HOW TO DO IT

Pleural Flap Closure of Pericardial Following *Intrapericardial Pneumonectomy Frederick G. Schechter, M.D., Richard R. Owens, M.D., and Lester R. Bryant, M.D. ABSTRACT Persistent pericardial defects following intrapericardial pneurnonectomy are, historically, the major cause of iatrogenic cardiac herniation. This complication is uniformly fatal when unrecognized and untreated and has been associated with a 43% mortality even with surgical correction. Suture approximation of all small defects is recommended, and a technique for routine pleural flap closure of moderate to large-sized defects is described.

6,13,14]. These data support the concept that all right and left lateral pericardial defects should be carefully closed primarily by approximation or patch [ 6 ] . Cardiac herniation has been reported to occur through both small and large defects, and it has been well documented that opening the pericardium widely does not consistently prevent herniation [5-10, 14, 151. Closure of pericardial defects has been accomplished using prosthetic [5, Intrapericardial ligation of the pulmonary artery 7, 81 and pleural [19] patches, fascia lata [lo], and veins shortens dissection time and increases pericardial slings [5], and webs of suture sewn to the safety of radical pneumonectomy, particu- and fro across the defect [14]. Suturing the edges larly in the presence of large hilar tumors [l]. The of the pericardial defect to the epicardium as usual pericardial defect is small and may be suggested by Dippel and Ehrenhaft [6] has been obliterated by edge-to-edge approximation. associated on this service with an instance of An occasional patient, however, is found to exsanguinating hemorrhage through an atrial have tumor involvement of the pericardium. tear produced during open cardiac massage apAdequate resection in such cases involves exci- proximately one week following radical insion of the pericardium and often results in a trapericardial pneumonectomy. In view of this moderate to large-sized defect. The presence of particular complication we have turned to the such defects arouses concern over the possibility routine use of a parietal pleural flap [5, 9, 10, 191 of cardiac herniation, which, though rare, is al- for closure of the pericardial defect when priways fatal if unrecognized and untreated. mary suture approximation is not possible. Although herniation has been reported with pericardial defects of congenital [3, 181, trauma- Technique tic [5, 17, 181, and iatrogenic [2, 4, 5, 7, 11-14, Following intrapericardial pneumonectomy, 16-18] etiology, the iatrogenic type is most with the patient in the lateral decubitus posicommon and generally occurs following radical tion, the extrapleural plane is sought at the edge intrapericardial pneumonectomy . In such cases of the upper rib of the thoracotomy incision. The herniation develops within the first twenty-four triangular flap of parietal pleura is developed hours postoperatively and has resulted in a 43% superiorly and anteriorly as outlined in the Figmortality even with surgical correction [5]. It is ure, A. The dissection is carried down to the clear that many sudden deaths following radical junction of the parietal pleura with the anterior intrapericardial pneumonectomy have been border of the mediastinum (Figure, B) and can caused by herniation that went unrecognized [5, be accomplished without injury to the internal thoracic vessels. The pleural flap is brought posFrom the Section of Thoracic and Cardiovascular Surgery, teriorly and medially to overlie the defect in the Louisiana State University Medical Center, New Orleans, LA. pericardium and is shaped to fit the edges of the Accepted for publication June 5, 1975. defect inferiorly, posteriorly, and superiorly. A Address reprint requests to Dr. Schechter, Section of tongue of pleura is left superiorly to allow the Thoracic and Cardiovascular Surgery, Room 713, Louisiana exposed bronchial stump to be covered. Tacking State University Medical Center, 1542 Tulane Ave, New Orleans, LA 70112. sutures are placed at the superior and inferior 67

68 The Annals of Thoracic Surgery

Vol 21 No 1 January 1976

B

V

( A ) Patient position w i t h left posterolateral thoracotomy incision (inset). T h e large pericardial defect resulting from radical intrapericardial pneumonectomy will be obliterated b y the triangular anterior parietal pleuralflap, as outlined. ( B ) The extrapleural plane is sought at the edge of the upper rib of the thoracotomy incision, and the parietal pleural flap is developed to its junction with the mediastinal pleura. Tacking sutures are placed at each corner of the anterior free edge of the pericardial defect andpassed through the base of the triangular pleuralflap. (C) Running3-0 nonabsorbable suture closes the remainder of the pericardial defect, and interrupted mattress sutures reinforce the pleural covering over the bronchial stump.

