Intercostal pericardial window: A Safe, expedient, and effective minimally invasive technique
Moheb A Rashid1, Fredrik Holmner2 1 Department of Surgery, Örnsköldsvik Hospital, Örnsköldsvik; Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden 2 Department of Cardiothoracic Surgery, Heart Center, Umeå University Hospital, Umeå, Sweden
Date of Web Publication
Correspondence Address: Moheb A Rashid Department of Surgery, Örnsköldsvik Hospital, Örnsköldsvik; Scandinavian Cardiovascular Surgery Center, Gothenburg Sweden
Source of Support: None, Conflict of Interest: None
How to cite this article: Rashid MA, Holmner F. Intercostal pericardial window: A Safe, expedient, and effective minimally invasive technique. J Cardiothorac Trauma 2017;2:21-2
How to cite this URL: Rashid MA, Holmner F. Intercostal pericardial window: A Safe, expedient, and effective minimally invasive technique. J Cardiothorac Trauma [serial online] 2017 [cited 2021 Dec 6];2:21-2. Available from: https://www.jctt.org/text.asp?2017/2/1/21/220847
In our era of modern surgical techniques, there is an increasing tendency to undertake minimally invasive procedures for different diseases, and pericardial effusion with or without tamponade is not exception of this statement. Over the years, the pericardium has been approached either through the abdomen or chest. Transabdominal procedures include subxiphoidal, percutaneous, or laparoscopic methods. The subxiphoidal pericardial window was first described in 1829 by Larrey known as “Napoleon's surgeon,” and since that time, it has been considered as a simple and safe approach, allowing visualization of the pericardium and its cavity, permitting a biopsy taking and a window could be created. Pericardiocentesis via a percutaneous catheter drainage, although less invasive, is associated with increased morbidity, mortality, higher incidence of recurrence of effusions, and does not permit visualization of the pericardial cavity or allow taking a biopsy of the pericardium. No window could be created by this technique. Laparoscopic drainage could be used, but it needs general anesthesia and pneumoperitoneum which cannot be tolerated by all patients, particularly ill ones. Transthoracic procedures can be done using median sternotomy, anterolateral thoracotomy, or video-assisted thoracoscopic surgery (VATS). Median sternotomy is indicated in cases with suspected cardiac lesions as in trauma or ruptured postischemic myocardial aneurysm. Left-sided anterolateral thoracotomy approach is created by a 6–8 cm long incision in the inframammary skin crease, dividing the pectoralis muscles to enter the chest. An alternative method is resection of the 5th rib with the adjacent costal cartilage, but it has a significant morbidity and is definitely not a minimally invasive method. VATS pericardial window using three ports  or one port  allows a perfect visualization of the pericardium and a window could be created with biopsy-taking maneuvers, but it requires general anesthesia and single-lung ventilation that are difficult in critically ill patients. However, we do believe that the management of pericardial effusion particularly with tamponade should be based on the effectiveness and safety of the technique used. Therefore, a safe, expedient, and effective minimally invasive technique is warranted.
The patient was a 79-year-old woman who underwent mitral and biological valvular replacement 1 week before she developed sepsis with pericardial tamponade as evidenced by echocardiography. The patient was consulted with the first author and was immediately taken to the operation theater to relieve the tamponade. A small (2.5 cm) incision was performed into the 5th intercostal space, in the safe triangle of the left side of the chest as shown in Video, without violation of major muscles. The pleural cavity was entered, the lung was held up with retractors, and the bulging pericardium was well identified together with the phrenic nerve. The pericardium was carefully incised first with a scalpel and extended longitudinally by scissors, anterior to the phrenic nerve. Once entered into the pericardial cavity, a jet of puss poured out. A window was then created and hold sutures were placed on the edges of the window as shown in Video. Lavage of the pericardium was performed, and large-bor drains were placed into the pericardium and pleural cavity and anchored to the skin as previously described in chest tube insertion technique. The incision was irrigated with hydrogen peroxide and saline and finally closed in layers. Follow-up of the patient about 4 weeks postoperatively showed a nicely healed incision without infection as lastly shown in Video.
This technique is minimally invasive, and the incision is versatile, allowing easy and rapid extension when needed in case of surgical resuscitation using urgent anterolateral thoracotomy, particularly in trauma. Creating a pericardial window is not a guarantee for a complete drainage, because the edges of the window are quickly sealed by the surrounding tissues; therefore, suction or passive drainage via a large-bore tube is important. Purulent tamponade is usually fatal if it is misdiagnosed or improperly drained. It is seldom seen in developed countries and once it exists, it is mostly due to purulent pericarditis typically seen in developing countries with Staphylococcus aureus as the main cause. This was similar to the findings in our patient. The patient had a prolonged postoperative course due to sepsis; however, it was unremarkable and the patient was discharged home in good condition without wound infection.
We conclude that intercostal pericardial window seems to be a safe, expedient, effective, versatile, and feasible technique in case of pericardial tamponade, especially in trauma and critically ill patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We acknowledge the great help of Dr. Mohammad Abdelhay Rashid, MB, BCh, for the technical help by making the video.
Liberman M, Labos C, Sampalis JS, Sheiner NM, Mulder DS. Ten-year surgical experience with nontraumatic pericardial effusions: A comparison between the subxiphoid and transthoracic approaches to pericardial window. Arch Surg 2005;140:191-5. [PUBMED]
Totté E, Hee R, Brabant P, Wollaert B, Gheuens E, Declerck S, et al. Laparoscopic transabdominal pericardial window: New standard in the treatment of recurrent pericardial effusion complicated by cardiac tamponade. Surg Endosc 2002;16:859-63.