Ann Thorac Surg 1997;63:1486-1488
© 1997 The Society of Thoracic Surgeons
How To Do It
Preperitoneal Suprahepatic Pacemaker Generator Placement in the Pediatric Population
J. Nilas Young, MD,
Tobias J. Bacaner, MD,
Carl A. Powell, MD
Division of Cardiac Surgery, Children's Hospital Oakland, and Department of Surgery, University of California Davis-East Bay, Oakland, California
Accepted for publication November 8, 1996.
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Abstract
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We have used a preperitoneal suprahepatic location for pacemaker generator placement in pediatric patients requiring permanent pacemakers with epicardial leads. The technique is rapid, simple, and safe, and cosmesis is excellent, making this approach particularly advantageous in the younger infant and neonate.
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Introduction
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Earlier diagnosis of congenital dysrhythmias as well as cardiac surgical interventions in neonates and younger infants require that pacemaker implantation increasingly be performed in pediatric patients with small body size. Despite a marked decrease in the size and weight of pacemaker generators during the past two decades, spatial and cosmetic considerations remain, particularly in the small infant or neonate. Between 1989 and 1995, our approach to the placement of pacemaker generators in patients who require epicardial leads has incorporated the use of a preperitoneal suprahepatic pocket. The safety, simplicity, reproducibility, and excellent cosmesis with the preperitoneal suprahepatic placement of pacemaker generators make this technique our current approach of choice for patients requiring epicardial pacemaker leads.
Between January 1989 and December 1995, fifty pediatric patients underwent pacemaker system implantation on our service for a variety of indications including congenital dysrhythmias, postoperative dysrhythmias including complete heart block, and replacement of failed previously implanted pacemaker systems. Ten patients (20%) underwent pacemaker insertion using transvenous lead placement with prepectoral or subpectoral pockets for generator placement. Forty patients (80%) had epicardial leads and abdominal wall placement of the pacemaker generator. Initially we used various types of abdominal wall pockets including the posterior rectus sheaths, or other sites within the anterolateral abdominal wall (n = 16; 32%). Twenty-four patients (48%) with an age range between 2 weeks and 16 years (size range, 2.0 to 65 kg) had epicardial pacemaker systems placed using a preperitoneal suprahepatic generator pocket. Ten patients (10/24 = 42%) in this latter group had dual-chamber systems implanted. Time of clinical follow-up ranged from 3 months to 7 years.
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Technique
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A limited upper abdominal midline incision beginning over the xiphoid and extending inferiorly approximately one half the distance to the umbilicus is carried down to the linea alba, which is then incised, and the suprahepatic preperitoneal space is exposed. This preperitoneal zone is typically located anterior to the medial aspect of the left lobe of the liver and inferior to the costal arch. The xiphoid is excised and the anteroinferior aspect of the pericardium exposed and opened to allow for adequate visualization of the right atrium and ventricular mass. Epicardial leads are placed as required, and then connected to the generator, which is placed in the midline preperitoneal pocket. Excess lead is placed posterior to the generator. Fixation sutures are usually not required (Fig 1
). The linea alba and soft tissues are then closed in layers with absorbable sutures providing a full-thickness abdominal wall closure with resultant excellent cosmesis (Fig 2).
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Results
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This technique is simple and rapid and has been associated with minimal morbidity. An ileus developed in 1 patient and resolved over 48 hours. One patient had extension of mediastinitis into the preperitoneal pacemaker pocket; this required removal and replacement of the pacemaker leads via a thoracotomy, with generator placement in a subpectoral pocket. Transcutaneous monitoring and system programming have been routinely uneventful in all patients. Four patients have had generators removed from the preperitoneal location and replaced for end-of-life parameters, and all of these generators were noted to be surrounded with a typical fibrous pocket that allowed for easy generator access and reimplantation of a new device. The potential complications of skin erosion, wound dehiscence, ventral hernia, intraperitoneal migration of the leads or generators, or respiratory embarrassment from the upper midline abdominal incision have not occurred.
