Eur J Cardiothorac Surg 1998;14:S93-S99
© 1998 Elsevier Science NL
Endoscopic harvest of saphenous vein graft for coronary artery bypass grafting: Saitama–Olympus technique
Shunei Kyo*,
Koichi Kaneko,
Yoshinori Nishikiori,
Ryoichi Konou,
Hiroshi Hojo,
Ryozo Omoto
Department of Surgery, Saitama Medical School, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-04 Japan
* Corresponding author. Tel.: +81 492 761330; fax: +81 492 959232; e–mail: eikyo501 @saitama-med.ac.jp
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Abstract
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Objective: This study was undertaken to examine the clinical feasibility of a newly developed video-assisted endoscopic technique (Saitama–Olympus technique) to harvest saphenous vein graft (SVG) in 40 CABG patients. Methods: There were 37 males and three females with an average age of 59±11 years. The special instruments developed were optical sheath, solid dilators, tunnel retractor, vessel dissector, GCC forceps which were utilized in conjunction with the thoracoscopic surgery system (Olympus, Tokyo, Japan). The course of the saphenous vein (SV) was marked on the skin prior to operation. SV was identified in the femoral region with a 4-cm skin incision and dissected with an open technique. The anterior surface of SV was dissected for 30 cm by the optical sheath mounted on the endoscope. Then another 4-cm skin incision above SV was placed in the popliteal region, resulting in a subcutaneous space over the SV. The subcutaneous space was then dilated and maintained with the tunnel retractor which has an endoscope channel at the top. With this system SV was visualized stably by endoscope without any assistance. All side branches were dissected and divided with the vessel dissector. When longer SVG is required, the same procedure was extended to the ankle with additional one or two skin incisions. Results: SV was easily harvested in all patients with spending 15–84 min. The average number of skin incisions was 2.4±0.5 and the average length of the harvested SVG was 41±12 cm. The average number of bypassed grafts was 3.4±1.0 with use of left internal mammary artery (IMA) in 31 patients. The average operation time was 272±52 min, there were no significant prolongation relating to endoscopic SVG harvesting. The remainder of SVG in each patients was pathologically examined and there were no evidence of intimal injury. There were no major wound complications during the average follow-up of 10±4 months and this technique seemed to be advantageous for patients with less wound pain and better cosmetic appearance. Conclusions: The Saitama–Olympus technique to endoscopically harvest the SV is a clinically feasible surgical technique with the unique potential of a significant reduction in morbidity and decreased wound scarring in CABG patients.
Key Words: Veins • Coronary disease • Surgery • Endoscope
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1. Introduction
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The goal of minimally invasive coronary artery bypass grafting (Mini-CABG) is to minimize the surgical trauma related to the magnitude of the surgery, cardiopulmonary bypass, and operation time. The advantages of Mini-CABG are considered to be less incisional pain and discomfort, shorter hospital stay, decreased patient morbidity, decreased reliance on post-hospital rehabilitation services, and improved cosmesis [1–6]. In the standard CABG surgery, most surgeons utilize a saphenous vein graft (SVG) in conjunction with arterial graft materials. The open surgical technique is most widely utilized for saphenectomy. However, despite meticulous surgical technique, major complication rates of 1 to 7% (deep infection) have been reported [7–10]. The use of skin bridges appears to have a slightly better morbidity profile but is technically difficult and the size of the incisions are not minimized. The recent interest in Mini-CABG including video-assisted IMA harvest [1, 3]has encouraged us to minimize the leg wound for saphenectomy as another minimally invasive option. The wound required in the lower extremity for harvesting the SV can be considered an ideal target to minimize the surgical invasion in CABG patients. Applications of endoscopic technique for vascular surgery have been reported in perforator vein interruption using laparoscopic equipment [11, 12]and in aortobifemoral bypass [13]. Although vein harvest is not frequently indicated in plastic surgery procedures, the initial trial of endoscopic vein harvest was described in a textbook of plastic surgery. [14]. More recently, several preliminary cadaver and clinical trials using endoscopic techniques for SV harvest in cardiovascular surgery were reported [15, 16]. Since 1994, we have been developing a new video-assisted endoscopic vein harvesting system (Saitama–Olympus technique) and reported the initial clinical results of 15 patients [17]. However, the clinical utility of the system has not yet been fully evaluated in terms of feasibility of the harvesting technique and late results. The purpose of this study was to examine the clinical feasibility of our newly developed video-assisted endoscopic technique to harvest the SV in CABG patients.
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2. Materials and method
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With the approval of the Institutional Review Board of the Saitama Medical School in December 1995, endoscopic harvest of the SV was performed on 40 patients undergoing CABG surgery.
