Asian Cardiovasc Thorac Ann 2001;9:3-6
© 2001 Asia Publishing EXchange Pte Ltd
Harmonic Scalpel: Initial Experience
Anil Bhan, MCh,
Shiv Kumar Choudhary, MCh,
Manuj Saikia, MS,
Rajesh Sharma, MCh,
Panangipalli Venugopal, MCh
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Department of Cardiothoracic and Vascular Surgery Cardiothoracic Sciences Centre All India Institute of Medical Sciences New Delhi, India
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For reprint information contact: Anil Bhan, MCh Tel: 91 11 686 1123 Ext. 4835 Fax: 91 11 686 2663 email: bhan{at}medinst.ernet.in Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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Abstract
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A Harmonic Scalpel was used to harvest arterial conduits in 80 patients undergoing coronary bypass grafting (group 1). Another 80 patients had electrocautery (group 2). Off-pump beating heart coronary grafting was performed in 24 patients in group 1 and 18 in group 2; these patients underwent coronary angiography. Moderately hypothermic cardiopulmonary bypass was used in all others. There were 134 arterial conduits (78 left internal mammary arteries, 14 right internal mammary arteries, and 42 radial arteries) in group 1, and 141 arterial conduits (80 left internal mammary arteries, 11 right internal mammary arteries, and 50 radial arteries) in group 2. The number of hemoclips used, postoperative blood loss, and homologous blood product requirements were significantly less in group 1. One patient in group 1 and 3 in group 2 required reoperation for excessive bleeding. Postoperative angiograms in 24 patients in group 1 (37 arterial conduits) revealed 100% graft patency. In group 2, 1 of 18 patients who had angiography showed marked narrowing of the left internal mammary artery in the distal third, attributable to electrocautery injury. The Harmonic Scalpel was a useful, safe, and probably superior alternative to electrocautery for arterial harvesting.
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Introduction
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After its initial use by Kolesov and Potashov1 in 1965 and subsequent popularization by Green and colleagues,2 the internal mammary artery (IMA) conduit has become the gold standard for coronary artery bypass grafting (CABG). Since the convincingly superior results with IMA grafts, other arterial conduits have been used more frequently. However, a prerequisite for the best results in terms of the patency is a well-harvested conduit. Electrocautery injury could be an important factor in suboptimal results with arterial conduits. Most surgeons use electrocautery to dissect IMA and other arterial grafts. Electrocautery can cause heat injury that manifests in the immediate or late postoperative period.3,4 To overcome this problem, the ultrasonic Harmonic Scalpel (Ethicon EndoSurgery, Cincinnati, OH, USA) has been used as an alternative.5–9 We report our early experience with the Harmonic Scalpel (HS) in CABG.
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Patients and Methods
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In 80 consecutive patients (aged 35 to 72 years) undergoing CABG from August 1998 through February 1999 by the same surgeon (AB), the HS was used to harvest arterial conduits (group 1). Conventional hypothermic cardiopulmonary bypass (CPB) with antegrade cold hyper-kalemic cardioplegia was used in 56 patients. In 24 patients, distal anastomoses were performed on a beating heart without CPB. There were 134 arterial conduits harvested (78 left IMAs, 14 right IMAs, and 42 radial arteries). All left IMAs were anastomosed to the left anterior descending artery, 11 right IMAs were anastomosed to the right coronary artery, and 3 were anastomosed to the posterior descending artery. All radial artery grafts were anastomosed to either a diagonal or obtuse marginal artery.
A retrospectively studied group of 80 consecutive CABG patients (aged 42 to 78 years), operated upon by the same surgeon from March 1998 through July 1998, in whom electrocautery (energy level, 20 watts) was used to dissect the arterial conduits, served as controls (group 2). There were 141 arterial grafts (80 left IMAs, 11 right IMAs, and 50 radial arteries). In 18 of these patients, the procedure was performed without CPB; conventional hypothermic CPB was used in the others.
