Abstract Although pericardiectomy remains an established method for pericardial resection, the choice of surgical approach is not definitive. Within South Africa, surgical referral for tuberculosis-induced chronic constrictive pericarditis has not declined. Anecdotal reports have indicated good operative results that appear to show an association with choice of surgical technique used. This study aimed to provide a functional anatomical perspective for performance and recovery of the heart during pericardiectomy based on anatomical dissection and surgical notes. En bloc specimens were harvested from 16 fresh cadavers and pericardial segments were measured in terms of percentage cover over surface area of the myocardium. Retrospective analysis of 116 surgical reports of pericardiectomy performed over a period of 20 years was conducted. Surgical notes were compared for median sternotomy and anterolateral left thoracotomy. Results from anatomical study indicated that although the anterior pericardium between the phrenic nerves constitutes about 58% of total selected pericardial area, total pericardium accessible over left ventricle from that approach was only 26%. When orientated in left anterolateral position, total accessible area of left ventricular pericardium was 37%. Standard deviations were found to be comparable. Means were significantly different, indicating that the left anterolateral approach allows wider access to the left ventricle. This paper provides a functional anatomical perspective for the choice of left anterolateral thoracotomy as a surgical approach for pericardiectomy.