmonary
bypass: a video presentation. Ann Thorac Surg. 2021;112:1483–92. https://doi.org/10.1016/j.
athoracsur.2020.10.045.
3. Sankhyan LK, Chowdhury UK, George N, Singh S, Chauhan A, Gupta A, Chowdhury P.Total
pericardiectomy via left anterolateral thoracotomy (UKC’s modication): a video presentation.
J Clin Cardiol Cardiovasc Intervent. 2020;3(13):1–4. https://doi.org/10.31579/2641- 0419/108.
Chapter 24
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Modied Left Anterolateral Thoracotomy
Approach Without Cardiopulmonary
Bypass (UKC’s Modication): AVideo
Presentation onTotal Pericardiectomy
forChronic Calcic Constrictive
Pericarditis
24.1 Surgical Steps (Videos 24.1 and24.2) [1–6]
24.1.1 Patient Position andSurgical Incision
• For left anterolateral thoracotomy, patient is positioned slightly tilted to the right.
Both the groins are draped for emergency exposure and cannulation of the femo-
ral vessels for institution of cardiopulmonary bypass, in case the need arises.
• After entering the chest through left fth intercostal space, transxation and divi-
sion of left internal thoracic artery is done. In order to avoid rib fractures poste-
riorly during opening of retractor blade, the intercostal muscles are divided
almost upto the angle of ribs. Undercutting of the intercostal muscles is facili-
tated using a deep-bladed retractor. Various manoeuvers are employed as
described further to gain safe exposure of right atrium and right ventricle across
midline without cutting the sternum.
24.1.2 Removing Excessive Fat Overlying Left Phrenovascular
Pedicle andLeft Ventricular Apex
• To facilitate exposure, a large wet sponge is used to retract the left lung posteri-
orly. Once the excessive fat overlying the left ventricular apex is removed, it is
crucial to identify the left phrenic neurovascular pedicle. Due to chronic inam-
matory process, the left phrenic nerve migrates anteriorly in most of the instances.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 981- 99- 5808- 5_24.
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_24
389
390
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• Routinely dissecting the thymus off the pericardium helps in exposing the peri-
24 Modied Left Anterolateral Thoracotomy Approach Without Cardiopulmonary…
cardium over the pulmonary trunk and ascending aorta. Subtotal excision of thy-
mus is carried out after transxing its superior pole.
24.1.3 Developing aDissection Plane Between Anterior
Surface ofthePericardium andSternum
• After retracting the posterior table of the sternum with a right-angled deep-blade
retractor, a new dissection plane is developed between anterior pericardial sur-
face and sternum using cautery.
24.1.4 Extending theDissection Plane Beyond theSternum
• After retracting the anterior part of pericardium using three silk sutures, the
newly developed dissection plane is further extended beyond the sternum upto
the right phrenovascular pedicle.
24.1.5 Developing Dissection Plane Between Diaphragm
andDiaphragmatic Pericardium
• A new plane is partially developed using cautery dissection, between the dia-
phragm and diaphragmatic pericardium avoiding opening the peritoneal cavity.
24.1.6 Mobilisation andIsolation oftheLeft
Phrenovascular Pedicle
• Once the pericardium is exposed, using low- voltage (around 8–10mV) cautery
two full-length parallel incisions are made 1cm anterior and posterior to the left
phrenovascular pedicle extending superiorly until the level of main pulmonary
trunk and inferiorly upto the diaphragm. The incised edges of pericardium are
retracted anteriorly and posteriorly using multiple silk stay sutures to facilitate
exposure. Two elastomer vessel loops are used to isolate the left phrenovascular
pedicle.
24.1 Surgical Steps (Videos 24.1 and 24.2)
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391
24.1.7 Dissecting thePericardium Posterior totheLeft
Phrenovascular Pedicle
• Posteriorly, pericardial ap is raised over left atrial appendage and posterolateral
surface of the left ventricle. The posterior pericardial ap is further divided in
two halves thus facilitating adequate mobilization upto the left-sided pulmonary
veins, and excised.
