Laparoscopic approach to pericardial effusions

The description of the laparoscopic approach to pericardial effusions covers all aspects of the surgical procedure used for the management of pericardial effusions. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   approach   to   pericardial   effusions

Authors
E Totté, R Ceulemans
Abstract
The description of the laparoscopic approach to pericardial effusions covers all aspects of the surgical procedure used for the management of pericardial effusions.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way. Consequently, this operating technique is well standardized for the management of this condition.
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2002-03
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E-publication
WeBSurg.com, Mar 2002;2(03).
URL: http://www.websurg.com/doi-ot02en262.htm

Laparoscopic   approach   to   pericardial   effusions

1. Introduction
As the inferior aspect of the pericardial sac is in close contact with the diaphragm, a pericardial effusion can be easily approached through the abdomen (Mayer, 1993) using a laparotomy or laparoscopy (Mann et al., 1994; Sastic et al., 1992).
These are useful alternatives for patients who cannot tolerate a thoracoscopic approach because of poor hemodynamic or respiratory conditions. Compared to the conventional subxiphoid approach, laparoscopy allows for better visualization and permits the creation of a large pericardial window. Further advantages of the laparoscopic approach are as follows (Rodriguez et al., 1999):
- the pericardium is readily and safely accessible through the diaphragm since no structures lie between the tendinous part of the diaphragm and the pericardial sac;
- direct communication with the abdominal cavity offers a large surface for pericardial fluid resorption;
- no penetration of the chest wall and pleura is involved, and single lung ventilation is not required;
- there is no need for postoperative chest drainage;
- a short hospital stay is sufficient.
2. Anatomy
• Pericardium
The pericardial sac and the central tendon of the diaphragm have a common embryological origin, so are in close contact.
The pericardium is located on the anterior half of the diaphragm, with one third on the right side and two thirds on the left.
1. Aorta
2. Left brachiocephalic vein
3. Pulmonary artery
4. Left auricle
5. Pericardium
6. Pleura
7. Coronary vessels
8. Septum
9. Central tendon
10. Inferior vena cava
• Innervation
The right phrenic nerve ramifies while still within the fatty tissue of the right cardiac angle, just before entering the central tendon of the diaphragm and usually lateral to the inferior vena cava.
The left phrenic nerve ramifies about 3 cm from the central tendon while still within the fatty tissue of the left cardiac angle.
Incising the central tendon will therefore not injure the phrenic nerve.
1. Pericardial sac
2. Internal thoracic vessels
3. Right phrenic nerve
4. Inferior vena cava
5. Central tendon
6. Aorta and esophagus
7. Left phrenic nerve
8. Fat pad
3. Indications
Diagnostic indications
- infectious pericarditis: identification of the responsible infectious agent after failed percutaneous techniques;
- neoplastic pericarditis;
- assessment of the extent of primary, secondary or hematological cancers (Hodgkin’s versus non-Hodgkin’s disease) is necessary.

Therapeutic indications
- drainage of recurrent pericardial effusion after failed percutaneous techniques;
- drainage of pericardial effusion with hemodynamic repercussions;
- drainage of acute life-threatening pericardial tamponade.

