Ann Thorac Surg 2003;76:1749-1750
© 2003 The Society of Thoracic Surgeons
How to do it
Harvesting the inferior epigastric artery through a transverse suprapubic incision
Bruno da Costa Rocha, MDa,b*,
José Ernesto Succi, MDb,
Renato Bauab Dauar, MDb,
Alberto Takeshi Kiyose, MDb,
Luiz Boro Puig, MDa,
Sérgio Almeida de Oliveira, MDb
a Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
b , and Hospital Bandeirantes, São Paulo, Brazil
Accepted for publication February 15, 2003.
* Address reprint requests to Dr Rocha, 408 Alves Guimarães Street, São Paulo, São Paulo, Brazil, 05410-000
e-mail: codecorltda{at}aol.com
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Abstract
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The inferior epigastric artery has been used as an alternative arterial conduit in coronary artery bypass graft surgery. Its harvesting requires a single or double, long abdominal paramedian incision that is technically difficult and does not yield a good cosmetic result. We describe an alternative new approach to one or both inferior epigastric arteries through a transverse suprapubic cosmetic incision.
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Introduction
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The use of the inferior epigastric artery (IEA) as an arterial conduit for coronary artery bypass grafting (CABG) was initially described by Puig and colleagues in 1988 [1]. Since then, it has been used as an alternative conduit in CABG [2]. The conventional surgical approach to access the IEA through a paramedian or an infraumbilical incision has potential morbidity [2, 3] and unsatisfactory cosmetic results [4]. The transverse suprapubic incision has the advantage of allowing the dissection of both inferior epigastric arteries simultaneously. In addition, this incision is in accordance with the recent trend toward minimally invasive approaches in cardiac surgery [5]. Furthermore, the transverse suprapubic incision offers better cosmetic results. Here we describe a new surgical technique: the dissection of the IEA through a transverse suprapubic cosmetic incision in patients undergoing a complete CABG.
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Technique
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Twenty-two patients referred for CABG between March and November 2002 were selected to receive a complete myocardial revascularization using internal thoracic arteries, radial arteries, and IEAs. Nineteen patients (86.4%) were men and the average age was 52 years (range 29 to 76 years). Patients with clinical evidence of obstructive aortoiliac disease were excluded. Two female patients exhibited a previous horizontal Cesarean scar, and 1 male patient had a bilateral inguinal scar due to hernia correction. We obtained written informed consent from all patients enrolled.
General anesthesia complemented by thoracic epidural analgesia was used, and the patients were positioned the usual way for draping. The skin was demarcated for a Pfannenstiel incision [6], which is a horizontal, slightly upward curved incision 2 cm above the pubis and symmetrical around the linea alba. When just one IEA was used, the incision started from the ipsilateral angle and extended until the median line. In 3 patients, we dissected the right IEA from the right side and in 17 the left IEA from the left side and others from both sides. The length of the skin incisions ranged from 5 to 15 cm (mean ± SD, 9.3 ± 2.7 cm). The widest incision was in a female patient who had had a previous Cesarean delivery whose scar required complete excision. The anterior rectum muscle (ARM) sheaths and the linea alba were transected and reflected upward approximately 5 to 10 cm. Then the freed anterior rectum muscle was retracted medially from its lateral border with a Gosset retractor exposing the preperitoneal field. After that, the iliohypogastric nerve was identified and protected with a "do-not-touch" technique. At the lower portion of the ARM next to its pubic insertion, the fascia transversalis was opened giving access to the IEA. At this point, the IEA can be easily isolated in the midst of the fat at a level corresponding to the lateral border of the ARM. Information about the quality of the graft regarding its width, length, and the eventual presence of arteriosclerosis was obtained. The harvesting was completed using delicate dissection scissors and ligature of the branches with HemoClip LT100/LT200 (Ethicon EndoSurgery Inc, Cincinatti, OH).
At the IEA origin from the external iliac artery, ligating the external spermatic and the pubic branches was necessary. Upward dissection continued under the ARM with the help of a plastic surgery retractor equipped with a lamp for illumination (Edlo Inc, Rio Grande do Sul, Brazil). In this stepwise approach, it was possible to progress under the ARM to 4 to 5 cm beyond the linea arcuata (Fig 1).
