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Pericardiectomy Right Side Approach (RSA)

Pericardectomy is the treatment of choice for the management of cardiac and pericardial diseases, such as pericardial effusions, constrictive pericarditis, cardiac and pericardial tumors. Moreover, it’s considered a surgical procedure for the management of idiopathic chylothorax. Pericardectomy is considered a curative procedure in case of idiopathic pericardial effusion, palliative in case of malignant effusion. Right side approach telescope paraxiphoid or subxiphoid location: T1, subxiphoid position (caudal and dorsal to the xiphoid process) or paraxiphoid position (between the xiphoid process and the la,st sternocostal junction) T2, ventral third of the 8th – 10th right intercostal space T3, ventral third of the 4th – 6th right intercostal space A 0,5-1 cm incision is made in a paraxiphoid or subxiphoid position for the insertion of a 5 mm cannula (T1). The 5 mm telescope is then inserted and a first exploration of the thorax is made. Under direct visualization, the second port is created (T3 or T2). The third port is created (T3 or T2). Using grasping forceps, the pericardium over the cardiac apex is grasped and an incision is made using the scissors. If a lot of effusion is present, it may be difficult to grasp the pericardium due to excessive distension. In this case we suggest to perform a pericardiocentesis under direct visualization. The first pericardial incision can also be performed using a sealing device, but a fold must be lifted to avoid to touch the epicardium while the device is being operated. A variable amount of pericardial fluid will exit from the incision. To allow a better visualization, an aspiration device can be inserted in T4 position for the removal of the fluid. While a tension is exerted with the grasping forceps, a portion of at least 3-5 x 3-5 cm of pericardium over the cardiac apex is dissected using scissors or a vessel sealing device (that reduce the hemorrhage). Our recommendation is to remove as much pericardial tissue as possible Small fragments of the pericardium can be extracted directly through the portal cannulas. For the extraction of larger tissue, especially if the effusion is of neoplastic origin, the pericardium is retrieved from the thorax using a retrieval bag to minimize the risk of port site metastasis. After performing the pericardial window, an exploration of the pericardial sac is recommended (pericardioscopy). This procedure is useful for visualizing lesions not always identifiable with preoperative investigations