Asian Cardiovasc Thorac Ann 1998;6:85-87
© 1998 Asia Publishing EXchange Pte Ltd
Minimally Invasive Vein Harvest for Coronary Artery Bypass Surgery
Li Chiu Yang, MD,
Lai Shiau Ting, MD,
Yu Tarng Jenn, MD,
Wang Jih Shiuan, MD
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Division of Cardiovascular Surgery Department of Surgery National Yang Ming Medical College and Veterans General Hospital Taipei, Taiwan
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For reprint information contact:Li Chiu Yang, MDDivision of Cardiovascular Surgery, Dept. of Surgery National Yang Ming Medical College and Veterans General Hospital 201 Sec 2 Shih Pai Road Taipei, Taiwan ROC Tel: 886 2 2875 7495 Fax: 886 2 2875 7656 Email:cyli{at}vghtpe.gov.tw
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ABSTRACT
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Between October 1996 and August 1997, 56 endoscopic vein harvests were performed with video monitoring. Incisions of 2 to 3 cm in length were made at the groin and above or below the knee. The harvested veins were used for coronary artery bypass grafting. The complication rate was 1.8%. The average hospital stay for patients undergoing the endoscopic procedure was 7.2 days. All incisions had healed well at the 12-week follow-up. Endoscopic saphenous vein harvest provides a minimally invasive alternative to the open procedure. It gives a good cosmetic result, promotes early ambulation, and may reduce postoperative pain.
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INTRODUCTION
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Mastery of laparoscopic skills and advances in technology in both general and thoracic surgery have shown advantages over conventional open surgery. Such advantages have led to the growth of minimally invasive techniques and instrumentation for cardiovascular surgery. In coronary revascularization, the saphenous vein is often used as a graft to bypass occluded coronary arteries. The standard technique involves a long incision from the groin to the ankle to harvest the vein. Endoscopic vein harvest avoids this long painful incision and requires only two or three small incisions of 2 to 3 cm in selected access sites at the groin and above and below the knee. This report reviews our initial experience with this technique.
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MATERIAL AND METHODS
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Between October 1996 and August 1997, 56 patients underwent coronary revascularization in our medical center. There were 44 men and 12 women with a mean age of 65.4 years. Patient characteristics are summarized in Table 1
. We employed video-assisted endoscopic vein harvest in all cases. The above-knee approach for harvesting the vein was used in 42 patients, and the below-knee approach in 8 cases, without any prior selection bias.
Patients were placed in a supine position. The legs were elevated on blankets. Both hips were externally rotated and the knees were fixed. The skin was swabbed with chlorhexidine gluconate 4% in a surfactant solution and then with 10% povidone-iodine solution in alcohol. A disposable full-length paper and plastic drape covered the patient while leaving the operative sites of the chest and legs exposed.
A 2-cm to 3-cm incision was made medial to the knee to gain access to the saphenous vein and worked up toward the groin. The knee was the primary incision site but the groin was used as a secondary incision site when only the upper limb segment of great saphenous vein was harvested. Additional incision sites were used to facilitate dissection, ligation of side branches, and vessel identification in case of great anatomic variation. Blunt dissection of the subcutaneous tissues at these small incision sites was carried out to identify the saphenous vein and then continued over the anterior surface of the vein. Side branches were initially ligated through the skin incision. This open dissection after vessel identification created an initial plane for insertion of a Subcu dissector (Johnson & Johnson, Taipei, Taiwan) in conjunction with an endoscope into the incision site, which was advanced carefully along the anterior surface of the vein while observing the video monitor. When the limit of dissection dictated by the length of the instrument or anatomy was reached, the dissector was withdrawn and the endoscope was inserted into a Subcu retractor (Johnson & Johnson, Taipei, Taiwan) that provided visualization and maintained the larger working space along the path created by the dissector. The vessel dissector was inserted along the under surface of the retractor to reach the optical field and was placed around the saphenous vein. The vessel dissector was advanced to bluntly dissect the vein from surrounding tissues. Side branches were clipped and cut with 5-mm curved endoscopic scissors.
Once the entire desired length of the vein was free, a small incision was made at the groin or the ankle to ligate the saphenous vein and take down the segment by gentle traction. The wound was irrigated with normal saline and checked for hemostasis. The extremity of the wound was closed using a tapered needle with 2/0 absorbable suture for the subcutaneous layer and a cutting needle with4/0 absorbable suture for the subcuticular layer. The patient was heparinized and before cardiopulmonary bypass was initiated, the wound was dressed with sterile gauze and elastic bandage to prevent hematoma at the surgical site.
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RESULTS
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Video-assisted endoscopic vein harvest was successfully completed in 52 of the 56 patients. In the other 4 cases, conversion to an open approach for vein harvest was necessary because of anatomic variation of the saphenous veins that lay between the deep fascial layer and the muscular layer. The mean time for endoscopic vein harvest was 61.5 minutes (range, 28 to 81 minutes). As more experience was gained with the technique, the time was reduced to between 10 and 20 minutes. The mean vein length was 37.2 cm (range, 25 to 52 cm). Only one leak was found in a vein graft, which was longitudinally repaired with 7/0 polypropylene suture. The patency of all vein grafts was acceptable. One minor complication occurred in the early postoperative period; one patient experienced hematoma at the incision site in the groin area, which was resolved before discharge. The average hospital stay was 7.2 days (range, 6 to 8.5 days). At the 12-week follow-up, all incisions had healed well with good cosmetic results.
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DISCUSSION
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Video-assisted endoscopic vein harvest is an emerging procedure that is gaining acceptance in spite of its technical difficulty. In the open procedure for vein harvesting, a long incision is made from the groin to the ankle to expose and remove the saphenous vein. Many patients suffer more postoperative pain from this long extremity wound than from the chest incision for coronary artery bypass grafting, which may delay ambulation. Delayed wound healing associated with wound dehiscence, cellulitis, lymphangitis, and edema not only limits patient mobility but prolongs hospital stay.1,2 To prevent harvest-site complications, careful selection of the donor extremity, meticulous closure of all layers, and avoidance of large skin flaps are important factors.3 Some published studies reported the incidence of extremity wound complications to be 12.9% to 24.3%.1,2,4 The average hospital stay for wound complications was 32.6 days.1 In spite of adherence to the recommendations, the incidence of wound com-plications from standard vein harvest in our center was 13.2% and the average hospital stay for wound complications was 31.5 days.3
In the endoseopic procedure for harvesting saphenous vein, a long incision can be avoided and 2 to 3 small incisions are usually sufficient. Additional incisions may be made to prevent the development of large flaps, particularly in individuals with anatomic variations of the great saphenous veins. In our study, one patient suffered hematoma at the incision site giving a 1.8% incidence of complications. The length of hospital stay after the endoscopic procedure was shorter than after the open procedure by an average of 4.3 days. Although there is a lack of prospective data regarding whether this endoscopic procedure is associated with less postoperative pain in the extremity wound, it seems reasonable to assume that the early ambulation and reduced hospital stay implies less pain.
The main criticism of the endoscopic approach concerns the quality of the vein graft. A number of studies have suggested that the best procedure is the no-touch dissection technique.5,6 In our center, we always ensure gentle handling of the saphenous vein and there has been no graft failure to date. Histopathological examinations showed all vein specimens were satisfactory. As the endoscopic approach is very attractive to the patient, we consider that minimally invasive endoscopic vein harvest is likely to become the preferred technique.
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REFERENCES
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ABSTRACT
INTRODUCTION