The inclusion criteria for the selection of the patient in this study were: (1) elective CABG surgical candidate with stable angina who requires at least one SVG in conjunction with arterial bypass graft materials, (2) aged between 20 and 80 years, (3) the expected length of SV above the knee joint longer than 30 cm, (4) the size of SV over 2.5 mm in diameter with straight course in preoperative echographic evaluation. The exclusion criteria were: (1) the size of SV smaller than 2.5 mm in diameter, (2) SV with bifid or varicose in some areas utilized for graft, (3) patients who carry major serious preoperative risks such as acute myocardial infarction, cardiogenic shock, unstable angina, hemodialysis or insulin dependent diabetis mellitus. Informed consent was obtained from all patients prior to the operation. The operations were conducted between December 1995 and February 1997.
The procedure to endoscopically harvest the SV is composed of the following steps.
- 1. Create a subcutaneous space along the anterior surface of the SV.
- 2. Dilate the subcutaneous space along the length of the exposed SV.
- 3. Retract the overlying tissue to create an enlarged working area for dissecting the SV.
- 4. Dissect the SV under optical guidance with careful division of its branches.
To perform these steps we have developed several specialized instruments: optical sheath, vessel protector, flat and solid dilators, dilator hook, tunnel retractor, vessel dissector, grasping-cutting-coagulating forceps (GCC forceps) and scope sheath (Fig. 1
). To create the initial subcutaneous space along the anterior surface of the SV, we used the optical sheath (Fig. 2
a) mounted over a rigid endoscope (A5291A, Olympus Winter and Ibe, Germany). The rigid endoscope is inserted into the optical sheath and is fixed by the sheath holder. With this system, clear endoscopic visualization of the SV and surrounding tissue may be obtained through the translucent cap of the optical sheath. The `T'-shaped vessel protector, the dilator, and the dilator hook are then used to dilate the subcutaneous space over the SV. The solid dilators (Fig. 2b) are made of stainless steel and are produced in five sizes: XS, S, M, L and XL. We have developed two types of `T'-shaped vessel protectors, S and L also made of stainless steel. The distal end of vessel protector S has a fixing mechanism to attach to the proximal end of the optical sheath. We have developed two types of tunnel retractors, S and L (Fig. 2c), which are utilized to retract the overlying tissues to provide a reasonable field in which to dissect the SV. Tunnel retractor S, which has a small cross-sectional area, is to be used in the calf. Tunnel retractor L, which has a larger cross-sectional area, is to be used in the thigh. Dissection of the SV is carried out under optical guidance with careful division of its branches. The tunnel retractor consists of an endoscope channel at the top and four frames on the sides to maintain the operating space. The endoscope is protected by the scope sheath which is slid inside the endoscope channel along the roof of the tunnel retractor. Its purpose is to prevent damage to the endoscope during the procedure. The tunnel retractor holds the endoscope securely in place without the need of assistance. This allows the surgeon to concentrate on manipulating the hand instruments during the operation. The instruments utilized for dissecting the SV are the vessel dissector (Fig. 2d) used in conjunction with standard thoracoscopic surgical instruments, such as scissors and clipping devices. The vessel dissector is made of stainless steel and carries a pair of right or left-curved hooks at the distal end. One of the hooks can be slid axially to assist in the dissection. During use, the vessel dissectors are inserted through the windows between the frames of the tunnel retractor. GCC forceps is a specially designed scissors to cut the SV branch grasping the distal stump of the divided stump, then the distal stump of the divided branch can be cauterized.
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Fig. 1. Special instruments for SV harvest. (1) GCC (grasping-cutting-coagulating) forceps, (2) vessel dissector (R, L), (3) scope sheath, (4) tunnel retractor (S, L), (5) solid dilator (XS, S, M, L, XL), (6) vessel protector (S, L), (7) dilator hook, (8) optical sheath, (9) rigid endoscope.
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Fig. 2. (a) Optical sheath. A translucent cap with a flattened bullet shape made of medical grade plastic material is attached to the distal end of the optical sheath. (b) Solid dilator. The solid dilators are made of stainless steel and were produced in five sizes: XS, S, M, L, and XL. They gradually increase in cross-sectional area from 116 to 608 mm2. The solid dilators provide greater protection from SV side branch injury during the dilation procedure. (c) Tunnel retractor. The tunnel retractors consist of an endoscope channel at the top and four frames at the sides and were produced in two sizes: (1) small (S) has a total length of 200 mm and a cross-sectional area of 500 mm2; (2) large (L) has a total length of 320 mm and a cross-sectional area of 560 mm2. A detachable semi-conical tunnel guide attaches to the distal end of the tunnel retractor for smooth insertion into the subcutaneous space. (d) Vessel dissector. The vessel dissector is constructed from stainless steel and carries a pair of hooks at the distal end. One of the hooks can be slid axially.
