Pericardial suturing

Pericardial suturing refers to a surgical procedure aimed at suturing the edges of a torn or damaged pericardium. Most often this procedure becomes necessary in case of traumatic damage or rupture of the pericardial cavity. The indication for the procedure of pericardial suturing is a violation of the anatomical integrity of the pericardial membrane that surrounds the heart. This is one of the most serious conditions in which the patient should be treated as soon as possible. The victim should be taken as soon as possible to a trauma or surgical unit for further suturing surgery, as otherwise the outcome will be fatal.

The main cause of rupture is trauma to the pericardium. It can also be caused by nutritional disturbance of muscle tissue, resulting from ischemia, infarction, necrosis of surrounding tissues. After mechanical rupture of the tissue, its damage, tissue necrosis occurs. It is he who is the leading link in the pathogenesis. Often the rupture of the pericardium is a consequence of infarction. After a heart attack, rupture is observed quite often. At the same time, it can occur both directly during the attack, and immediately after it, and even after a certain period of time (the so-called delayed rupture). Therefore, postinfarction patients should stay at least a week in the department under the supervision of specialists, even if their health has normalized.

Suturing of the pericardium may also be required in the development of dystrophic processes, against the background of which there is depletion of the pericardial walls. This condition occurs as a result of a deficiency of certain substances, in violation of trophic processes. In rare cases, rupture may be a consequence of recently transferred infectious and inflammatory processes.

Currently, the question of the necessity of puncture before the suturing procedure is very acute. Thus, it is known that rupture often develops against the background of acute cardiac tamponade, which is accompanied by intensive accumulation of a large amount of fluid in the pericardial cavity. Therefore, in this case, the opinions of experts differ. Some argue that before starting suturing, it is advisable to perform puncture and pump out the accumulated fluid. Others are in favor of the fact that suturing can be performed without preliminary drainage of the cavity or puncture. As practice shows, the decisive factor in the choice of treatment tactics is not so much the fact of exudate formation in the cavity as the rate of its accumulation. Thus, with a rapid accumulation of fluid (at least 300-400 ml), death occurs almost immediately. Therefore, it is natural that in this case it is necessary to first pump out the fluid, after which the pericardium itself can be sutured. In slow accumulation of fluid, for example, in stab wounds of the pericardium, atria, sharp tamponade does not develop. Therefore, in this case, it is possible to perform suturing without prior drainage of the cavity. It should also be noted that in case of unstable hemostasis and development of tamponade, it is advisable to drain the pericardial cavity in the first place. It is possible to perform pericardial suturing without preliminary drainage of the cavity if the surgeon has not often performed this procedure and is not sure that he can accurately and accurately perform it. The loss of time can have a huge cost, up to the point where the patient dies. It should also be taken into account that the puncture is performed under local anesthesia, which will negatively affect further suturing. It is also not worth resorting to puncture if the patient has problems with blood pressure and clotting. Clots may form in the pericardium. They can block the needle during puncture. And searching for liquid blood without clots in the pericardial cavity can be dangerous because it can lead to the development of iatrogenic damage to the pericardium.

The algorithm of actions during pericardial suturing is approximately as follows: first, the cardiac pouch is opened, and then the edges of the pericardial wound are sutured. Immediately after opening the cardiac sac, the doctor applies wound expanders, which allows easy manipulation of the wound edges. It is also important to evacuate blood, and other fluid from the pleural cavity. For this purpose, an electric suction is used. In most cases, blood is used later for reinfusion. With caution, it is necessary to perform manipulations in case of cyanosis (if the tissues have acquired a blue hue), since in such a state in them trophism is disturbed, hypoxia and hypercapnia develop. Therefore, tissues are easily damaged. When wounding the heart, the surgeon and his team must perform all manipulations with extreme caution, because there is a high risk of damage to the trunk of the diaphragmatic nerve. Sometimes special holders with crossing are applied to protect the nerve. Often during surgery it is necessary to face the development of a thrombus in the pericardial cavity. In this case, it must be removed, and check for the presence of other foreign bodies, blood residues. It should also be taken into account that when removing a thrombus or foreign body, there is a sharp bleeding, so it must be stopped, and this course of events should be prepared in advance. It is also worth noting that during suturing, some foreign bodies are not subject to removal. So, for example, small knife fragments, bullets fixed in the pericardium should not be removed, as they do not cause harm. Moreover, if they are removed, they can cause serious bleeding. Small foreign bodies that lie freely in the thickness of the pericardium, are subject to delayed removal. Artificial circulation is used in most cases. To stop bleeding is often used such a technique such as vein clamping. However, this technique requires widening the access by transverse sternotomy. Sometimes a right thoracotomy is used. There is a separate technique for suturing the myocardium. In this case, special pads are used. One of the sutures is placed vertically near the coronary artery. For suturing the wound, a knotted suture is used. U-shaped sutures are used. Suturing is done with 3/0 nonabsorbable synthetic sutures. A round atraumatic needle is used for suturing. In this case, the puncture is made at a depth of approximately 0.6-0.8 cm from the edge of the wound. The pericardium is sewn through its entire thickness. Ligatures are tightened until the seepage of blood does not stop completely. At the same time, it is not allowed to cut through the sutures. Often after suturing, the threads are not cut, they are used as holders. At the time of the next injections and punctures, these sutures are pulled up. A fine suture material should be used. It is recommended to use a cicatellar suture. A final Luer clamp is placed on the wound ear and a non-absorbable suture is placed directly under the ear.