Contraindications
- acute tamponade with an unstable hemodynamic condition is a contraindication to laparoscopy as the pneumoperitoneum may lead to cardiac decompensation. These patients should be operated on via a subxiphoid incision;
- patients who cannot undergo general anesthesia.
4. Operating room set-up
• Patient
- dorsal decubitus with legs spread apart;
- a reverse Trendelenburg position of 10° to 20° facilitates downward movements of the liver.
• Team
1. The surgeon stands between the patient’s legs.
2. The camera assistant or the scope holder is on the patient’s right.
3. The scrub nurse stands on the patient’s left.
• Equipment
1. The video unit and the monitor are placed at the patient’s head.
2. The electrocautery unit is placed next to the patient’s right foot.
5. Trocar placement
Three trocars are used. One 10 mm trocar is inserted on the midline more or less cephalad depending on the shape of the abdomen to introduce the telescope. Two 5 mm trocars are inserted in the right and left hypochondrium.
6. Instruments
• Optical device
10 mm 0° laparoscope
• Operating instruments
1. 5 mm hook, connected to electrocautery;
2. 5 mm Metzenbaum type scissors;
3. 5 mm suction-irrigation device, usually inserted in the left hypochondrium;
4. 5 mm atraumatic fenestrated grasping forceps, usually inserted in the right hypochondrium;
5. Specimen bag.
7. Procedure
• Exploration
A complete examination of the abdominal cavity will detect possible adhesions. If these are present, the placement of the working trocars may be modified.
• Dissection
The tendinous part of the diaphragm is grasped using the atraumatic forceps inserted in the right hypochondrium.
Dissection is first carried out with the coagulation hook that is inserted in the left trocar.
Meticulous dissection of the diaphragm is started at the left aspect of the hepatic falciform ligament. Care is taken to progressively dissect all the different anatomical layers before entering the pericardium. The peritoneum, the central tendon of the diaphragm and the pericardium are opened one after another.
1. Peritoneum
2. Central tendon of the diaphragm
3. Pericardium
• Opening the pericardium
Before opening the pericardium, intraperitoneal pressure must be decreased to a maximum of 9 mm Hg to avoid a barotamponade. The pericardial sac is opened sharply using the Metzenbaum type scissors. Electrocoagulation must not be used at this stage, to avoid arrhythmia.
Pericardial fluid is taken for pathological and microbial examination.
A 3x3 cm window is made with the scissors. The window should not be made larger, to prevent cardiac herniation.
1. Peritoneum
2. Heart
3. Diaphragm
4. Pericardium
5. Inflammatory response with thickening of the pericardium
• Extraction
The specimen is placed in a retrieval bag and extracted through the left trocar.
The pneumoperitoneum is exsufflated.
No drain is necessary.
8. Limitations
Previous abdominal surgery
Although previous abdominal surgery is not a formal contraindication, special care should be taken. Laparoscopic access is obtained through the left hypochondrium using open laparoscopy (Hasson technique).
All adhesions should be dissected until there is a clear view of the central tendon.
If access through the left is made difficult by adhesions, access from the right hypochondrium may be possible with partial division of the falciform ligament.

Inflammatory and infectious diseases
Inflammatory and infectious diseases may result in dense fibrous adhesions between the pericardium and the epicardium. A thorough examination with preoperative cardiosonography and CT scans must be obtained to evaluate whether the pericardium can be opened safely.
Inflammatory disease may cause thickening of the pericardium, which makes penetration difficult. In these cases, a stitch can be placed on the borders of the pericardial incision and used as a retraction suture. This maneuver allows safe dissection of the thickened pericardium by widening the pericardial cavity.

Malignant diseases
Special care is taken in the sampling of pericardial fluid and extraction of the pericardial biopsy. The specimen should be placed in a retrieval bag before extraction to keep the trocar sites free of malignant cells.
Inspection of the entire pericardial sac is possible and required to guide biopsies of any suspicions.
9. Reference
Mann GB, Nguyen H, Corbet J. Laparoscopic creation of pericardial window. Aust N Z J Surg
1994;64:853-5.
Mayer HJ. Transdiaphragmatic pericardial window: a new approach. J Cardiovasc Surg (Torino)
1993;34:173-5.
Ready A, Black J, Lewis R, Roscoe B. Laparoscopic pericardial fenestration for malignant pericardial
effusion. Lancet 1992;339:1609.
Rodriguez MI, Ash K, Foley RW, Liston W. Pericardio peritoneal window: laparoscopic approach. Surg
Endosc 1999;13:409-11.
Sastic JW, Stalter KD, Goddard RL. Laparoscopic pericardial window. J Laparoendosc Surg 1992;2:263-
6.