The HS consists of 3 major components: a generator, a handpiece or transducer, and a foot switch. A GEN 32 generator with a GEN 03 foot switch and a HPTUV handpiece were used in this study. The handpiece has different attachments or probes fitted to its distal end for cutting and coagulation. A sharp hook or a dissecting hook, both of 10 cm in length and 5 mm in diameter, were used most often. The generator produces 55.5-kHz electric signals that are transmitted via coaxial cable to the handpiece that converts them into ultrasonic energy for coagulation of tissue.10,11 Hemostasis occurs when the tissue couples with the vibrating tip as the tissue is incised. The coupling causes collagen molecules within the tissue to vibrate and become denatured, forming a coagulum. Thus, the device allows coagulation and division of tissues with low heat (< 100°C) and minimal smoke.
For arterial harvest, the generator was set at level 3, as recommended by the manufacturer. To harvest the radial artery, the HS was used to cut the tissues down to the brachioradialis muscle after the initial skin incision with a surgical knife. The brachioradialis muscle was lifted off with the HS. The radial artery was identified and parallel incisions were made on both sides with the HS in cutting mode. On encountering any branches, the HS was changed to coagulation mode and the blunt edge of the hook was kept in contact with the branch until it blanched. It was then cut with the sharp edge of the hook (Figure 1
). The artery was transected at both ends and gently dilated with papaverine solution (1 g•L–1). Calcium channel blockers were not used postoperatively. The IMA was harvested after incising the pleura, except in 2 patients with adhesions between the lung and the chest wall. The procedure was started with 2 parallel incisions on either side of the IMA by electrocautery. A plane was established in the middle using the HS and dissection was carried out in both directions. Branches were treated as for the radial artery. However, a clip was preferred on major branches of the IMA. After harvesting, gentle dilation was carried out with papaverine solution.
Time taken to harvest the grafts, the number of titanium hemoclips used, homologous blood requirement, post-operative drainage, and the reexploration rate were recorded. When the radial artery was harvested, the incidence of numbness in the hand was also noted. All patients undergoing CABG without CPB were subjected to coronary angiography before discharge from the hospital.
Continuous or interval-related variables were expressed as mean ± standard deviation. Categorical variables were expressed as percentages. The Mann-Whitney U test, chi-squared (2%) test, and FisherÕs exact test, were used to compare the 2 groups.
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Results
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Both groups were comparable in respect of preoperative and perioperative variables (Table 1). There was one operative death in group 1 due to disseminated intra-vascular coagulation. There was no mortality in group 2. Intraoperative and postoperative variables are shown in Table 2. Clips were used mainly on the satellite veins at both ends of the radial artery. Significantly more clips were used in group 2. Mean postoperative blood loss and homologous blood requirement were less in group 1. One patient in group 1 required reoperation for excessive bleeding from the suprasternal vein. In the 3 patients in group 2 who required reoperation, bleeding was from a branch of the left IMA in 1, and from the sternal edges in 2. The harvesting time in group 2 was not available as these patients were analyzed retrospectively. There was no sensory deficit in the distribution of the superficial radial nerve in group 1, whereas 7 patients in group 2 complained of some sensory loss in the hand.
The quality of grafts harvested with the HS was good. There was no instance of IMA spasm or injury. Post-operative angiograms in 24 patients from group 1 (37 arterial grafts; 24 left IMAs, 3 right IMAs, and 10 radial arteries) revealed 100% graft patency with no localized constriction or spasm. One patient in group 2 showed marked narrowing of the left IMA (string sign) in the distal third, attributable to electrocautery injury (Figure 2).
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Figure 2. Postoperative angiogram in lateral view, showing a left internal mammary artery graft (arrows). The internal mammary artery is markedly narrowed in the distal third (string sign). The anastomosis to the left anterior descending artery is patent.
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Discussion
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We have been concerned about electrocautery injury during harvesting of arterial conduits. In recent postoperative angiographic studies, we encountered instances where such injury was strongly suspected. This prompted consideration of an ultrasonic device. However, the available literature on use of the HS for harvesting arterial conduits was scant.5–9 In this experience, the HS proved to be a useful alternative to electrocautery, with the advantages of fast, safe, and spasm-free harvesting with minimal use of hemoclips for arterial branches. Post-operative blood loss and requirement for homologous blood products were significantly less with this technique, however, as only 18 patients (22.5%) in group 2 underwent surgery without CPB, compared to 24 (30%) in group 1, this observation must be considered tentative. The absence of neurological symptoms in the hand after radial artery harvest was a distinct added advantage.
