**4.1 Anterior thoracotomy approach**

I believe for surgical approach to pericardial effusion that simple is better and the best is the enemy of the good. Like many other surgical techniques, different approaches have been described to get to the same end point. My suggested surgical approach is summarized in **Figure 3**. Left anterior thoracotomy is most commonly done in my surgical practice and it is outlined below.

As mentioned earlier, whenever possible I advocate percutaneous drainage of the pericardial effusion before bringing the patient to the operating theater. This will reduce the risk of cardiovascular collapse upon initiation of general anesthesia. Often, nonsurgical colleagues or even the patient will ask the need for surgery if the

**Figure 3.** *Suggested flowchart for surgical approach.*

#### *Inflammatory Heart Diseases*

effusion has been already drained. The answer is simple; creation of a surgical window is to bring about long-term benefits by reducing the risk of recurrent effusions.

The patient is positioned supine before general anesthesia via a single-lumen endotracheal tube. This approach has several advantages. Firstly, in sick and unstable patients, there is no need to turn to lateral decubitus position compared to lateral thoracotomy or VATS approaches. Conversion to midline sternotomy is also easier if required in emergency situation. Subsequently, this incision is also optimal if ascending aorta and superior vena cava cannulations are needed for crash cardiopulmonary bypass. There is always the risk of injury to the heart during surgery that requires the bypass circuit for repair. If the patient is unwell, communication with the anesthesia team is paramount. It takes an experienced anesthesiologist to intubate a patient who cannot lie flat and who requires only a little more sedation to collapse. I frequently ensure the surgical team and scrub team are ready to proceed with crash incision if required prior to onset of anesthesia.

The left anterior thoracotomy incision is made at left fourth intercostal space. This is done by surface marking the left fifth rib. I would also utilize any recent computed tomography (CT) scan of the thorax to help guide the incision over the pericardium (**Figure 4**). The incision is centered over the mid-clavicular line and extends either side to about a total of 4–5 cm in length. This is just below the nipple line in males, but care is required to avoid incision thru breast tissue in females. The incision is deepened pass the intercostal muscles, staying close and on top of the inferior fifth rib to avoid injury to any intercostal vessels. Another pitfall is to extend too medially, where the internal mammary vessels run about 1 cm from the lateral sternal margin (**Figure 4**). If done correctly, the pleural cavity is breached first, with the surface of the pericardium seen after (**Figure 5**). If the incision is too low, pericardial fat could be obscuring the actual pericardium tissue. This fat would need to be removed for adequate exposure. Further exposure could be also improved by using a sponge-stick to gently retract the lung laterally again from the pericardium.

Before incision of the pericardium, proper communication with the anesthesia team is important. Frequently, a drop in blood pressure can be encountered on drainage of the pericardial effusion. This is attributed to inadequate venous return

#### **Figure 4.**

*CT used to plan incision at left fourth intercostal space (white line), inferior to the nipple. Take a note of the location of left internal mammary artery, about 1 cm from the lateral sternal edge (arrow).*

**61**

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

*pleural cavity is breached first before the pericardium is seen.*

injury to the heart chambers.

**Figure 5.**

to the patient's re-expanded heart chambers; hence, fluids should be prepared prior to drainage. Occasionally, blood-stained pericardial fluid is seen from a malignant process. If this occurs, caution is required. I suggest waiting to ensure no further hemodynamic compromise occurs before extension of the incision. Injury of the myocardium can mimic this, and even experienced surgeons can get into trouble via

*Circumferential pericardial effusion (arrow) in noncontrast scan. Following the direction of the white line, left* 

Once the pericardial cavity is drained, I would usually excise the pericardium approximately to 3–4 cm diameter. It should be extended as laterally as possible. I believe that a bigger-sized incision and going more lateral reduces the risk of spontaneous closure of the window. A surgical pitfall is to injure the phrenic nerve which runs on the lateral pericardial surface. To avoid this, the tough pericardial tissue can be grasped and retracted towards the ceiling while the lung is retracted laterally. This is usually enough to identify the phrenic nerve and to avoid it. From this approach the pericardium can only be opened anterior to the phrenic nerve. A left-sided approach is better suited if the effusion is circumferential as minimal retraction of the lung is required to reach the pericardium (**Figure 6**). For right anterior thoracotomy, I would reserve this for redo-window creation or when there is a loculated effusion that is only accessible from the right. From the right, more of the lung is in the way before the pericardium can be seen. This may require lung isolation or even periods of intermittent apnoea from the anesthesia team for optimal visualization.

