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Ann Thorac Surg 1997;64:1183-1185
© 1997 The Society of Thoracic Surgeons

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How To Do It

Endoscopic Saphenous Vein Harvesting: Minimally Invasive Video-Assisted Saphenectomy

Cardiac Surgical Research Center and Section of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

Accepted for publication April 14, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
A technique of greater saphenous vein harvesting for coronary artery revascularization using an endoscopic approach is herein detailed. The saphenous vein is directly identified at the knee through a single incision. An endoscopic dissector is advanced proximally and distally along the course of the vein, ligating side-branches with clips. The vein is divided at the ends of dissection, dependent on patient anatomy, by either a counterincision, endoscopic clips, or ligation with an Endo-loop.

	Introduction

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
Complications of greater saphenous vein harvesting include cellulitis, hematoma/seroma, edema, saphenous neuropathy/neuralgia, and ischemic sequelae [1, 2]. Female sex, diabetes mellitus, peripheral vascular disease, obesity, and anemia are preoperative predictors of an unacceptable surgical outcome [3]. Advancements in surgical excision of the saphenous conduit may affect this morbidity.

Although greater saphenous vein harvesting is customarily performed through an extended medial lower extremity incision, alternative approaches have previously been reported [4, 5]. Here we describe a method to allow vein dissection under endoscopic assistance.

	Technique

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
The present instrumentation is commercially known as the Endo-Path (Ethicon Endo-Surgery, Inc, Cincinnati, OH). It comprises a subcutaneous dissector, retractor, and modified vein stripper (Fig 1). In addition, standard endoscopic equipment, including a television monitor, light source, fiberoptic camera, and a 5-mm lens (300 mm in length), is required, all readily available in centers with thoracoscopic capabilities.

View larger version (22K): [in this window] [in a new window]   Fig 1. . The legs are prepared circumferentially and positioned in a "frog-leg" manner. A longitudinal incision is made at the level of the knee and the vein dissected under direct vision (left insert). The equipment (from top) consists of (a) an endoscopic dissector, (b) an endoscopic retractor, (c) a modified Mayo vein stripper, (d) an endoscopic clip applicator, and (e) endoscopic scissors. The dissector and retractor have ports for a 5 mm x 300 mm videoscopic lens.

The 5-mm lens is placed in the subcutaneous dissector, the light source is connected, and the camera is calibrated to white. We prefer to first dissect the thigh portion of the vein. The subcutaneous retractor is inserted in the incision and the vein is identified on the television monitor. The dissector is advanced along the proximal course of the saphenous vein and a subcutaneous tunnel is subsequently fashioned. A slight upward pressure is exerted on the dissector during advancement. Acceptable technique will be viewed on the television monitor as the vein "passes" under the lens, analogous to the appearance of the road as one is driving along the highway. If this passage of the vein is not noted, the vein is being stretched as the dissector is advanced, potentially damaging the conduit.

Side-branches of the saphenous vein are identified as the dissector is advanced. Of particular note, the vein will roll from one side of the television screen to the other during dissection. This occurs at points of fixation; either an anterior or an anterolateral branch has been encountered. We find it useful to ligate and divide these anterior branches as they are encountered to prevent inadvertent avulsion. The ligation of these branches is slightly different than that of lateral branches. As the cone of the dissector approaches the anteriorly oriented branches, there is a tendency of the equipment to pull the branch over the cone. Therefore, counterintuitively, one must pull the dissector away from the branch, applying upward pressure on the dissector handle. In this manner, the anterior branch "hangs" within the endoscopic field, allowing ligation and division.

After the dissector has been advanced to the saphenofemoral junction, it is withdrawn and replaced with the subcutaneous retractor. Our customary practice is to advance the retractor to the limits of the groin and then insert the vein stripper. Gentle circumferential dissection with the stripper will identify lateral branches. These are clipped endoscopically (Fig 2). An endoscopic scissors is passed and the branch is transected so the clip is retained in the body; the saphenous portion of the branch will venospasm and no bleeding will be noted (see Fig 2).