comers of the anterior free edge of the pericardial defect and passed through the pleural flap at some point near the base of the triangle. The anterior edge of the pericardial defect is then sutured to the pleural flap using interrupted 3-0 nonabsorbable sutures placed from within the pericardium and tied on the surface of the parietal pleura. The remainder of the flap is next brought down and sutured to the superior, posterior, and inferior edges of the pericardial defect using a running 3-0 nonabsorbable suture, as shown in the Figure, C. The tongue of parietal pleura that has been left behind is brought over the end of the exposed bronchial stump and sutured in place with several 3-0 mattress su-

tures. When completed, the mesothelial surface of the pleural flap faces the epicardial surface of the heart.

References 1. Allison PR: Intrapericardial approach to the lung root in the treatment of bronchial carcinoma by dissection pneumonectomy. J Thorac Surg, 15:99, 1946 2. Bettman RB, Tannenbaum WJ: Herniation of the heart through a pericardial incision. Ann Surg 128:1012, 1948 3. Boxall R: Incomplete pericardial sac: escape of heart into the left pleural cavity. Trans Obstet SOC 28:209, 1886 4. Dahlback 0, Nilsson E: Incarceration of the heart

69 How to Do It: Schechter et al: Pleural Flap Closure of Pericardial Defect

following right pneumonectomy . Acta Chir Scand 110:447, 1956 5. Dieraniya AK: Cardiac herniation following intrapericardial pneumonectomy . Thorax 29: 545, 1974 6. Dippel WF, Ehrenhaft JL: Herniation of the heart after pneumonectomy. J Thorac Cardiovasc Surg 65:207, 1973 7. Gates GF, Sette RS, Cope JA: Acute cardiac herniation with incarceration following pneumonectomy. Radiology 94:561, 1970 8. Gravel JA: Herniation of the heart-a hazard of thoracic surgery: report of two fatal cases. Can J Surg 9:72, 1966 9. Higginson JF: Block dissection in pneumonectomy for carcinoma. J Thorac Surg 25:582, 1953 10. Levin PD, Faber LP, Carleton RA: Cardiac herniation after pneumonectomy. J Thorac Cardiovasc Surg 61:104, 1971 11. McKIveen JR, Urgena RB, Rossi NP: Herniation of the heart following radical pneumonectomy: a case report. Anesth Analg 51:680, 1972 12. Neville WE, Jubb ED: Successful treatment of car-

diac herniation through a surgical rent in the pericardium. Am J Surg 93: 1038, 1957 13. Patel DR, Shrivastav R, Sabety AM: Cardiac torsion following intrapericardial pneumonectomy . J Thorac Cardiovasc Surg 65:626, 1973 14. Sharma VN, Bates M, Hurt RL: Herniation of the heart after intrapericardial pneumonectomy for bronchial carcinoma. Thorax 14:36, 1959 15. Takita H, Nijares WS: Herniation of the heart following intrapericardial pneumonectomy. J Thorac Cardiovasc Surg 59:443, 1970 16. Walmsley DA: Herniation of the heart after intrapericardial pneumonectomy. Lancet 1:645, 1961 17. Warburg R: Subacute and Chronic Pericardial and Myocardial Lesions Due to Non Penetrating Traumatic Injuries. London, Oxford University Press, 1938 18. Wright MP, Nelson C, Johnson AM, et al: Herniation of the heart. Thorax 25656, 1970 In Yacoub MH, Williams WG, Ahmad A: Strangdation of the heart following intrapericardial pneumonectomy. Thorax 23:261, 1968

Pleural flap closure of pericardial defects following intrapericardial pneumonectomy.

Persistent pericardial defects following intrapericardial pneumonectomy are, historically, the major cause of iatrogenic cardiac herniation. This comp...
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