If the patient is stable enough for lung isolation via double-lumen endotracheal tube or a bronchial blocker, VATS approach can be utilized. The benefits of VATS and other minimally invasive approaches have been described at length by many authors [5, 6, 9–11]. Visualization is definitely better through a camera; the entire pericardium can be visualized once the lung is isolated well. The phrenic nerve which is the lateral limit of excision can be accurately identified and preserved. Another benefit of VATS includes a less painful incision during the perioperative period, which will reduce the amount of opioids given and hence reduces their side effects. However, this effect is less pronounced compared to my preference for the anterior thoracotomy incision, which is not that painful as there is minimal spreading of ribs. The patient could be positioned either supine or lateral position for VATS, depending on the surgeon's preference. I prefer the supine approach as

**4.2 Video-assisted thoracoscopic surgery (VATS) approach**

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

#### **Figure 5.**

*Inflammatory Heart Diseases*

effusion has been already drained. The answer is simple; creation of a surgical window is to bring about long-term benefits by reducing the risk of recurrent effusions. The patient is positioned supine before general anesthesia via a single-lumen endotracheal tube. This approach has several advantages. Firstly, in sick and unstable patients, there is no need to turn to lateral decubitus position compared to lateral thoracotomy or VATS approaches. Conversion to midline sternotomy is also easier if required in emergency situation. Subsequently, this incision is also optimal if ascending aorta and superior vena cava cannulations are needed for crash cardiopulmonary bypass. There is always the risk of injury to the heart during surgery that requires the bypass circuit for repair. If the patient is unwell, communication with the anesthesia team is paramount. It takes an experienced anesthesiologist to intubate a patient who cannot lie flat and who requires only a little more sedation to collapse. I frequently ensure the surgical team and scrub team are ready to proceed

The left anterior thoracotomy incision is made at left fourth intercostal space. This is done by surface marking the left fifth rib. I would also utilize any recent computed tomography (CT) scan of the thorax to help guide the incision over the pericardium (**Figure 4**). The incision is centered over the mid-clavicular line and extends either side to about a total of 4–5 cm in length. This is just below the nipple line in males, but care is required to avoid incision thru breast tissue in females. The incision is deepened pass the intercostal muscles, staying close and on top of the inferior fifth rib to avoid injury to any intercostal vessels. Another pitfall is to extend too medially, where the internal mammary vessels run about 1 cm from the lateral sternal margin (**Figure 4**). If done correctly, the pleural cavity is breached first, with the surface of the pericardium seen after (**Figure 5**). If the incision is too low, pericardial fat could be obscuring the actual pericardium tissue. This fat would need to be removed for adequate exposure. Further exposure could be also improved by using a sponge-stick to gently retract the lung laterally again from the pericardium. Before incision of the pericardium, proper communication with the anesthesia team is important. Frequently, a drop in blood pressure can be encountered on drainage of the pericardial effusion. This is attributed to inadequate venous return

*CT used to plan incision at left fourth intercostal space (white line), inferior to the nipple. Take a note of the* 

*location of left internal mammary artery, about 1 cm from the lateral sternal edge (arrow).*

with crash incision if required prior to onset of anesthesia.

**60**

**Figure 4.**

*Circumferential pericardial effusion (arrow) in noncontrast scan. Following the direction of the white line, left pleural cavity is breached first before the pericardium is seen.*

to the patient's re-expanded heart chambers; hence, fluids should be prepared prior to drainage. Occasionally, blood-stained pericardial fluid is seen from a malignant process. If this occurs, caution is required. I suggest waiting to ensure no further hemodynamic compromise occurs before extension of the incision. Injury of the myocardium can mimic this, and even experienced surgeons can get into trouble via injury to the heart chambers.

Once the pericardial cavity is drained, I would usually excise the pericardium approximately to 3–4 cm diameter. It should be extended as laterally as possible. I believe that a bigger-sized incision and going more lateral reduces the risk of spontaneous closure of the window. A surgical pitfall is to injure the phrenic nerve which runs on the lateral pericardial surface. To avoid this, the tough pericardial tissue can be grasped and retracted towards the ceiling while the lung is retracted laterally. This is usually enough to identify the phrenic nerve and to avoid it. From this approach the pericardium can only be opened anterior to the phrenic nerve. A left-sided approach is better suited if the effusion is circumferential as minimal retraction of the lung is required to reach the pericardium (**Figure 6**). For right anterior thoracotomy, I would reserve this for redo-window creation or when there is a loculated effusion that is only accessible from the right. From the right, more of the lung is in the way before the pericardium can be seen. This may require lung isolation or even periods of intermittent apnoea from the anesthesia team for optimal visualization.

#### **4.2 Video-assisted thoracoscopic surgery (VATS) approach**

If the patient is stable enough for lung isolation via double-lumen endotracheal tube or a bronchial blocker, VATS approach can be utilized. The benefits of VATS and other minimally invasive approaches have been described at length by many authors [5, 6, 9–11]. Visualization is definitely better through a camera; the entire pericardium can be visualized once the lung is isolated well. The phrenic nerve which is the lateral limit of excision can be accurately identified and preserved. Another benefit of VATS includes a less painful incision during the perioperative period, which will reduce the amount of opioids given and hence reduces their side effects. However, this effect is less pronounced compared to my preference for the anterior thoracotomy incision, which is not that painful as there is minimal spreading of ribs. The patient could be positioned either supine or lateral position for VATS, depending on the surgeon's preference. I prefer the supine approach as

**Figure 6.** *Healed scar from the left anterior thoracotomy incision (arrow).*

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 treatment like chemotherapy or radiotherapy could be initiated.
