Pericardial drainage using the transdiaphragmatic route: refinement of the laparoscopic technique

Four patients with malignant pericardial fluid requiring permanent drainage are reported. A three-port video-assisted thoracoscopic surgery modification of the pericardioperitoneal shunt procedure is described, in which the Ultracision Harmonic Scalpel is used. The supraumbilically introduced camera secures direct vision for the trocars in the left and the right hypochondrium of the patient in a modified lithotomy position. Grasping the diaphragm anterolateral to the hiatus esophagei with the manipulator, we cut through the diaphragm-pericardium complex with the Harmonic Scalpel. After creation of a hole with a diameter 3 to 5 cm, the abdomen is closed without a drain. The usage of Ultracision scalpel minimizes the risk of epicardium injury previously described with the use of scissors or electrocautery. Clips are unnecessary because the Harmonic Scalpel has a sealing effect. Two figures demonstrate the port placements and the facilitated cutting with the Harmonic Scalpel. Four patients underwent surgery using the described technique. All of them suffered from ultrasound-guided tapping or drainage-resistant, lung cancer-related malignant pericardial fluid, which caused pericardial tamponade. All the procedures were successful. The technique is easy to learn and simple to perform.