Pericardial window is often performed for the treatment of recurrent pericardial effusions. The classical minimal invasive technique is the three-port video-assisted thoracic surgery (VATS) approach, utilizing a 10-mm thoracoscopic camera port, and a further two 10 mm or more incisions for the instrument ports. Needlescopic VATS (nVATS) surgical procedures, such as bullectomy for pneumothorax and thoracic sympathectomy, have gained increasing popularity in the past few years. nVATS, utilizing 3-mm instruments, can result in even less access trauma, smaller external scars, and might further reduce postoperative pain and lead to a quicker recovery.1 This video shows a left VATS pericardial window creation performed using needlescopic instruments.
A 55-year-old woman, who had no significant past medical history, presented with chest discomfort that had persisted for several weeks. Echocardiography showed moderate pericardial effusion located posteriorly, with no tamponade effect and good biventricular function. Extensive investigations failed to ascertain the underlying cause of the effusion. nVATS pericardial window was performed for drainage and to aid diagnosis. The patient received general anaesthesia and was intubated with a double-lumen endobronchial tube. In the lateral decubitus position, with the operating table flexed at 30 degrees, the left lung was deflated. Pre-emptive wound infiltration with local anaesthesia was performed. A 10-mm left chest wall incision was made at the eight intercostal space mid-axillary line for the insertion of a 10-mm 30-degree thoracoscope; 3-mm stab incisions for the two instrument ports were made at the sixth intercostal space mid-clavicular line, and sixth intercostal space mid-axillary line, inserted under direct thoracoscopic vision. Any lung overlying the anterior apart of the pericardium could be gently retracted away. Three-millimetre endograspers were used to retract and create a hole with diathermy in the pericardium (Fig. 1). An endosucker was used intermittently to facilitate the drainage and collection of pericardial effusion for analysis. Endohook diathermy was used to facilitate the creation of a 3-cm pericardial window anterior to the phrenic nerve. The pericardium specimen was retrieved through the 10-mm port using 3-mm endograsper under direct vision, sharing the port with a 5-mm thoracoscope. Haemostasis was secured at the port sites and pericardial edge. A 24-Fr chest drain was placed via the inferior thoracoscopic port and secured with an O silk suture. A single 4/0 nylon suture was applied to each 3-mm incision. The operative time was 25 min, with minimal blood loss recorded. Chest drain output was not high, and talc poudrage was unnecessary. The chest drain was removed on postoperative day 2, and the patient was discharged in the same afternoon without complications.
VATS is increasingly being accepted as the approach of choice over open techniques.2 The advantages of using 3-mm needlescopic access and instruments over conventional 10–15-mm VATS access remain unclear. A recent trial comparing nVATS sympathectomy with standard VATS showed no significant difference in the incidence of postoperative paraesthesia up to a follow up of 40 months between the groups.3 However, to minimize postoperative pain following nVATS procedures, pre-emptive wound infiltration with local anaesthesia might be useful.1 Nevertheless, nVATS is associated with less access trauma and better cosmesis when compared with conventional VATS or open pericardial window techniques, with the potential of quicker recovery and less postoperative pain. Future studies are warranted to investigate the role of nVATS in pericardial window creation and appropriate patient selection.
nVATS pericardial window can be performed safely, with minimal chest wall access trauma and optimal cosmesis results, without compromising the surgical result.
Additional video images may be found in the online version of this article.