24.1.8 Dissecting thePericardium Anterior totheLeft
Phrenovascular Pedicle
• The anterior pericardial ap is raised over the right ventricle and pulmonary
trunk using cautery at 8–10 mV. Dissection is facilitated by placing silk stay
sutures on the incised pericardial edge.
• Further division of the anterior pericardial ap in two halves minimizes intermit-
tent cardiac compression and prevents unstable haemodynamics. Utmost precau-
tions need to be exercised while dissecting the anterior pericardial ap overlying
the dilated and thin- walled inferior cavo-atrial junction.
• The pericardium is dissected upto 1cm anterior to the right phrenovascular ped-
icle. The anterior pericardial ap is thereafter excised till the level of the superior
caval vein superiorly and upto the inferior cavoatrial junction inferiorly.
24.1.9 Developing aDissection Plane Between Diaphragm
andDiaphragmatic Pericardium
• Inferiorly, a new dissection plane is developed between the diaphragm and the
thickened pericardium all along its length. A loculated pus pocket surrounded by
brocalcic pericardial tissue is encountered. 100ml of putty-like material is
evacuated from the pocket. Three to four silk stay sutures are placed on the edge
of diaphragmatic pericardium dividing into two halves. Dissection is done
between pericardium and diaphragmatic surface of right ventricle and left ven-
tricle. The apex is completely freed from pericardial adhesions. After the cardiac
chambers are freed off the underlying adhesions, the entire width of the dia-
phragmatic pericardium is excised in toto, taking special precautions near the
inferior cavoatrial junction.
• All constricting layers of epicardium are peeled off the great vessels and cardiac
chambers, taking care to avoid any injury to the underlying structures particu-
larly the coronary arteries and veins.
392
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24 Modied Left Anterolateral Thoracotomy Approach Without Cardiopulmonary…
• A bone cutter and a thick hemostat are used to divide and remove circumferential
patches of calcied pericardium and calcic plaques while taking care to avoid
injury to underlying vascular structures and the phrenic nerves.
The chest cavity is irrigated with 1% dilute betadine and warm normal saline. Two
ventricular placing wires are placed. The chest is closed in layers after placing an
intercostal chest drain.
Dopamine at a dose of 5μg/kg/min is electively started on completion of pericardiectomy. The median right atrial pressure immediately reduced from 28 mmHg
(preoperative) to 4–6mmHg postoperatively, after completion of mobilization.
References
1. 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. Int Med. 2019;1(4):246.
2. Chowdhury UK, George N, Singh S, Sankhyan LK, Sengupta S, Ray R, Vaswani P, etal. Total
pericardiectomy via modied left anterolateral thoracotomy without cardiopulmonary bypass:
a video presentation. Ann Thorac Surg. 2021; https://doi.org/10.1016/j.athoracsur.2020.10.045.
3. Chowdhury UK, Kumari LS.Pericardiectomy for chronic constrictive pericarditis: where are
we after 100 years? World J Surg Surg Res. 2018;1:1027–30.
4. Chowdhury UK, Kumari LS, Hasija S.Surgery for chronic constrictive pericarditis, tubercu-
lous pericarditis and effusive-constrictive pericarditis. Cardiological Society of India; 2018.
Essentials of Postgraduate Cardiology, Evangel Publishers, Invited Chapter 64, p.1–10.
5. Chowdhury UK, Jena JK, Hasija S, Kumari LS.Successful use of intra-aortic balloon counter-
pulsation for systemic ventricular failure following total pericardiectomy for calcic chronic
constrictive pericarditis. World J Ped Cong Heart Surg. 2020;11(4):NP203–6.
6. Sankhyan LK, Chowdhury UK, George N, Singh S, Chauhan A, Gupta A, Chowdhury P.Total
pericardiectomy via left anterolateral thoracotomy (UKC’s modication): a video presentation.
J Clin Cardiol Cardiov Interv. 2020;3(13) https://doi.org/10.31579/2641- 0419/108.
