Ann Thorac Surg 1999;67:571-572
© 1999 The Society of Thoracic Surgeons
How To Do It
Minimally invasive vein harvest: new techniques with old tools
Roxanne V. Newman, MDa,
W. Greg Lammle, PA-Ca
a Department of Cardiothoracic Surgery, MeritCare Medical Center, Fargo, North Dakota, USA
Accepted for publication July 18, 1998.
Address reprint requests to Dr Newman, Department of Cardiothoracic Surgery, MeritCare Medical Center, Desk 32, 737 Broadway, Fargo, ND 58123
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Abstract
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Greater saphenous vein harvest has been the focus of increasing applications of endoscopic techniques aimed at reducing wound complication, increasing patient comfort, and providing more acceptable cosmetic results. A retired, reusable, lighted retractor used for breast surgery was adapted using minimally invasive and bridge techniques resulting in decreased incisions, gentle vein handling, decreased harvest to closure time, and better wound healing compared with open techniques.
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Introduction
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Greater saphenous vein harvest has been the focus of increasing applications of endoscopic techniques aimed at reducing wound complication, increasing patient comfort, and providing more acceptable cosmetic results [1–3]. We have tried several commercially available endoscopic and direct minimally invasive products but abandoned them because of unacceptable results, complications, and cost. A previously retired, reusable, lighted retractor used for breast surgery was adapted using minimally invasive and bridge techniques resulting in decreased incision length, decreased harvest to closure time, and better wound healing compared with open techniques.
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Technique
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The patients were positioned and prepared in the standard fashion including circumferential lower leg preparation. A 3- to 5-cm parallel incision was made above the knee, being careful to stay as directly over the vein as possible. The vein was identified and dissected free at the level of the incision extending into the tunnel at either end. The 15-mm x 150-mm, lighted retractor (Luxtec, Worcester, MA) with an ACMI connector and light cable (Fig 1) was introduced into the tunnel. The subcutaneous tissue was divided with electrocautery and the retractor was advanced toward the groin. Approximately two thirds of the way up the thigh, a second parallel incision was made in the same manner over the light. The retractor was placed in this incision and dissection carried up to the groin and inferior to meet the other tunnel. The vein was dissected under direct vision and side branches were ligated and divided. If an entire leg was used, the tunnel was created around the knee making sufficient room by dividing the subcutaneous tissue. A third parallel incision was made inferior to the knee crease and dissection carried superior and inferior. A fourth parallel incision can be made two thirds of the way below the knee and the steps repeated to remove the entire saphenous vein (Fig 2). The proximal end was ligated with right-angle medium-large hemoclips, the distal end was ligated with medium-large hemoclips, and the vein was removed. The skin was closed with monofilament 4-0 absorbable suture, 1-inch steri-strips were applied in a parallel manner, a sterile towel was placed over the incisions, and elastic wraps were applied from foot to groin. As the legs were circumferentially prepared, this allowed the spaces to be compressed while the patient was fully heparinized, dramatically decreasing hematomas. The wraps were removed the following morning.
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Comment
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More than 100 patients had saphenous vein harvest using this technique and retractor. The vein was removed by the time the internal mammary artery was harvested (25 to 30 minutes), incisions closed, and dressings applied before bypass was instituted. Initial applications required a second person to hold the retractor; however, with experience, this was required only at knee creases and during ligation. Although actual harvest times were comparable, the time for closure was 10 minutes for an entire leg. This technique can be applied to thin patients, emergency operations, and those on anticoagulants with a conversion to open rate of less than 5%. Traumatic injury to the vein, hematomas, wound infection (especially noted in patients with vasculopathies or diabetes and obese patients), and postoperative pain has been reduced to less than 1% compared with 5% with open technique. We believe this technique results in faster vein harvest to closure time, superior wound healing, improved patient comfort, and reduced equipment burden and cost, and has the ability to be mastered by individuals without previous minimally invasive experience.
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References
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Allen K.B., Shaar C.J. Endoscopic saphenous vein harvesting. Ann Thorac Surg 1997;64:265-266.[Abstract/Free Full Text]
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Tevaearai H.T., Mueller X.M., von Segesser L.K. Minimally invasive harvest of the saphenous vein for coronary artery bypass grafting. Ann Thorac Surg 1997;63:119-121.
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Cable D.G., Dearani J.A. Endoscopic saphenous vein harvesting: minimally invasive video-assisted saphenectomy. Ann Thorac Surg 1997;64:1183-1185.[Abstract/Free Full Text]
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Abstract
Introduction
