DIAPHRAGM, VAGUS, AND PHRENIC NERVES (FIRST SECTION DIAPHRAGM INCISIONS)
You may choose to perform a pericardial window to start this chapter. If not, skip to Incision (next paragraph). A 6-cm upper midline incision is performed over the xiphoid process. Resection of the xiphoid process will facilitate the procedure. Once the xiphoid has been resected, anterior traction on the sternum will allow dissection of the diaphragmatic surface of the pericardium with electrocautery and blunt dissection. Grasp the pericardium with two Allis or tonsil clamps and, retracting inferiorly, incise the pericardium between the clamps. A rush of pericardial effusion (clear or bloody, depending on the etiology) is expected. Identify an area of the central tendon of the diaphragm, which is contiguous with the pericardium. Using an Allis clamp, grip the diaphragm and make a 2-cm incision to gain access to the pericardial space (Fig. 3.1). A chest tube is then placed through a separate stab incision immediately below the surgical incision and placed into pericardial sac for postoperative drainage. This “pericardial window” is very useful for pericardial effusions such as malignant effusions. A chest tube can be placed through this pericardial window to gain drainage for the effusion causing tamponade. With release of the tamponade fluid, a rather vigorous gush of fluid is generally experienced. Care must be taken not to injure the heart or cardiac vessels.