Pericardectomy

Pericardectomy was the first procedure commonly performed thoracoscopically and is now nearly the standard of care in veterinary medicine. Indications include idiopathic pericardial effusion, neoplastic effusion, and constrictive pericarditis. Many techniques exist including pericardial window, pericardial fenestration, and subphrenic subtotal pericardectomy. Most dogs requiring pericardectomy have clinical signs associated with compromise of right heart filling and most have lethargy, tachypnea, and decreased appetite, and may show signs of labored breathing, abdominal distention or fluid, and weak femoral pulses with muffled heart sounds.

The procedure has been described via lateral thoracoscopic or paraxiphoid approaches, mimicking the lateral thoracotomy and median sternotomy, respectively. A left or right lateral approach may be done, with ports in the mid-third, dorsal 5th, and ventral third of the 9th intercostal spaces. Some surgeons prefer a right-sided approach with ports in the 4th, 6th, and 8th intercostal spaces. Alternatively, the heart may be identified ultrasonographically and ports may be placed in 3 intercostal spaces triangulated with the central port most dorsal in the appropriate intercostal spaces. The paraxiphoid approach is more commonly done and provides exposure to the majority of the pericardium. A port is placed adjacent to the base of the xiphoid process directed into the ipsilateral hemithorax. Subsequent ports are placed on either side of the chest in the 9th intercostal spaces or 2 ports can be placed on one side of the chest directed at the pericardium. Slight tilt (10-15 degrees) to one side facilitates exposure. Ports should be placed ventral enough to avoid pulmonary excursions. The mediastinum must be divided to provide exposure to both hemithoraces.  [...]