Teknik Operasi Perikardiostomi

Presentan: Lius Marson Ling Pembimbing: dr. Rama N, Sp.BTKV

 Surgical procedure to create a window from the pericardial space to the pleural cavity. The excision of a portion of the pericardium, which allows the effusion to drain continuously into the peritoneum or chest.
Stuart J. Hutchison (10 December 2008). Pericardial diseases: clinical diagnostic imaging atlas. Elsevier Health Sciences. pp. 93

The fluid can be drained in any of 3 ways:

via a small subxiphoid incision thoracoscopically via a thoracotomy

Indications

Indications
Cardiac tamponade (CT) Symptomatic pericardial effusions Asymptomatic pericardial effusions that warrant a pericardial window for diagnosis Hemodynamically stable patients with an undiagnosed pericardial effusion Coexisting pericardial, pleural, or pulmonary pathology that requires diagnosis or therapy

Indications
Known benign effusions that reaccumulate after aspiration Drainage of a purulent pericardial effusion Loculated effusions situated unilaterally or posteriorly Chylopericardium Delayed hemopericardium or effusions after cardiac surgery

In 1935, Beck described diagnostic triad for CT

Decreasing arterial pressure Increasing venous pressure Quiet heart

1 2

Hasan Ali Gumrukcuoglu, Dolunay Odabasi Management of Cardiac Tamponade: A Comperative Study between EchoGuided Pericardiocentesis and Surgery A Report of 100 Patients. Cardiology Research and Practice. Volume 2011. 19 June 2011.

Clinical signs in patient with CT include : Hypotension, Tachycardia, Pulsus paradoxus, Raised jugular venous pressure, Muffled heart sounds, Decreased electrocardiographic voltage, and Enlarged cardiac silhouette on chest x-rays

Hasan Ali Gumrukcuoglu, Dolunay Odabasi Management of Cardiac Tamponade: A Comperative Study between EchoGuided Pericardiocentesis and Surgery A Report of 100 Patients. Cardiology Research and Practice. Volume 2011. 19 June 2011.

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Medicine/Pericardial_effusion2.htm

Two-dimensional echocardiographic criteria of CT were:

Accumulation of pericardial fluid creates an anechoic space Early diastolic collapse of the right ventricle, Late diastolic collapse of the right or left atrium, and Plethora of the inferior vena cava with pericardial effusion

Hasan Ali Gumrukcuoglu, Dolunay Odabasi Management of Cardiac Tamponade: A Comperative Study between EchoGuided Pericardiocentesis and Surgery A Report of 100 Patients. Cardiology Research and Practice. Volume 2011. 19 June 2011.

CT Scan

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Medicine/Pericardial_effusion2.htm

Preparation
Anesthesia
For the subxiphoid approach, general anesthesia is preferred and optimal. May be performed with local anesthesia plus adequate sedation in the patient with severe tamponade who cannot tolerate general anesthesia Arterial and central venous pressure monitoring may be needed intraoperatively, as well as in the postoperative period, to guide hemodynamic management.
Darroch W. O. Moores, MD, Keith B. Allen, MD. Subxiphoid pericardial drainage for pericardial tamponade. J Thorac Cardiovasc Surg 1995

Positioning
For the subxiphoid approach, the patient is placed in the supine position.

Teknik

M.I.A. Muhammad. Interactive CardioVascular and Thoracic Surgery 12 (2011) 174178 Dale K Mueller, MD; Chief Editor: Eric H Yang, MD. Pericardial Window. http://emedicine.medscape.com/ Aug 3, 2011 Darroch W. O. Moores, MD, Keith B. Allen, MD. Subxiphoid pericardial drainage for pericardial tamponade. J Thorac Cardiovasc Surg 1995

1. A short vertical incision (about 5-8 cm long) is made over the xiphoid, extending onto the midline of the abdomen 2. The linea alba is incised, and the xiphoid is split or often completely removed. 3. The retrosternal space is entered by means of finger dissection.

4. With upward retraction, the distal sternum is elevated, the diaphragmatic aspect of the pericardium is visualized 5. The pericardium is grasped with the hook or Allis clamp, alternatively, it may be incised directly. 6. The opening in the pericardium is enlarged by sharply incising the pericardium.

7. 8. 9.

A sucker is inserted into the pericardial space and the fluid aspirated. Fluid is sent for bacteriologic and cytologic analyses Often, this sucker or a finger is used for further dissection of any adhesions. 10. A biopsy specimen is also taken from the pericardium. 11. After all the fluid has been aspirated, the epicardium is inspected. 12. A finger is introduced into the pericardial space to determine if any additional adhesions exist and if any nodules are in the pericardium.

12. Finally, through a separate stab wound, a 28 F chest tube is inserted into the pericardial space and connected It is important to place the chest tube through a separate incision because a chest tube left in the operative wound can lead to improper wound healing, wound infection

13. the incision is closed in layers with absorbable sutures

 The chest tube is left in place for 4 to 5 days after the operation. The chest tube was removed when the amount of daily drainage was < 100 ml.

Komplikasi
Perdarahan infeksi Arrhythmia cardiac arrest mortality

TERIMA KASIH