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Comment
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Numerous techniques for implantation of pacemakers in the pediatric population have been employed in many centers. These include transvenous as well as epicardial lead placement, and generator placement within the chest wall, pleural cavity, and abdominal wall. Our general preference in children is for dual-chambered pacing via the transvenous route, but small children (<10 kg), particularly neonates, patients with systemic venous or single ventricle anomalies, and children requiring pacemaker implantation at the time of cardiac operations remain candidates for epicardial pacemaker lead placement. Abdominal wall generator pockets in the subcutaneous position are unsightly and prone to skin erosion, and are best avoided in young children. Medial or lateral abdominal wall submuscular pockets, including the use of reconstructed fascial layers (eg, the posterior rectus sheaths) or prosthetic patches, have been used successfully [1–9]. We have had experiences with most of these techniques; however, we find that the simplicity and ease of insertion with the preperitoneal suprahepatic approach is advantageous. The small size and low weight of contemporary generators, and the suprahepatic location of the generator pocket, allow for preperitoneal placement with no evidence in our series of generator migration or penetration into the peritoneal cavity by either the generator or the epicardial leads. In patients undergoing pacemaker implantation at the time of cardiac operations, the advantages of the preperitoneal pacemaker pocket are particularly evident. The typical sternotomy incision does not require lengthening. Very little time is required for blunt finger dissection of the upper midline preperitoneal space, and there is minimal associated bleeding, with small bleeders controlled with the electrocautery, followed by generator implantation. There is no requirement for takedown or restructuring of the abdominal fascial layers, and additional prosthetic materials are avoided. Because essentially the full thickness of the abdominal wall covers the generator, the device is very well protected and wound erosion, disruption, and infection have not occurred. In the early postoperative period after a cardiac operation when permanent epicardial pacing is required, the preperitoneal approach also simplifies generator placement by utilizing the inferior aspect of the midline sternotomy incision with or without a slight extension of the excision. In cases when implantation of a permanent pacemaker is deemed possible in the early postoperative period, chest tubes and temporary pacemaker wires are kept away from the abdominal midline to allow for ease of implementation of the preperitoneal approach.
Contraindications to the preperitoneal approach in our patients have included excessive edema and friability of the parietal peritoneum (eg, with ascites), or scarring of the abdominal wall layers from a previous operation, making dissection either difficult or hazardous. We anticipate, because of the known tendency of epicardial leads to develop exit block, that many of these patients will ultimately be candidates for transvenous lead placement and chest wall generator pockets. We recognize and agree with the current trend of preferentially using transvenous pacemaker lead implantation in the younger age groups. The limitations of this latter technique remain evolutionary and we suspect that, particularly in the small infant, epicardial lead placement remains an important alternative and therefore also so does generator pocket location.
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Footnotes
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Address reprint requests to Dr Young, Division of Cardiac Surgery, Children's Hospital Oakland, 747 52nd St, Oakland, CA 94609.
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References
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- Ohmi M, Tofukuju M, Kato K, et al. Permanent pacemaker implantation in premature infants less than 2,000 grams of body weight. Ann Thorac Surg 1992;54:1223–5.[Abstract]
- Gillette PC, Edgerton J, Kratz J, Zeigler V. The subpectoral pocket: the preferred implant site for pediatric pacemakers. PACE 1991;14:1089–92.
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- Ulicny KS, Detterbeck FC, Starek PJ, Wilcox BR. Conjoined subrectus pocket for permanent placement in the neonate. Ann Thorac Surg 1992;53:1130–1.[Abstract]
- Esperer HD, Singer H, Reide FT, Blum U, Mahmoud FO, Weniger J. Permanent epicardial transvenous single- and dual-chamber cardiac pacing in children. Thorac Cardiovasc Surg 1993;41:21–7.[Medline]
- Molina JE, Dunnigan AC, Croson JE. Implantation of transvenous pacemakers in infants and small children. Ann Thorac Surg 1995;59:1689–94.
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Abstract
Introduction
