Ann Thorac Surg 1999;67:565-566
© 1999 The Society of Thoracic Surgeons
How To Do It
Videoscopic harvest of the inferior epigastric artery
Stephen J. Hoenig, MDa,
Richard A. Hodin, MDa,
Gordon Novak, MDa,
William E. Cohn, MDa
a Division of Cardiothoracic Surgery, Beth Israel Hospital, Boston, Massachusetts, USA
Accepted for publication July 15, 1998.
Address reprint requests to Dr Cohn, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Dana 905, Boston, MA 02215
e-mail: wcohn{at}bidmc.harvard.edu
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Abstract
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The inferior epigastric artery has been found to be a useful conduit for performing arterial coronary revascularization. The present report describes a minimally invasive port access technique for harvesting the inferior epigastric artery.
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Introduction
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The inferior epigastric artery (IEA) has been described as a conduit for coronary artery bypass grafting and has been demonstrated to provide satisfactory intermediate term patency. The standard harvest technique requires a lower abdominal paramedian incision with its attendant postoperative pain and potential morbidity. We devised a minimally invasive, port access technique for harvest of the IEA, avoiding a paramedian abdominal incision.
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Technique
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Four patients were selected for videoscopic IEA harvest. All were men with significant proximal left anterior descending coronary artery stenosis who were candidates for minimally invasive bypass by the H-graft technique, which entails bypass from the side of the in situ mammary artery to the left anterior descending coronary artery with a short segment of conduit [1].
Informed consent was obtained from each patient. None of the 4 patients had evidence of arteriosclerotic aortoiliac disease by physical examination or history. One patient had undergone previous appendectomy through an oblique right lower quadrant incision.
Anesthetized patients were positioned and draped in the standard fashion for coronary artery bypass grafting. A 1-cm horizontal incision was made within the umbilicus, at the inferior margin. Blunt dissection was used to expose the fascia overlying the right rectus abdominis muscle. The fascia was incised vertically and the rectus muscle retracted laterally. A lubricated Spacemaker II surgical balloon dissector (GSI, Cupertino, CA) was passed in a caudal direction, posterior to the rectus, into the properitoneal space with the tip positioned posterior to the symphysis pubis. The Spacemaker II is a sheathed polyurethane bladder that can be introduced into an undissected tissue plane by way of a 1-cm port. Inflation of the bladder with 800 mL of saline results in gentle blunt dissection of the plane and development of a potential space. The device was used to dissect the properitoneal plane in this fashion, after which the saline was evacuated and the balloon removed. The 1-cm port was then advanced and the space insufflated with CO2 to a pressure of 12 mm Hg.
A 30-degree video laparoscope was used to visualize the properitoneal space. In each case, the inferior epigastric vessels were readily identified arising from the external iliac artery and vein and ascending along the roof of the insufflated cavity. A 5-mm port was introduced 1 cm to the left of the midline, approximately 3 cm above the symphysis. A second 5-mm port was introduced halfway between the first port and the scope (Fig 1). Videoscopic visualization precluded injury to the left inferior epigastric vessels during placement of these ports.
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Fig 1. Videoscopic harvest of the right inferior epigastric artery demonstrating port and instrument placement into the insufflated properitoneal space. The vessels are readily identified hanging from the posterior aspect of the rectus abdominis muscle.
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Harvest of the right IEA was performed from the left side of the operating table. Using a combination of blunt and sharp dissection, the vessel was mobilized and the branches serially dissected, clipped, and divided using a 5-mm laparoscopic clip applier (USSC, Norwalk, CT) and laparoscopic scissors. Each inferior epigastric vessel had from three to six branches spaced evenly along its length. A pedicle surrounding the artery was preserved, which included the vena comitantes and fat. Dissection was extended cephalad to approximately 2 cm below the umbilicus. Harvest of additional conduit length was facilitated by moving the laparoscope to the inferior port; however only a short segment of artery was required in each of our patients.
Once an adequate length of vessel was mobilized from the anterior abdominal wall, intravenous heparin (1.5 mg/kg) was administered, and both ends of the artery and veins were clipped and divided. The arterial stumps were clipped twice to ensure hemostasis. The free segment of IEA was removed through the inferior port and placed in heparinized blood. After careful inspection for hemostasis, the compartment insufflation was released and the ports removed. The rectus fascia and skin were each closed with a single absorbable suture. No drains were placed within the properitoneal space.
Each artery was irrigated externally with papaverine solution (300 mg/100 mL normal saline) and flushed with heparinized blood. Each was carefully examined to ensure absence of injury or unclipped branches.
These harvests took 25, 32, 50, and 55 minutes, including wound closure. Harvested IEA segments measured between 6 and 9 cm in length. The completed H-grafts measured between 3 and 6 cm in length.
Interoperative Doppler evaluation and postoperative angiography were obtained in each case, revealing a widely patent graft in 3 of the 4 patients. In the fourth patient, a technical problem was identified at the anastomosis of the IEA to the internal mammary artery, but there were no issues with the IEA. Two of the patients subsequently underwent repeat angiography at 12 and 13 months, demonstrating widely patent grafts. On follow-up at 12 to 15 months, there were no instances of infection or fascial herniation. The patient with the anastomotic problem received systemic heparin postoperatively for myocardial ischemia, and subsequently experienced a moderate properitoneal hematoma that resolved without intervention.
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Comment
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Use of the IEA as a conduit for coronary artery revascularization was first described in 1990 [2]. Since that time, several series have been reported demonstrating good intermediate term patency [3–5]. Recent series report good clinical results using the IEA as part of a composite graft, in which the proximal IEA is anastomosed to the side of the pedicled internal mammary artery graft [6]. More recently, we have described the H-graft technique for performing minimally invasive bypass that uses a segment of inferior epigastric or radial artery interposed between the side of the in situ mammary artery and the left anterior descending coronary artery [1]. These results may increase the use of IEA grafts. Although few abdominal wall complications from the open harvesting technique have been reported [4, 5], the technique requires an abdominal incision, can result in abdominal wall denervation, and is associated with moderate postoperative pain.
The present report describes a minimally invasive technique by which the IEA may be harvested. The approach is similar to that described for laparoscopic properitoneal hernia repair, and is quickly mastered by those familiar with videoscopic surgery.
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References
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Cohn W.E., Suen H.C., Weintraub R.W., Johnson R.G. The "H"-graft: an alternative approach for performing minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg 1998;115:148-151.[Abstract/Free Full Text]
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Vincent J.G., Van Son J.A.M., Skotnicki S.H. Inferior epigastric artery as a conduit in myocardial revascularization: the alternative free arterial graft. Ann Thorac Surg 1990;49:323-325.[Abstract/Free Full Text]
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Puig L.B., Ciongolli W., Cividanes G.V., et al. Inferior epigastric artery as a free graft for myocardial revascularization. J Thorac Cardiovasc Surg 1990;99:251-255.[Abstract]
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Buche M., Schoevaerdts J.C., Louagie Y., et al. Use of the inferior epigastric artery for coronary bypass. J Thorac Cardiovasc Surg 1992;103:665-670.[Abstract]
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Manapat A.E., McCarthy P.M., Lytle B.W., et al. Gastroepiploic and inferior epigastric arteries for coronary artery bypass: early results and evolving applications. Circulation 1994;90:II-144-II-147.
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Calafiore AM, Di Giammarco G, Teodori G, et al. Radial artery and inferior epigastric artery in composite grafts: improved midterm angiographic results. Ann Thorac Surg 1995;60:517–4.
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Abstract
Introduction
