**4.4 Alternatives including subxiphoid approach**

A subxiphoid approach (**Figure 7**) is usually less painful than VATS. The reason is that being in midline, less respiratory muscles are incised. It is also the preferred approach for patients who had recent sternotomy and subsequently presents with a

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*Pericardial Diseases: Surgery for Pericardial Effusion DOI: http://dx.doi.org/10.5772/intechopen.81927*

are at high risk with general anesthesia.

*Healed scar from the subxiphoid incision (arrow).*

**5. Summary**

**Figure 7.**

postsurgery.

pericardial effusion. In this group of patients, rather than to redo sternotomy, only the inferior portion of the scar needs to be reopened for access to the pericardial cavity. The sternum and wires used to oppose the bone during the initial sternotomy do not require any further manipulation from this approach. This type of effusion, if related to bleeding postsurgery, usually does not recur frequently or long term; hence, this approach is simple and effective. A subxiphoid incision can be also used to create a pericardial-peritoneum window. This method, when paired with a pleuroperitoneal shunt, has been described to have comparable results to other methods [13]. The proposed shunt pumps fluid actively into the peritoneum cavity, and this can possibly reduce accumulation rates by preventing omentum from occluding the pathway from the pericardium to the peritoneum. Authors have been successful with this with only local anesthesia; hence, this alternative is useful for patients who

Surgical approach to pericardial effusion involves many a thought process. Different patients require different approaches for the best results. Decisionmaking should be made with the patient's best interest and wishes. It is rewarding indeed when patients get symptomatic relief and are able to return to their function *Pericardial Diseases: Surgery for Pericardial Effusion DOI: http://dx.doi.org/10.5772/intechopen.81927*

*Inflammatory Heart Diseases*

**Figure 6.**

mentioned earlier; it is easier to convert to sternotomy if required. However, most surgeons would avoid sternotomy if possible, as it brings about more pain with a bigger scar as well as higher risk of infection to both the superficial tissue and sternum. The greater the surgical trauma, the longer healing requires before adjuvant

Another variation of technique involves the consideration between general anesthesia and local anesthesia. General anesthesia remains the most common way of anesthesia for patients; it involves intubation and protection of airway under muscle paralysis, sedation and amnesia. But for patients who have hemodynamic compromise from pending cardiac tamponade due to a significant acute pericardial effusion, general anesthesia remains very high risk. In fact this group of patients is frequently the American Society of Anesthesiologists (ASA) class V, the highest-risk class. Many a surgeon have been demoralized after losing patients on the operating table, after this group of patients collapse upon giving the slightly amount of medication that could lower the vascular tone and reduce the blood pressures. Local anesthesia has been advocated to be safer in these patients, but often not practical as few patients could tolerate the pain of an anterior thoracotomy incision even with the best local infiltration. Mentioned later below, a subxiphoid incision could be more tolerable with this, and some surgeons have been successful with it. A new method in the middle ground could be non-intubated general anesthesia. This has been successful in reported VATS surgery [12]. Without muscle paralysis and using a laryngeal mask airway to continue spontaneous-assisted ventilation, this resulting loss of vascular tone could be reduced and perhaps reduce the risk of anesthesia. But the surgeon must also realize and cope with the increased muscle tone and continued ventilation of the lungs. Exposure

treatment like chemotherapy or radiotherapy could be initiated.

needs to be ensured as the lung cannot be isolated in this setting.

A subxiphoid approach (**Figure 7**) is usually less painful than VATS. The reason is that being in midline, less respiratory muscles are incised. It is also the preferred approach for patients who had recent sternotomy and subsequently presents with a

**4.4 Alternatives including subxiphoid approach**

**4.3 Variation in anesthesia methods**

*Healed scar from the left anterior thoracotomy incision (arrow).*

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pericardial effusion. In this group of patients, rather than to redo sternotomy, only the inferior portion of the scar needs to be reopened for access to the pericardial cavity. The sternum and wires used to oppose the bone during the initial sternotomy do not require any further manipulation from this approach. This type of effusion, if related to bleeding postsurgery, usually does not recur frequently or long term; hence, this approach is simple and effective. A subxiphoid incision can be also used to create a pericardial-peritoneum window. This method, when paired with a pleuroperitoneal shunt, has been described to have comparable results to other methods [13]. The proposed shunt pumps fluid actively into the peritoneum cavity, and this can possibly reduce accumulation rates by preventing omentum from occluding the pathway from the pericardium to the peritoneum. Authors have been successful with this with only local anesthesia; hence, this alternative is useful for patients who are at high risk with general anesthesia.
