心包积液胸腔镜的方法（图文演示）

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Depending on the anatomy and the surgeon’s choice, the pericardium is opened above or below the phrenic nerve.
A grasper is introduced through the lower trocar. It helps to lift the pericardial flap. The window is created with blunt scissors once they have been passed under the pericardium. The window should be made in an area free of adhesions The pericardial flap is excised and an anatomopathological exam is carried out. When the effusion is hemorrhagic, the pericardial cavity is washed under pressure with a saline solution. Any potential clots are evacuated.
1. Phrenic nerve
2. Window
3. Lower lobe

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Endoscopic exploration of the pericardium is done when doubts are raised over adhesions or in the presence of certain pathologies, especially in the intrapericardial evaluation of the extent of bronchial cancers (Azorin et al., 1986; Wurtz et al., 1992). This should only be performed when the cardiorespiratory status of the patient is stable. The exam may be done:
- either with the rigid endoscope that is introduced in the pericardial space once the border of the pericardial incision has been retracted upwards sufficiently;
- or with a flexible endoscope (Urschel and Horan, 1993). The endoscope that is connected to an additional cold light source is introduced through the upper trocar. This trocar should be large enough for the introduction of the sheath of the endoscope.
Two types of flexible endoscopes may be used: a rigid thoracoscope with a deflatable tip or a bronchoscope. Because of its extreme flexibility, the latter is less easy to manipulate. It should not be held with a grasper, which may damage its sheath. The simplest way is to introduce a No. 28 thoracic drain into the pericardial window, pass the bronchoscope through it and then remove the drain. The view is often blurred by the residual fluid accumulation, hence the need to regularly clean the scope.
1. Diaphragm
2. Phrenic nerve
3. Myocardium

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A No. 24 thoracic drain is placed in the pleural cavity. A No. 18 drain is left in the pericardium for 24 to 48 hours in case of hemorrhagic effusion. A multiperforated drain may also be used to drain both the pericardium and the pleura.
1. Diaphragm
2. Pericardium
3. Phrenic nerve
4. Lower lobe
5. Upper lobe

13. Complications
Arrhythmia
Monopolar cautery should not applied to the pericardium (risk of arrhythmia). When it is necessary, it should be performed once the pericardium has been retracted from the myocardium. The use of ultrasonic scissors has been suggested to eliminate the risk of dysrhythmia (Ohtsuka et al., 1998).

Hemorrhage
- bleeding of the pericardium when it is hypervascularized
There may be some bleeding at the cut edge of the pericardium. In case of important bleeding, the hemostasis of the borders may be carried out with a running suture or with bipolar cauterization or stapling.
- injury to the myocardium or a coronary artery
These complications are exceptional. They make it necessary to check for the absence of loculation by preoperative echocardiography. Puncture of the pericardium should also be done cautiously.

14. Postop period
- cardiorespiratory monitoring;
- correction of potential hypovolemia after drainage of the effusion;
- prevention of dysrhythmia;
- low-pressure suction on the pericardial drain (- 10 mm Hg);
- removal of the drain between the first and the third postoperative day depending on the output. The drain is usually removed when it yields less than 150 mL over a 24-hour period;
- chest X-ray to detect pleural effusion secondary to the creation of the pericardial window;
- postoperative respiratory therapy when needed.

15. Reference
Azorin J, Lamour A, Destable MD, de Saint-Florent G. La péricardoscopie: définition, intérêt et limite. Rev
Pneumol Clin 1986;42:138-41.
Gossot D, Mourey F, Roland E, Celerier M. Abord thoracoscopique des épanchements péricardiques.
Presse Med 1994;23:1480-2.
Hazelrigg SR, Mack MJ, Landreneau RJ, Acuff TE, Seifert PE, Auer JE. Thoracoscopic pericardiectomy
for effusive pericardial disease. Ann Thorac Surg 1993;56:792-5.
Krasna M, Fiocco M. Thoracoscopic pericardiectomy. Surg Laparosc Endosc 1995;5:202-4.
Nakamoto H, Suzuki T, Sugahara S, Okada H, Kaneko K, Suzuki H. Successful use of thoracoscopic
pericardiectomy in elderly patients with massive pericardial effusion caused by uremic pericarditis. Am J
Kidney Dis 2001;37:1294-8.
Ohtsuka T, Wolf RK, Wurnig P, Park SE. Thoracoscopic limited pericardial resection with an ultrasonic
scalpel. Ann Thorac Surg 1998;65:855-6.
Urschel JD, Horan TA. Pericardioscopy and biopsy. Surg Endosc 1993;7:100-1.
Wurtz A, Chambon JP, Millaire A, Saudemont A, Ducloux G. La péricardoscopie : techniques, indications
et résultats. A propos d'une expérience de soixante-dix cas. Ann Chir 1992;46:188-93.