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Fig 1. The right inferior epigastric artery pedicle in the midst of preperitoneal fat giving branches to the posterior aspect of the rectus muscle and the artery relationship to the linea arcuata.
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The length of the harvested IEA ranged from 6 to 15 cm (mean ± SD, 9.3 ± 2.6 cm) with an internal proximal diameter from 1.3 to 4.0 mm (2.58 ± 0.6 mm) and a distal diameter from 1.5 to 3.5 mm (2.2 ± 0.48 mm). Harvesting time was 10 to 45 minutes (21.1 ± 7.3 minutes). The artery was removed after partial (2 mg/kg) systemic infusion of heparin and kept in papaverine solution (1.0 mg/mL).
The incision was protected with gauze pads until the infusion of protamine had been completed at the end of the CABG. The rectum muscle sheath was sutured with a running 1-0 polygalactin suture. Drainage was not performed in any patient.
In 20 patients, the IEAs were Y-grafted to the left internal thoracic artery and in 2 cases directly from the ascending aorta. Distal anastomoses were made with a running stitch of 8-0 polypropylene suture to the lateral wall vessels. One to five distal anastomoses per patient were performed (mode ± SD, 3.0 ± 1.0). The off-pump coronary artery bypass technique was used in 15 patients (68.2%).
During recovery and follow-up, the patients received analgesia medication according to the respective institution’s postoperative analgesia protocols. The patients were evaluated according to a pain score (0 to 10 points) on the first and second postoperative days. Localized pain in the abdominal incision ranked between 0 and 4 points (mean ± SD, 0.5 ± 1.0). These values were lower than 0 to 5 points (2.14 ± 1.7) for the thoracic incision (p = 0.039). The patients reported no abdominal discomfort during walking.
During 4 to 32 weeks follow-up, no wound infection or incisional hernias were observed. Most importantly, all patients were pleased with the cosmetic results of the transverse suprapubic incision.
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Comment
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The technique reported here is derived from the well-known Pfannenstiel incision for Cesarean delivery used by almost all surgeons during residency training. Interestingly, in 2 female patients, the harvesting was easily done through an old Pfannenstiel scar. Despite the great advantage of allowing access to both IEAs, one limitation was the length of IEA dissection, normally 4 to 5 cm above linea arcuata allowing a final length from 6 to 15 cm (mean ± SD, 9.3 ± 2.6 cm); nonetheless, the dissection length was similar to values reported for longitudinal incisions [2–4]. These lengths were well suited for free grafts to the diagonal artery, or T grafts from left internal thoracic artery to lateral wall arteries.
The alternative to this technique is the video-assisted dissection proposed by Hoenig and associates [5] that may result in longer harvesting times, longer learning curves, and demands expensive instrumentation.
We think most surgeons are familiar with this technique, allowing it to be easily reproduced. Besides yielding excellent cosmetic results, this procedure is also, as far as we could observe, less painful.
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References
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- Puig L.B., Ciongolli W., Cividanes G.V.L., et al. Artéria epigástrica inferior como enxerto livre. Uma nova alternativa na revascularização do miocárdio. Arq Bras Cardiol 1988;50:259-261.
- Vicent J.G., Son J.A.M., Skotnicki S.H. Inferior epigastric artery as conduit in myocardial revascularization: the alternative free arterial graft. Ann Thorac Surg 1990;49:323-325.[Abstract/Free Full Text]
- Puig L.B., Sousa A.H.S., Cividanes G.V.L., et al. Eight years experience using the inferior epigastric artery for myocardial revascularization. Eur J Cardiothorac Surg 1997;11:243-247.[Abstract/Free Full Text]
- Mills N.L., Everson C.T. Technique for use of the inferior epigastric artery as a coronary bypass graft. Ann Thorac Surg 1991;51:208-214.[Abstract/Free Full Text]
- Hoenig S.J., Hodin R.A., Novak G., Cohn W.E. Videoscopic harvest of the inferior epigastric artery. Ann Thorac Surg 1999;67:565-566.[Abstract/Free Full Text]
- Pfannenstiel J.H. Uber die Vortheile des supra symphysarean Fascienquerschnitts fur die gynakologischen Koliotomien, zuglein lin Beitrag zu der Indicationsstellung der Operationswege, Samlung Klinischer Vortrage. Gynakologie Leipzig 1900;268:1735-1756.
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Abstract
Introduction