In more severe cases, Beck's technique is used, in which the edges of the pericardium are sutured to the large pectoral muscle, diaphragm. In this procedure, synthetic material is not used, as the risk of purulent-inflammatory and even septic process increases significantly. Also in such a case, there is a risk of developing arrhotic bleeding. Thus, bleeding ends in a fatal outcome, since it is impossible to stop it. It should also be taken into account that sometimes the technique of suturing with bypassing the coronary artery is used. This significantly reduces the risk of developing atelectasis of the lung. In this case, the patency of the left bronchus is sharply disturbed. There is a risk of the lung falling into the wound, in connection with which it becomes inaccessible for surgery. A sufficient level of anesthesia is necessary, and it is also necessary to carefully monitor hemodynamics. If the wound of the posterior surface of the pericardium is sutured, it is necessary to do the operation carefully, strongly without eversion of the heart. This is due to the fact that its eversion can cause the development of a fatal complication - asystole. In such a case, if this complication occurs, it is necessary to finish suturing as soon as possible and apply direct cardiac massage. If necessary, defibrillation is applied. The risk of fatal outcome increases in the presence of prior bleeding.

It is worth noting that the choice of technique depends on what type of pathologic process develops. The choice is made by the surgeon and often directly during surgery, since the degree of lesion and the risk of complications can largely be distinguished and detected only during surgery. Depending on the type of severity of the pathologic process, 3 types of rupture develop.

The first type of rupture is characterized by necrosis of the muscle layer, which occurs within 24 hours. In this case, it is mandatory to remove necrotized areas during surgery. This is one of the earliest complications of myocardial infarction, which is often observed in persons with pronounced dystrophic processes, extensive lesions of the heart muscle. Surgical manipulations should be performed in the first 3-6 hours from the manifestation of the first clinical symptoms.

The second type of rupture is characterized by a violation of the anatomical integrity of the pericardium, in which the severity of pathological processes increases gradually. In this case, urgent surgery is required. In trauma, the operation is carried out immediately, in the first 24 hours, because in the future there will be the development of necrosis and lethal outcome. If the rupture occurred as a complication of myocardial infarction, or other rheumatic and inflammatory process. In this case, treatment is possible, it should begin no later than 7 days after the first symptoms appear. If the first signs of rupture appear, treatment should be started immediately.

The third type includes such forms of rupture, which are accompanied by aortic lesions. This condition is the most dangerous, and leaves virtually no chance of recovery. This condition is absolutely fatal. In this case, surgery is possible (theoretically), but in fact, the operation is impossible due to the fact that it simply does not have time to conduct. The lethal outcome occurs more quickly.

However, it is worth noting that regardless of what type of pathology the condition belongs to, it is necessary to perform emergency suturing of the pericardium. In this case, it is necessary to act as quickly as possible, there is no time to develop a treatment tactic.

Pericardial fenestration

Pericardial fenestration refers to a complex operation to suture the pericardium, its ruptures. This surgical technique is widely used in the treatment of wounds of the heart and major vessels. Indications for the procedure - exudate formation, life-threatening conditions, tamponade, fluid accumulation, air in the pericardial cavity. One of the main indications for the procedure of pericardial fenestration is the formation of purulent exudate. Pericardial fenestration is used in diseases that are accompanied by general circulatory disorders, hemorrhages and necrotic processes.

Pericardial fenestration is also performed in case of cardiac tamponade. Pericardial tamponade is a pathological condition accompanied by increased fluid content in the pericardial cavity.