Ann Thorac Surg 2001;71:739-741
© 2001 The Society of Thoracic Surgeons
How to do it
Endoscopic vein harvesting with the aid of carbon dioxide insufflation
Malcolm J.R. Dalrymple-Hay, FRCSa,
Aiman Alzetani, FRCSa,
Robert Costa, FRACSa,
Sunil K. Ohri, FRCSa
a Wessex Cardiothoracic Center, Southampton General Hospital, Southampton, United Kingdom
Accepted for publication April 17, 2000.
Address reprint requests to Dr Dalrymple-Hay, Department of Cardiothoracic Surgery, Southampton General Hospital, Tremona Rd, Southampton SO16 6YD, UK
e-mail: mdh{at}btinternet.com
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Abstract
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Endoscopic harvesting of the long saphenous vein has been introduced to decrease the morbidity of obtaining venous conduit for coronary artery bypass grafting. Herein is described an endoscopic method using carbon dioxide insufflation into the tissues around the vein. This has several advantages; improved vision, no physical retraction required, easier development of tissue planes, and improved hemostasis.
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Introduction
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Despite the growing trend to use arterial conduit for coronary artery bypass grafting, venous conduit is still used in the majority of patients. The long saphenous vein is usually harvested using an open technique either with one long incision or with several shorter incisions, leaving skin bridges between [1]. Complication rates after long saphenous vein harvest vary widely, but an incidence as high as 24% to 44% [2, 3] has been reported. This results in significant morbidity, increased length of stay, and higher cost.
Endoscopic harvesting of the long saphenous vein has been introduced to decrease the morbidity of obtaining venous conduit [4, 5]. It results in less postoperative leg pain and has been shown to result in a significant decrease in wound infections [6]. In addition, it is cosmetically a more attractive option.
Descriptions of endoscopic vein harvesting techniques using Ethicon equipment have been described (Ethicon, Edinburgh, Scotland). We have, however, chosen to use the VasoView equipment (Origin USA, Menlo Park, CA) because it allows insufflation of carbon dioxide into the tissue around the vein. This has several advantages. It improves the visibility around the vein, thus aiding in the dissection. No physical retraction is required. Insufflation of carbon dioxide allows for easier development of tissue planes, particularly digital manipulation of the skin over the vein under direct vision allows the pressure of the carbon dioxide in the tissues to separate the vein and its branches from surrounding tissue; Therefore, trauma to the vein is minimal. In addition, the pressure of the carbon dioxide reduces bleeding from venules and capillaries. We describe our technique and initial results.
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Technique
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The majority of the equipment, a camera, video monitor, light source, and carbon dioxide insufflator are commonly used in other endoscopic procedures and hence, are available in most units. The specific instruments include a balloon dissector cannula (integrated blunt dissector and scope incorporating an inflatable balloon), a vein cradle (integrated scope and vein cradle), a blunt tip trocar or port, and endoscopic bipolar scissors (Fig 1).
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Fig 1. Origin VasoView Instrumentation. (A) 1. Scope with vein cradle (seen magnified in inset C). 2. 10-mm telescope. 3. Bipolar endoscopic scissors (seen magnified in inset B). 4. 12-mm blunt tip trocar. 5. Cone dissector with an inflatable balloon near tip (seen magnified in inset B).
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The position of the long saphenous vein behind the knee is marked. With the patient supine, the knee is externally rotated 15 degrees. The surgeon stands on the side of the donor leg with the video screen opposite. A 2-cm incision is made over the vein and the vein dissected to its adventitia. A 12-mm blunt tip trocar is mounted onto the balloon dissection cannula. The balloon dissection cannula is inserted and the first 4 to 5 cm of vein toward the groin dissected by sliding the blunt translucent tip along the anterior aspect of the vein. The premounted trocar is then railroaded over the balloon dissection cannula into the wound. The balloon on the end of the blunt tip trocar is inflated creating a gas tight seal just inside the wound. Carbon dioxide is then insufflated through a trocar port into the tissue at a pressure of 15 mm Hg. The balloon dissection cannula is again used to dissect the vein by sliding the blunt translucent tip (Fig 1) initially anterior then posterior to the vein. The vein tributaries are then dissected out using the same balloon dissection cannula under direct vision using digital manipulation through the skin. The pressure of the carbon dioxide allows the separation of the vein and its branches from the fat with very little trauma.
The whole length of the vein and its tributaries are mobilized, the balloon dissection cannula is withdrawn along the whole length off the vein, and at 2-cm intervals the balloon on the end is inflated. This enlarges the tunnel in which the vein is sitting. The vein cradle is then inserted. This consists of a scope with a cradle that is used to cup and manipulate the vein (Fig 2) and a port for insertion of rotatable bipolar scissors.
The vein lying in the enlarged tunnel is placed under traction using the cradle so that the branches can be divided using the bipolar scissors (Fig 3). The tributaries are all divided and under endoscopic vision the vein is delivered to the skin through a stab incision in the groin. It is tied, divided, and the mobilized length delivered through the knee incision.
If two lengths of the vein are required, the vein is divided at the knee; when further lengths are needed, the introduction port is removed and the process repeated through the same incision toward the ankle. The required length of vein is cannulated and the side tributaries dealt with in the preferred manner of the surgeon. Steristrips (Ethicon, Edinburgh, Scotland) are placed on the stab incisions and the knee incision closed with an absorbable suture when the protamine has been administered (Fig 4).
We have harvested vein in 25 patients using this technique at the Wessex Cardiothoracic Center, Southampton, UK. One vein was rejected due to varices. There were no wound complications. Four veins required suturing with 6-0 Prolene (Ethicon, Edinburgh, Scotland) to repair small holes tears not suitable for tying. The mean harvest times were 36, 44, and 67 minutes for one, two, and three lengths of vein, respectively. There were no conversions to an open technique.
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Comment
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This study demonstrates that the long saphenous vein can be harvested using an endoscopic technique. Macro-scopically, the quality of vein is similar to an open technique. As was expected, the harvest time was long for those procurements early in our experience; it has decreased as our expertise has improved and we anticipate that it will approach the time scale of the open technique.
No formal postoperative pain assessment was made; however, all patients were able to fully flex their leg on the morning after operation. The precise role of endoscopic vein harvesting remains to be defined and several prospective randomized trials are underway. We believe that endoscopic vein harvesting offers an attractive alternative to the open technique and that carbon dioxide insufflation offers advantages over alternative endoscopic techniques.
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References
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Slaughter M., Gerchar D., Pappas P. Modified minimally invasive technique for greater saphenous vein harvesting. Ann Thorac Surg 1998;65:571-572.[Abstract/Free Full Text]
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Lumpsen A., Eaves F., Ofenloch J., Jordan W. Subcutaneous, video assisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg 1996;4:771-776.[Medline]
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Wipke-Tevis D., Stotts N., Skov P., Carriereri-Kohlman V. Frequency, manifestations, and correlates of impaired healing of saphenous vein harvest incisions. Heart Lung 1996;25:108-116.[Medline]
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Lutz C., Schlensak C., Lutter G., et al. Minimally invasive, video assisted vein harvesting for cardiac and vascular surgical procedures. Eur J Cardiothoracic Surg 1997;12:519-521.[Abstract/Free Full Text]
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Cable D., Dearani J. Endoscopic saphenous vein harvesting: minimally invasive video-assisted saphenectomy. Ann Thorac Surg 1997;64:1183-1185.[Abstract/Free Full Text]
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Allen K., Griffith G., Heimansohn D., et al. Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial. Ann Thorac Surg 1998;66:26-32.[Abstract/Free Full Text]
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Abstract
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