Asian Cardiovasc Thorac Ann 2001;9:246-247
© 2001 Asia Publishing EXchange Pte Ltd
Minimally Invasive Saphenous Vein Harvesting Using Conventional Instruments
Vijay Agarwal, MS,
Surendra K Agarwal, MCh,
Nirmal K Gupta, MCh,
Ashok K Srivastava, MCh
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Department of Cardiovascular & Thoracic Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India
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For reprint information contact: Ashok K Srivastava, MCh Tel: 91 522 44 0004 Ext. 2204 Fax: 91 522 44 0017 email: ashok{at}sgpgi.ac.in Department of Cardiovascular & Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India.
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Abstract
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A technique to harvest saphenous vein using conventional surgical instruments is described. The method carries the advantage of dissection under direct vision without trauma to the vein.
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INTRODUCTION
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The importance of the venous conduit and the morbidity associated with its harvesting cannot be overlooked. Minimally invasive techniques to harvest saphenous vein have been found to be associated with less morbidity. We describe a simple technique of saphenous vein harvesting using conventional instruments with minimal vein handling, which is useful when endoscopic instruments are unavailable. This method avoids the use of a Mayo vein stripper as described in most harvesting techniques.1,2
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TECHNIQUE
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The technique involves multiple 3- to 4-cm longitudinal incisions. The first incision is made above the medial malleolus and the saphenous vein is identified. A subcutaneous tunnel is created as far as possible up to a Langenbeck retractor (Aesculap AG, Tuttingen, Germany) held by an assistant, with an overhead light focused on the skin over the tunnel (Figure 1
). The vein is similarly dissected on the posterior aspect as no branches are found on the undersurface. Thus, the vein is freed on the anterior and the posterior surfaces, leaving it attached to the surrounding tissues only by tributaries. A gentle tug is applied to the exposed vein near the ankle, which makes the vein prominent so that the skin above it can be marked for the next incision. Through the second incision, a similar subcutaneous tunnel is made, aiming to connect with the tunnel from the ankle. This frees the vein along its entire length. The side branches are ligated or clipped under vision. The vein lies free and can be transected distally and pulled out via the proximal incision (Figure 1). After achieving hemostasis, the wound is closed with 1/0 Vicryl and subcuticular stitches of 3/0 Vicryl (Ethicon Division of Johnson & Johnson Ltd, Aurangabad, India).
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DISCUSSION
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Minimally invasive saphenous vein harvesting reduces postoperative complications at the site of explantation, and affects vascular reactivity in the same manner as the conventional method.3 Besides producing cosmetically more acceptable scars, there is a lower incidence of wound infection.4 Tran and colleagues5 showed that the tunneling method resulted in better preservation of endothelial architecture than the open harvest technique, suggesting that factors other than direct handling during vein harvest are also important. Due to the lack of availability of endoscopic instruments in most centers in developing countries, locally available conventional instruments have been tried. A laryngoscope was tested as a retractor in one study.2 We used a conventional Langenbeck retractor with good results.
This method has several advantages: it avoids the use of a vein stripper, therefore averting possible trauma, especially at the junction of branching; there is almost no handling of the vein; and a longitudinal incision is employed instead of the commonly used transverse incision. The longitudinal incision has the advantage of allowing extension of the incision proximally to open the skin bridge if difficulty is encountered in lengthening the tunnel in obese individuals or those with veins that are adherent and difficult to dissect. A transverse incision commits the surgeon to pursue the technique, and on conversion to the conventional method, it will result in a T-shaped cosmetically ugly scar.2 With experience, the length of the single skin incision can be decreased, producing a longer length of intervening skin bridge.
We have used this technique in 41 patients. Most harvests have been below the knee, and the skin bridge between the 2 incisions varied from 8 to 12 cm, with individual incisions of 2.5 to 4.5 cm. The time taken to harvest the length of vein up to knee level, approximately 30 cm, was 10 to 20 minutes longer than the conventional method undertaken by the same surgeon. However, the smaller incisions required less time to close the leg. There have been no incidences of wound infection, hematoma, or need for conversion to the conventional method. It was also perceived that the patients experienced less pain postoperatively. For better vision under the tunnel, we are currently designing a reusable retractor with a long blade length and incorporating a light source.
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REFERENCES
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O'Regan DJ, Borland JA, Chester AH, Pennell DJ, Yacoub M, Pepper JR. Assessment of human long saphenous vein function with minimally invasive harvesting with the Mayo stripper. Eur J Cardio-thorac Surg 1997;12:428–35.[Abstract]
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Goel P, Sankar NM, Rajan S, Cherian KM. Use of direct laryngoscope for better exposure in minimally invasive saphenous vein harvesting. Eur J Cardio-thorac Surg 2000;17:182–3.[Abstract/Free Full Text]
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Rinia-Feenstra M, Stooker W, de Graaf R, Kloek JJ, Pfaffendorf M, de Mol BA, et al. Functional properties of the saphenous vein harvested by minimally invasive techniques. Ann Thorac Surg 2000;69:1116–20.[Abstract/Free Full Text]
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Meldrum-Hanna W, Ross D, Johnson D, Deal C. An improved technique for long saphenous vein harvesting for coronary revascularization. Ann Thorac Surg 1986; 42:90–2.[Abstract]
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Tran HM, Paterson HS, Meldrum-Hanna W, Chard RB. Tunnelling versus open harvest technique in obtaining venous conduits for coronary bypass surgery. Eur J Cardio-thorac Surg 1998;14:602–6.[Abstract/Free Full Text]
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Abstract
INTRODUCTION
