Pericardial Window
This procedure is performed for treatment of pericardial effusions. The most common indication is malignancy. Two approaches are described here—the open subxiphoid approach and the thoracoscopic approach. Rarely, subxiphoid exploration is performed during trauma resuscitations when pericardial tamponade is suspected. This has largely been superseded by echocardiography.
The open subxiphoid approach provides only limited drainage but can be performed rapidly under local anesthesia, if the patient is in extreme distress.
Steps in Procedure
Subxiphoid Approach
Short midline incision from above xiphoid extending approximately 5 cm inferiorly
Resect xiphoid process
Suture ligate small branches of inferior phrenic artery if encountered
Sweep diaphragm and preperitoneal fat inferiorly to expose pericardium
Elevate pericardium from heart and incise it (do not use cautery)
Excise pericardium to create an approximately 2 cm circular defect; send to pathology (if cancer)
Gently explore pericardium and break down any soft loculations
Suture edges of defect to surrounding tissues
Place one or two small diameter chest tubes or closed suction drains
Close incision in layers
Thoracoscopic Approach
Three ports
Divide inferior pulmonary ligament and retract lung cephalad
Visualize phrenic nerve
Create anterior window by elevating pericardium and incising it, then excising a rectangular window anterior to phrenic nerve (do not use cautery)
On the left side, space may allow creation of a similar window inferior to the phrenic nerve
Place chest tubes
Close trocar sites
Hallmark Anatomic Complications
Injury to phrenic nerve
Bleeding from inferior phrenic artery
Cardiac herniation through lateral window
List of Structures
Pericardium
Mediastinal pleura
Sternum
Manubrium
Body
Xiphoid process
Inferior pericardiosternal ligament
Diaphragm
Peritoneal cavity
Inferior phrenic artery
Phrenic nerve
Inferior pulmonary ligament
Figure 22.1 Subxiphoid Approach
Technical Points
This is the quickest and simplest approach. When the pericardium is simply entered and drained, the term drainage is used. The term window is used if a connection is established between the pericardium and the peritoneal cavity.
Make a short midline incision from just above the xiphoid extending inferiorly for several centimeters. Deepen this incision through subcutaneous tissues to expose the xiphoid cartilage. Surround this and resect it at its junction with the sternum
(Fig. 22.1A). Small branches of the inferior phrenic arteries commonly run on each side of the xiphoid process and must be suture ligated if encountered. Deep to the xiphoid process some preperitoneal fat and muscular slips of the diaphragm will be encountered. Sweep these inferiorly to expose the pericardium (Fig. 22.1B).
(Fig. 22.1A). Small branches of the inferior phrenic arteries commonly run on each side of the xiphoid process and must be suture ligated if encountered. Deep to the xiphoid process some preperitoneal fat and muscular slips of the diaphragm will be encountered. Sweep these inferiorly to expose the pericardium (Fig. 22.1B).
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