Ann Thorac Surg 1999;67:872-873
© 1999 The Society of Thoracic Surgeons
How To Do It
Advantages of a modified gastroscope for video-assisted internal mammary artery harvesting
Hendrik T. Tevaearai, MDa,
Xavier M. Mueller, MDa,
Frank Stumpe, MDa,
Patrick Ruchat, MDa,
Ludwig K. von Segesser, MDa
a Department of Cardiovascular Surgery, University Hospital, Lausanne, Switzerland
Accepted for publication August 27, 1998.
Address for reprint requests to Dr Tevaearai, Department of Cardiovascular Surgery, University Hospital, CH-1011 Lausanne, Switzerland
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Abstract
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Instead of standard rigid thoracoscopes, we used a modified gastroscope for video assistance during 12 minimally invasive left internal mammary harvesting. Flexibility and remote control of its last centimeters give to the gastroscope a total freedom of movements, and perfect positioning in every direction. The scope is equipped with cold light, a suction canal and an irrigation canal, which allow for in situ washing without needing to remove it from the thoracic cavity. Thanks to these advantages, vision and lighting are always perfect.
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Introduction
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Minimally invasive approach to coronary operations is still limited because of restrained visual control of the operative field. Even if special rib retractors have been designed to create a maximal opening, lighting through a small incision remains difficult and direct vision is sufficient only for a nearby area. Thoracoscopy offers the possibility of a better visual control of the distant operative areas, but standard rigid thoracoscopes have limited maneuverability and have to be permanently held by a third hand.
We use a modified gastroscope (Fujinon EVE 200, Willich, Germany) for visual assistance during our thoracoscopic activity. It is flexible on its 110-cm length (Fig 1 ) and the last centimeters can be moved in every direction thanks to a remote control placed in the grip. It is equipped with two fibers for light transmission, one suction canal, which allow for smoke aspiration and one irrigation canal (Fig 2 ). This one permits either spouting of water or cleans up of the camera during the operation. Therefore, there is no need to remove it from the thoracic cavity each time the lens is dirty. Compared to standard gastroscopes, it has been modified by suppression of the insufflation canal, so that no external air can be blown in the thoracic cavity. The camera is at the end of the scope and no optic fibers are required in this system. Thus, it offers a better definition and avoids the honeycomblike pattern seen in fiberscopes. Moreover, the numerous black dots (due to fractures of the fibers) that appear on the screen after several uses of fiberscopes, cannot be seen with this system. Connected to a video system, the image is reproduced on a television monitor. At the end of each operation, every canal is carefully rinsed before ethylene oxide sterilization.
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Fig 1. General view of the modified gastroscope. The length of the tube without the grip is 110 cm. The grip comprises two wheels that control the movements of the last centimeters of the tube. Combination of the two-wheel manipulations allows for total freedom of these movements. The grip also includes one key for either spouting of water or rinsing of the camera and one key for suction.
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Fig 2. Focused view of the tip of the gastroscope with 1 = camera, 2 and 3 = cold lights, 4 = occluded canal, 5 = aspiration canal, 6 = irrigation canal.
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This endoscope was recently used for assistance in 12 minimally invasive direct coronary artery bypass procedures. The scope was inserted into the thoracic cavity, either through the left anterior thoracotomy or through a lateral 10-mm port. In 2 patients, left internal mammary artery (LIMA) was totally harvested with endoscopic instruments under scopic vision only, before the thoracotomy was performed to do the anastomosis. In the remaining 10 patients, the left anterior thoracotomy was directly performed and distal LIMA was first dissected under direct vision. The scope was nevertheless considered helpful for bringing perfect lighting on the operative field. The proximal part of the LIMA was then dissected both under direct and scopic vision with regular instruments. Discrimination of far structures was improved and precision and safety during LIMA dissection was enhanced as compared to direct vision alone. In these 12 patients, LIMA was dissected over a 15.6 ± 2.0 cm, for a mean cutaneous incision of 9.9 ± 1.5 cm. The mean operative time was 222.6 ± 55 minutes. No conversion to sternotomy and no reoperation were necessary.
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Comment
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Dissection of the LIMA and its anastomosis to the left anterior descending coronary artery through a small left anterior thoracotomy, without cardiopulmonary bypass, is now commonly accepted as a good alternative to sternotomy and cardiopulmonary bypass [1, 2]. Most of the surgeons use an adapted rib retractor, which lifts up the superior ribs and pushes down the inferior ribs [2, 3]. In that way, a tunnel is created and the LIMA can be visualized in its axial view. Instruments are entered through the thoracotomy and allow for an easy dissection of the few distal centimeters of the LIMA. But as the harvesting is prolonged to its proximal part, distant from the cutaneous opening, vision becomes limited and dissection is more difficult. Moreover, as the instrument’s direction is the same as the visual axes, precision in movement, grasping, section, and cautery is reduced and safety during LIMA harvesting becomes restrained.
Totally endoscopic harvesting of the LIMA is an alternative to direct vision dissection through the submammary thoracotomy [4], but standard rigid thoracoscopes are held by a third hand, which hinder the operative field and often focus on different areas than the one that is targeted by the surgeon. We use an adapted gastroscope in our minimally invasive thoracic procedures, including minimally invasive direct coronary artery bypass procedures. This instrument offers many advantages over the rigid scopes. The tip of the gastroscope is introduced into the chest cavity through a lateral port that will serve later for the thoracic drain, but because of the flexibility of the instrument, it can also be entered through the thoracotomy itself. The flexible tube is placed on the lateral side of the opening, in a manner that it is not in the same axes and never in conflict with the other instruments or the operator’s direct view. The grip lays on the patient’s abdomen, distant from the thoracic opening, and thanks to the remote control system placed into it, the extremity of the scope can be moved in every direction, without interfering with the direct view or the surgeon’s hands. Cold light being at the tip of the scope, the operative field is perfectly illuminated. The camera is at the extremity of the scope and offers a better definition as compared to fiberoptic transmitted images. In situ washing thanks to an irrigation canal avoids repeated removal from the thoracic cavity, which is frequent in conventional endoscopic procedures and has proved to be time consuming [5]. These repeated maneuvers compel to look for the marks at each time the camera is reintroduced into the thoracic cavity. Finally, the suction canal allows for smoke aspiration during electrocautery.
These several consistent advantages make the modified gastroscope particularly indicated in minimally invasive direct coronary artery bypass procedures.
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References
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Calafiore A.M., Teadori G., Di Giammarco G., et al. Minimally invasive coronary artery bypass grafting on a beating heart. Ann Thorac Surg 1997;63:S72-S75.
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Mariani M.A., Boonstra P.W., Grandjean J.G., van der Schans C., Dusseljee S., van Weert E. Minimally invasive coronary bypass grafting without cardiopulmonary bypass. Eur J Cardio-thorac Surg 1997;11:881-887.[Abstract]
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Qaqish N.K., Pagni S., Spence P.A. Instrumentation for minimally invasive internal thoracic artery harvest. Ann Thorac Surg 1997;63:S97-S99.
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Nataf P., Lima L., Benarim S., et al. Video-assisted coronary bypass surgery; clinical results. Eur J Cardio-Thorac Surg 1997;11:865-869.[Abstract]
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Abstract
Introduction
