Indications and preparation for surgery
According to surgical standards, the only absolute indication for this procedure is chronic constrictive pericarditis. This condition leads to critical compression of the myocardium and great venae cavae, preventing adequate hemodynamics. Conditions such as hemopericardium, exudative pericarditis, or hydropericardium require different tactical approaches and are not direct indications for total excision of the sac.
The surgery is performed under general anesthesia with artificial lung ventilation (endotracheal anesthesia). To ensure a wide and safe exposure of all mediastinal compartments, surgeons use median sternotomy as the optimal surgical approach.
Surgical technique and strict sequence
The basis of a successful procedure is finding the correct anatomical plane strictly between the epicardium and the altered pericardium. The edges of the incised pericardial sac are securely grasped with surgical clamps, after which dissection begins. Tissue separation is performed in a combined manner — both sharply and bluntly — to minimize myocardial trauma.
Strict adherence to the sequence of tissue release is extremely critical. Violating this order is unacceptable:
- Left ventricle. Excision must always start from this area.
- Left heart chambers and great arteries. The left atrium, as well as the orifices of the aorta and pulmonary trunk, are released next.
- Right ventricle. The surgeon moves to the right heart chambers only after full release of the left side.
- Right atrium and venae cavae. At the final stage of the operation, the right atrium and the orifices of the venae cavae are released.
Managing calcification and final steps
Chronic inflammation is often accompanied by pronounced tissue calcification. If calcified areas penetrate deep into the myocardium, they must strictly never be removed by force. Such dense conglomerates are carefully circumvented with a scalpel and left on the epicardium as isolated "islands".
Specialized bone instruments — Liston bone cutters or Luer rongeurs — are used to remove calcified fragments of the pericardium itself. They allow rigid tissues to be cleanly nibbled away without excessive tension.
Throughout the procedure, utmost precision and caution are required when working near the coronary vessels, atria, and venae cavae, as their walls are easily damaged. Upon completion of the excision, a drain must be left in the anterior mediastinum to monitor hemostasis and fluid outflow.
Briefly: answers to topical questions
What alternative surgical approaches exist for pericardiectomy besides median sternotomy?
Alternative surgical approaches for pericardiectomy include various types of thoracotomy. The choice of a specific approach depends on the planned extent of surgery.
- Right thoracotomy can be used for partial pericardiectomy.
- Left thoracotomy can also be used for partial pericardiectomy.
- Anterolateral thoracotomy is performed in the right intercostal space.
Median sternotomy is the optimal approach for total pericardiectomy and provides easier access to the aorta and right atrium.
What specific intraoperative complications can occur during pericardiectomy?
During pericardiectomy, one must consider the risk of hemorrhage and injury to adjacent structures.
- Hemorrhage is associated with dense adhesions and pronounced calcification.
- Injury to the phrenic nerve (n. phrenicus) must be prevented; the phrenic nerves must be preserved intact.
- Special caution is required during excision in the area of coronary vessels, atria, and venae cavae.
To prevent trauma and bleeding, areas of dense adhesion or calcification that deeply penetrate the myocardium are not excised, but rather circumvented and left on the epicardium as "islands".
The "Left-to-Right" vector rule: release of the heart always begins with the left ventricle and atrium and ends with the right atrium and venae cavae.
Class and exam questions
In which layer should the surgeon perform tissue dissection?
All tissue separation must be performed strictly within the plane between the pericardium and epicardium, using both blunt and sharp dissection.
What should be done with deep calcifications invading the myocardium?
Deeply penetrating calcifications must not be completely excised. They are circumvented and left as small "islands" on the epicardium to avoid severe myocardial injury.
What instruments are used to remove the calcified pericardium?
Luer rongeurs or Liston bone cutters are used to excise rigid calcified areas of the pericardium.
What is the final stage of the operation?
After completing the pericardial excision and thoroughly checking for hemostasis, a drain is placed in the anterior mediastinum.
What else to study on this topic
- Topographic anatomy of the heart wall layers and pericardium
- Technique of median sternotomy
- Surgical anatomy of coronary vessels and risk zones
- Design and working principle of Liston and Luer surgical bone cutters
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