Ann Thorac Surg 2001;72:924-925
© 2001 The Society of Thoracic Surgeons
Case report
Pericardiectomy for constrictive pericarditis using the Harmonic Scalpel
Tetsuro Uchida, MDa,
Ko Bando, MDa,
Kenji Minatoya, MDa,
Yoshikado Sasako, MDa,
Junjiro Kobayashi, MDa,
Soichiro Kitamura, MDa
a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
Accepted for publication September 6, 2000.
Address reprint requests to Dr Bando, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
e-mail: kobando{at}hsp.ncvc.go.jp
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Abstract
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A 35-year-old man with constrictive pericarditis underwent pericardiectomy. The pericardium was dissected with a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH). This new device has many advantages including no muscular stimulation, low heat, a smokeless field, and easy hemostasis. The Harmonic Scalpel is beneficial for dissection of thickened pericardium.
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Introduction
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The ultrasonically activated scalpel is broadly accepted as a beneficial tool for laparoscopic surgery. We have employed the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) for dissection of thickened pericardium. We describe here our clinical experience with this new device for treatment of constrictive pericarditis.
A 35-year-old man presented with abdominal distention and general fatigue of several months’ duration. Abdominal echography revealed a large amount of ascites. Echocardiography and computed tomography indicated the presence of severe constrictive pericarditis. Cardiac catheterization revealed the typical dip and plateau pattern. Central venous pressure was 15 mm Hg. Magnetic resonance imaging clearly demonstrated thickened pericardium all around the heart (Fig 1A). The etiology of pericarditis was unclear. There was no previous history of chest irradiation, surgery, or tuberculosis.
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Fig 1. (A) Preoperative magnetic resonance imaging revealed thickened pericardium all around the heart (arrowhead). (B) Postoperative magnetic resonance imaging showed no pericardial thickening.
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The patient was placed in a supine position. After general anesthesia the chest was entered through a median sternotomy. Cardiopulmonary bypass was on standby in case of unstable hemodynamics due to retracting the heart. There was a thick (7 mm) pericardium all around the heart. We used the Harmonic Scalpel with a hook blade for dissecting the thickened pericardium (Fig 2). The sharp hook side was used for identifying the proper plane and for transecting small vessels. The blunt back side was gently pressed against small bleeding points from the surface of myocardium to control bleeding (Fig 3). The dissection was started from the anterior part of the right ventricle. When we reached the plane between the thickened pericardium and myocardium, the pericardial flap was dissected superiorly, inferiorly, and laterally toward both phrenic nerves, the right atrioventricular groove, and the lateral left ventricular wall. The dissection proceeded all around the heart except in the area of the posterior left atrium. Hemostasis was quite easily achieved by using the Harmonic Scalpel and no major bleeding from myocardium was observed. No arrhythmia was induced during the operation. The operation was completed without cardiopulmonary bypass. No blood transfusion was required and the patient was extubated 5 hours after surgery. He is doing well 1 year after the procedure without pericardial thickening around the heart (Fig 1B).
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Fig 2. Intraoperative view and diagram of the dissection of thickened pericardium using Harmonic Scalpel.
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Fig 3. Comparison of the Bovie scalpel and the Harmonic Scalpel. Top to bottom: Bovie scalpel, Harmonic Scalpel, and ruler showing scale.
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Comment
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The Harmonic Scalpel is activated with ultrasonic energy produced by longitudinal vibrations up to 55,000 Hz [1]. It allows division of tissues and hemostasis with low heat at about 80°C. The blunt back side of this blade is used for hemostasis and the sharp hook side is used for the dissection. Each branch of the vessel is coagulated with excellent hemostasis. In this case we employed a Harmonic Scalpel to dissect the thickened pericardium of constrictive pericarditis. Despite adherent nature of the pericardium to the myocardium, it was relatively easy to find the right plane to avoid injuring the coronary arteries. This device avoided electrical muscular stimulation and hemodynamic deterioration due to arrhythmia was not induced throughout the operation even when heart was retracted. Hyperthermic damage to the heart should be less than with standard electrocautery. Producing less smoke allows an excellent surgical exposure. It is also useful for hemostasis. Postoperative bleeding was minimal; thus no homologous blood transfusion was required. In addition to the use for constrictive pericarditis, this device may also be useful for dissecting the heart at reoperation. The instrument has been used to harvest the internal thoracic artery during minimally invasive coronary artery bypass grafting [2]. We have employed this new surgical device for harvesting the internal thoracic artery, radial artery, and saphenous vein and have found it useful for dissecting these vessels without injuring surrounding tissues [3].
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References
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Amaral J.F. The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laparosc Endosc 1994;4:92-99.[Medline]
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Ohtsuka T., Wolf R.K., Hiratzka L.F., Wurnig P., Flege J.B. Thoracoscopic internal mammary artery harvest for MICABG using the Harmonic Scalpel. Ann Thorac Surg 1997;63:S107-S109.
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Kobayashi J, Yamamoto F, Sasako Y, Kosakai Y, Kitamura S. Efficacy of Harmonic Scalpel for radial artery harvest: evidence by postoperative coronary angiography [Abstract in Japanese]. Presented at the 3rd Annual Meeting of the Japanese Association for Coronary Artery Surgery, Tokyo, Japan, July 1–2, 1998.
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Abstract
Introduction