View larger version (38K): [in this window] [in a new window]   Fig 2. . (A) The anterior surface of the saphenous vein has been dissected endoscopically. A modified Mayo vein stripper is used to dissect the posterior and lateral connective tissue. (B) The side branch is ligated with endoscopic clips and (C) incised on the specimen side of the clip. Venospasm prevents bleeding into the surgical field. The clip retained in the body prevents bleeding late after the operation.

In the initial learning curve of this technique, we would recommend a 1- to 2-cm groin counterincision, aided with transillumination by the subcutaneous retractor, to ligate the proximal vein under direct vision. Alternatively, one can endoscopically ligate the vein with either clips or an Endo-loop (Ethicon). Certainly, with advancement of instrumentation, a counterincision can be avoided in the majority of patients. We have not needed a counterincision in the calf for vein ligation.

Once the vein has been removed, the vein is cannulated and the branches ligated with 3-0 silk sutures as Plasmalyte is injected. Although this represents an additional step in comparison with the traditional open technique of harvesting, we have found it to require no greater time commitment than the skin closure would require in an extended median incision. Our initial experience has rapidly progressed to a consistent total harvest time of 45 minutes.

The leg is wrapped with Kerlex until completion of the bypass procedure. After reversal of heparin anticoagulation, the small leg incision(s) is closed in layers with absorbable suture and the leg is tightly wrapped with supportive ACE bandages. The leg wrap is left in place for 24 hours and removed once the patient has begun ambulation.

	Comment

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
We have found this endoscopic harvesting of the saphenous vein to provide a high level of patient comfort while preserving conduit integrity. As noted in the previous discussion, there are several technical considerations to be learned and applied with this method of harvest. However, we have been impressed with the rapidity with which this technique can be learned.

Because the reported incidence of serious adverse reactions to saphenous vein harvesting is roughly 1% to 5%, especially in patients with numerous comorbidities, our early experience only begins to define the complication rate with this procedure. Intuitively, fewer or smaller incisions in patients would appear to reduce many of the current complications. We have noted only mild ecchymosis in patients on preoperative anticoagulation, but the painless nature of this condition has been well accepted by the patients. In conclusion, although the widespread application of minimally invasive techniques to cardiac surgery requires skeptical optimism, the minimal pain associated with endoscopic saphenous vein harvesting will likely prompt patient request in the near future.

	Acknowledgments

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
We thank Greg A. Cooper, Vern D. Lee, Daniel L. McHone, Bradley J. Phelps, Randy Wilbur, and Scott Wibben for expert surgical assistance in performing the procedures. In addition, we thank John V. Hagen for preparation of the illustrations.

	Footnotes

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 
Address reprint requests to Dr Dearani, Section of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, 200 First Street SW, Rochester, MN 55905 (e-mail: jdearani{at}mayo.edu).

	References

Top Footnotes Abstract Introduction Technique Comment Acknowledgments References

 

1. DeLaria GA, Hunter JA, Goldin MD, et al. Leg wound complications associated with coronary revascularization. J Thorac Cardiovasc Surg 1981;81:403–7.[Abstract]
2. Gandhi RH, Katz D, Wheeler JR, et al. Vein harvest ischemia: a peripheral vascular complication of coronary artery bypass grafting. Cardiovasc Surg 1994;2:478–83.[Medline]
3. Utley JR, Thomanson ME, Wallace DJ, et al. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Cardiovasc Surg 1989;98:147–9.[Abstract]
4. Rashid A, Fabri B, Meade JB. Subcutaneous technique for saphenous vein harvest. Ann Thorac Surg 1984;37:169–70.[Abstract/Free Full Text]
5. Meldrum-Hanna W, Ross D, Johnson D, Deal C. An improved technique for long saphenous vein harvesting for coronary revascularization. Ann Thorac Surg 1986;42:90–2.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David G. Cable Joseph A. Dearani Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cable, D. G. Articles by Dearani, J. A. Search for Related Content PubMed PubMed Citation Articles by Cable, D. G. Articles by Dearani, J. A.