In addition to producing minimal smoke, the HS is less liable to cause thermal injury to arterial conduits. With the HS, tissue temperature was shown to be less than 80°C, compared to more than 300°C with electrocautery.6 Coulson and Bakhshay12 found a rise of 1°C or less in tissue 0.5 cm away from an activated HS. The advantages of the HS in radial artery harvesting could be more substantial because graft occlusion (possibly secondary to spasm and traumatic harvesting) led to the initial abandonment of this artery as a conduit in the early 1970s.4
Some difficulties were encountered during IMA harvesting when the chest wall was rigid and had limited mobility. It was suggested to the manufacturers that modifying the tip of the handpiece and giving it an angulation of approximately 45 degrees would facilitate harvesting in such circumstances. A word of caution: after IMA harvest, the white coagulum generated in the branches of the IMA might move into the lumen of the artery, and at times, we were surprised to recover this material after allowing the IMA to bleed freely. Therefore, it is recommended that all harvested IMAs should be allowed to bleed freely to flush out any coagulum. This is of the utmost importance as embolism of this material could prove harmful.13
In patients with excessive fat deposits on the surface of the heart, the HS was used to explore the native artery without fear of injuring the vessel or causing arrhythmias. An additional advantage of the HS over electrocautery could be the absence of interference with electrocardio-graphic monitoring, and thus with a functioning intraaortic balloon pump. It was concluded that the HS could be a useful tool in CABG. With the possibility of superior conduits harvested with this device, improved patency of such grafts is anticipated.
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References
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Kolesov VI, Potashov LV. Operations of the coronary arteries [Russian]. Exep Chirurgia 1965;2:3–8.
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Green GE, Stertzer SH, Reppert EH. Coronary arterial bypass grafts. Ann Thorac Surg 1968;5:443–50.[Medline]
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Lehtola K, Verkkala K, Jarvinen A. Is electrocautery safe for internal mammary artery (IMA) mobilization? A study using scanning electron microscopy. Thorac Cardiovasc Surg 1989;37:55–7.[Medline]
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Mills NL. Arterial grafts for coronary artery bypass. Recent Adv Card Surg 1997;9:195–216.
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Tanemoto K, Kanaoka Y, Murakami T, Kuroki K. Harmonic Scalpel in coronary artery bypass surgery. J Cardiovasc Surg (Torino) 1998;39:493–5.[Medline]
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Isomura T, Suma H, Sato T, Horii T. Use of the Harmonic Scalpel for harvesting arterial conduits in coronary artery bypass. Eur J Cardio-thorac Surg 1998;14:101–3.[Abstract/Free Full Text]
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Posacioglu H, Atay Y, Cetindag B, Saribulbul O, Buket S, Hamulu A. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998; 65:984–5.[Abstract/Free Full Text]
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Ohtsuka T, Wolf RK, Hiratzka LF, Wuring P, Flege JB Jr. Thoracoscopic internal mammary artery harvest for MICABG using the Harmonic Scalpel. Ann Thorac Surg 1997;63:S107–9.
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Wolf RK, Ohtsuka T, Flege JB Jr. Early results of thoracoscopic internal mammary artery harvest using an ultrasonic scalpel. Eur J Cardio-thorac Surg 1998;14: S54–7.[Abstract/Free Full Text]
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Anarlal JF. The experimental development of an ultrasonically activated scalpel for laparoscopic use. Surg Laprosc Endosc 1994;4:92–9.
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Laycock WS, Trus TL, Hunter JG. New technology for the division of short gastric vessels during laparoscopic Nissen fundoplication. Surg Endosc 1996;19:71–3.
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Coulson AL, Bakhshay S. The use of Harmonic Scalpel in minimally invasive coronary artery bypass surgery. Surgical Rounds 1997;20:52–6.
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Talwar S, Bhan A, Sharma R, Venugopal P. Harmonic Scalpel: a word of caution. Ann Thorac Surg 2000;69: 1643–4.[Free Full Text]
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Abstract
Introduction
