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Ann Thorac Surg 1995;59:1590-1591
© 1995 The Society of Thoracic Surgeons

How to Do it

Surgical Technique and Application of Pericardial Fat Pad and Pericardiophrenic Grafts

Timothy M. Anderson, MD, Joseph I. Miller, Jr, MD

Department of Cardiothoracic Surgery, Emory University School of Medicine, The Emory Clinic, Atlanta, Georgia

Accepted for publication February 13, 1995.


   Abstract
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 Abstract
Introduction
 Technique
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Oncologic developments in stage IIIA lung cancer and complex tracheal reconstruction have renewed interest in bronchial stump and tracheal coverage. The surgical techniques to mobilize and apply pericardial fat pad and pericardiophrenic grafts are discussed.


   Introduction
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 Abstract
 Introduction
Technique
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 References
 
Recent surgical developments in stage IIIA lung cancer, and complicated tracheobronchial operations, have renewed interest in the application of bronchial stump coverage, coverage of complex tracheobronchial fistula, and protection of suture line reinforcement [1]. Pleural flaps, intercostal muscle pedicle flaps, pericardial flaps, and intrathoracic muscle transposition flaps such as the serratus anterior and latissimus dorsi muscle flaps have been applied in these situations [2–5]. Our recent experience with pedicle pericardial fat pad grafts and pericardiophrenic pedicle grafts have shown their usefulness for bronchial coverage and suture line reinforcement.


   Technique
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The methods for harvesting the pedicled pericardial fat pad grafts are as follows (Fig 1Go).



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  		Fig 1. . Anterior-inferior pericardial fat pad graft for coverage of the middle and lower lobe bronchial stumps (upper right). Anterior-superior pericardial fat pad graft for coverage of the upper lobe bronchial stump (upper left). (IMA = internal mammary artery.)

 
The anterior-inferior pericardial fat pad graft is based on the middle pericardial and musculophrenic branches of the internal mammary artery. The mediastinal pleura is incised along the periphery of the graft. The pedicle then is freed up off the pericardium. The anastomotic vessels to the pericardiophrenic branch anteriorly and the tributary between the middle pericardial branch and musculophrenic artery inferiorly are divided. The pedicle consisting of overlying mediastinal pleura, blood vessels, and adipose tissue then is turned up gently to the bronchial stump. Using 4-0 interrupted Vicryl sutures, the end of the graft is fixed meticulously to the overlying bronchial tissues to form a caplike closure over the bronchial end, and the pedicle is reinforced with tacking sutures to the mediastinum more proximally. This graft works well for pneumonectomy stumps or remnant of middle or lower lobe bronchi.

An alternative and somewhat shorter graft can be derived by an anterior-superior pericardial fat pad graft, where the blood supply is mainly from the anterior mediastinal vessels and superior pericardial branch of the internal mammary artery. The pedicle is developed as shown in the upper left of Figure 1Go and is useful to cover the stump of a main bronchus or upper lobe bronchus.

A potential alternative with a pneumonectomy patient or when the phrenic nerve requires sacrifice is to use the pedicled pericardiophrenic graft. The technique of harvesting this graft is as follows (Fig 2Go).



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  		Fig 2. . Pericardiophrenic graft for coverage of the pneumonectomy stump.

 
The parietal pleura, phrenic nerve, and accompanying adipose tissue surrounding the pericardiophrenic vessels are freed, beginning at the most inferior aspect of the structure. The phrenic nerve and vessels are divided above the diaphragm, then the pedicle is swung posteriorly over the pneumonectomy or lobar bronchial stump. It then is attached to the stump in a manner similar to that of the pericardial fat pad graft with interrupted Vicryl sutures. This graft has variable amounts of adipose tissue, and occasionally the accompanying fat is too scant for a suitable pedicle. The accompanying pericardial defect is closed with 2-0 interrupted silk sutures as the defect is small. These should be placed 1 cm apart. Occasionally a strip of bovine pericardium is placed, but this rarely is required.


   Comment
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The pedicled pericardial fat pad graft initially was devised out of an attempt to reinforce a torn bronchus after pulmonary resection and since has been employed as an adjunct to prevent bronchopleural fistula after lobectomy or pneumonectomy. Lyman Brewer and associates first described this technique in 1953 [6, 7]. When the phrenic nerve is sacrificed, a pedicled pericardiophrenic graft is an acceptable alternative and has been used to reinforce to the right pneumonectomy stump with success. (Pellett JR, personal communication).

Over the past 4 years we have applied these techniques with excellent results in 54 cases, particularly for the irradiated bronchial stump in stage IIIA lung cancer, in complex tracheal reconstruction such as carinal pneumonectomy, and in tracheal resections complicated by marked inflammation. These have resulted in only three late fistula recurrences.

Pedicled pericardial fat pad grafts to reinforce bronchial closure in pulmonary resections have follow-up both experimentally and in humans supporting their long-term durability. Human postmortem examination has revealed intact, viable graft reinforcing the bronchial stump as long as 2 years 9 months postoperatively [6].

In summary, anterior-inferior pericardial fat pad grafts are most desirable for reinforcing the resected bronchial or pneumonectomy stump, carrying with them a fairly constant blood supply from the middle pericardial artery. For the upper lobe or main bronchus, anterior-superior fat pad grafts provide a suitable alternative. In addition, the pericardiophrenic pedicle serves as a viable alternative to pericardial fat pad grafts when sacrifice of the phrenic nerve is necessary and the amount of adipose tissue contained within the pedicle is deemed sufficient.


   Footnotes
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 References
 
Address reprint requests to Dr Miller, Department of Cardiothoracic Surgery, The Emory Clinic, 25 Prescott St, Suite 3420, Atlanta, GA 30308.


   References
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 Technique
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 References
 

  1. Rusch VW, Albain KS, Crowley JJ et al. Surgical resection of stage IIIA and stage IIIB non–small-cell lung cancer after concurrent induction chemoradiotherapy: a Southwest Oncology Group trial. J Thorac Cardiovasc Surg 1993;105:97–106.[Abstract]
  2. Weisel RD, Cooper JD, Delarue NC, et al. Sleeve lobectomy for carcinoma of the lung. J Thorac Cardiovasc Surg 1979;78:839–49.[Abstract]
  3. Sano T, Naruke T, Watanabe H, et al. An esophagobronchopleural fistula successfully treated by a surgical procedure combined with conservative therapy after resection for lung cancer. Jpn J Clin Oncol 1989;19:402–8.[Abstract/Free Full Text]
  4. Moghissi K. Tracheal reconstruction with a prosthesis of Marlex mesh and pericardium. J Thorac Cardiovasc Surg 1975:69:499–506.[Abstract]
  5. Miller JI, Mansour KA, Nahai F, et al. Single stage complete muscle flap closure of the post-pneumonectomy empyema space: a new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38:227–31.[Abstract]
  6. Brewer LA, King EL, Lilly LJ, et al. Bronchial closure in pulmonary resection: a clinical and experimental study using a pedicled pericardial fat graft reinforcement. J Thorac Cardiovasc Surg 1953;26:507–32.
  7. Icenogle TB, Levinson MW, Copeland JG, et al. Use of pericardial fat pad flap to prevent bronchopleural fistula. Ann Thorac Surg 1986;42:216–7.[Abstract]



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