Chapter 25
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Total Pericardiectomy forCalcic
Constrictive Pericarditis via Median
Sternotomy Without Cardiopulmonary
Bypass: AVideo Presentation
25.1 The Operation (Video 25.1) [1–5]
25.1.1 Median Sternotomy, Subtotal Thymectomy,
Mobilization ofPleural Reection
• Both groins are electively prepared for emergency institution of cardiopulmo-
nary 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 later-
ally to obtain a wide width of pericardium to be excised.
25.2 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 dia-
phragm inferiorly
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 981- 99- 5808- 5_25.
Ltd. 2023
U. K. Chowdhury, L. K. Sankhyan, Surgical Treatment of Chronic Constrictive
Pericarditis, https://doi.org/10.1007/978-981-99-5808-5_25
393© The Author(s), under exclusive license to Springer Nature Singapore Pte
394
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25 Total Pericardiectomy for Calcic Constrictive Pericarditis via Median Sternotomy…
25.3 Piecemeal Removal ofCalcic Pericardium
andDevelopment ofaDissection Plane Between
Pericardium andHeart
• The pericardial incision is deepened using low voltage cautery until the epicar-
dial fat and coronary arteries are visualized. With the help of a thick hemostat,
the calcic pericardium overlying the myocardium is crushed into multiple frag-
ments and removed piecemeal. Utmost precautions are taken to develop the
plane of dissection between the epicardial peel of Harrington and epicardial fat
avoiding injury to the underlying coronary vessels and myocardium. The calcic
fragments are removed from the myocardium with the help of De Bakey’s for-
ceps, thick hemostat and No.15 scalpel blade in varying combinations.
25.4 Development ofaPericardial Flap ontheLeft 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.
25.5 Division oftheLeft-Sided Pericardial Flap
inTwo Halves
• Multiple silk stay sutures are placed on the incised pericardial edges to facilitate
dissection. Subsequently the ap is divided in mid-portion to facilitate mobiliza-
tion and dissection with minimal compression of the cardiac chambers and great
vessels, maintaining stable haemodynamics as much as possible.
25.6 Excision oftheLeft Superior Half oftheCalcic
Pericardium Using aBone 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 cut-
ter followed by a heavy scissor and cautery. Precautions are taken not to injure
the left atrial appendage, left phrenic nerve and the pericardiophrenic vessels.
25.10 Irrigation of the Middle Mediastinum and Placement of the Pacing Wires
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395
25.7 Mobilization oftheDiaphragmatic Pericardium
andExcision oftheLeft Inferior Half oftheCalcic
Pericardium Using aBone 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 1cm 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.
25.8 Mobilization ofDiaphragmatic Pericardium
• A new cleavage plane is subsequently 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.
25.9 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 dilation, these structures are more vulnerable to injury during dis-
section. 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.
25.10 Irrigation oftheMiddle Mediastinum andPlacement
ofthePacing Wires
• After securing haemostasis, the pericardial and pleural cavities are irrigated
using dilute 1% betadine solution and warm normal saline.
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25 Total Pericardiectomy for Calcic Constrictive Pericarditis via Median Sternotomy…
• Two ventricular pacing wires are placed as a routine. Two intercostal drains are
placed, and the wound is closed in layers.
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, Jena JK, Hasija S, Kumari LS.Successful use of intra-aortic balloon counter-
pulsation for systemic ventricular failure following total pericardiectomy for calcic chronic
constrictive pericarditis. World J Ped Cong Heart Surg. 2020;11(4):NP203–6.
4. Chowdhury UK, Kumari LS.Pericardiectomy for chronic constrictive pericarditis: where are
we after 100 years? World J Surg Surg Res. 2018;1:1027–30.
5. Chowdhury UK, George N, Kumari LS, Singh S, Chauhan AS, Gupta A, Chowdhury S.Total
pericardiectomy via median sternotomy (Holman and Willett): a video presentation. Int Med.
2019;1(4):244.
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