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3. Surgical method
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The course, size, and number of tributaries of the SV are highly variable. In addition, the vein can also bifid or varicose in some areas which may make it unsuitable for CABG grafting [10]. Therefore, the anatomical location and the quality of the SV was examined by echography and the course of the SV was marked on the skin prior to the operation. The sequence of the operation and video images during SV harvest are shown in Fig. 3
and Fig. 4
. The first step was to locate the SV in the femoral region through a 4-cm vertical or longitudinal skin incision and dissect it as far as possible using an open technique. The rigid endoscope covered by the optical sheath was then inserted and the anterior surface of the SV was bluntly dissected with the optical sheath under endoscopic guidance for about 30 cm, to the popliteal region above the knee joint. A second 4-cm vertical or longitudinal skin incision was then made at the distal end of the dissected space (Fig. 3a). The subcutaneous tunnel created over the SV was then dilated to 4 cm in width using the solid dilators. During the dilation procedure, the SV was protected using the `T' shaped vessel protector (Fig. 3b). The tunnel retractor was then introduced (Fig. 3c,d) and the SV was dissected from the surrounding tissue using the vessel dissector (Fig. 4a,b). The major side branches were carefully clipped (Fig. 4c,d) and divided between the SV and the point of clipping (Fig. 4e,f). The minor side branches were divided by GCC forceps without clipping and the distal stump was cauterized. The side branch stumps remaining on the SV were carefully ligated on the table after harvesting the SV. Most of the time we harvested the SV from the thigh; however, when longer SV grafts were required, the same procedure was extended to the ankle with one or two additional skin incisions.
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Fig. 3. Sequence of events in endoscopic SV harvesting. (a) Dissection of the anterior surface of the SV using optical sheath, (b) dilation of the subcutaneous space using the solid dilator and T-shape vessel protector, (c) insertion of the tunnel retractor in to the subcutaneous space, (d) retention of the subcutaneous space using tunnel retractor.
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Fig. 4. Sequence of still video images. (a,b) Dissection of the surrounding tissue of the SV using the vessel dissector, (c,d) clipping the side branch of SV by clipping device (ALLPORT, Ethicon Endo-Surgery, OH, USA), (e,f) division the side branch of SV with scissors (T 1145, Olympus Optical, Japan).
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4. Results
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The SV was harvested in 40 CABG patients. There were 37 males and 3 females, with an average age of 59±11 years. During the study period we performed 232 CABGs in our institute, however, 46 patients were excluded because of emergency surgery, 81 patients were excluded due to unsuitable anatomy of SV, and 22 patients were excluded due to short SV (namely short leg). Finally 40 patients out of the remaining 83 patients agreed to join this clinical study. Data regarding the patients are shown in Table 1
. As our clinical experience with this approach increased, the operative time to harvest the SV was substantially reduced. The SV was easily harvested in all patients within 15–84 min. The average number of skin incisions was 2.4±0.5, and the average length of the harvested SV was 41±12 cm. The average number of bypass grafts was 3.4±1.0. We used the left IMA in 31 patients. The average operating time was 272±56 min. Aortic cross clamp time was 42±14 min. There was no significant prolongation of the operation due to endoscopic vein harvesting, although the average operating time for CABG surgery by the same surgical team was about 20 min shorter when standard surgical SV harvest technique is used. The remaining portion of graft segments of the SV harvested from each patient (total 105 segments) was examined histologically and there was no evidence of intimal injury. We found no evidence of intimal disruption, deposition of platelets and leukocytes on the intima, contraction damage to smooth muscle mechanisms, or disruption of the extracellular matrix. There were no serious wound complications associated with endoscopic SV harvesting except prolonged erythema and edema around the wound in two patients (5%). The erythema and edema were not serious and disappeared within 4 weeks without drainage in both patients. The average postoperative follow-up period was 10+4 months (range 2–18 months). During this time, the patients expressed fewer than normal complaints of pain and sensory abnormality around the SV harvest wound. All patients were satisfied with the small incisions and improved cosmetic appearance during the follow-up period (Fig. 5
).
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Fig. 5. Comparison of the wound scar of the open surgical harvest and the endoscopic harvest at 2 weeks after operation. (a) Wound scar of 48-year-old male resulting from open surgical harvest of the SV (50 cm) from the femur to the knee. (b) Wound scar of 60-year-old male resulting from endoscopic harvest of the SV (48 cm) from the femur to the knee.
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5. Discussion
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The application of video-assisted minimally invasive techniques to CABG surgery is especially exciting since it could be potentially applicable to the majority of adult cardiac surgical patients, and only requires access to the surface of the heart. The initial success of minimally invasive CABG encouraged us to expand this technique to multi-vessel CABG utilizing the IMA, SV, and other graft materials. The recent progress in minimally invasive techniques for IMA harvest has sparked a secondary interest in minimally invasive options for saphenectomies. The use of an endoscopic technique for vein harvesting was first described in a textbook of plastic surgery [14]. More recently, several companies have begun to offer instruments specifically designed for endoscopic SV harvest. These products include the Endo-CABG system (Snowden Pencer DSP, USA) and the SpacemakerTM Balloon Dissector (GSI, USA). Preliminary cadaver and clinical trials using these endoscopic techniques for SV harvest were reported [15, 16]. However, the clinical utility of these systems has not yet been fully evaluated.
Since 1994, we have been developing a new video-assisted endoscopic vein harvesting system in collaboration with Olympus Optical (Japan) and reported the initial clinical experience in 1996 [17]. However, the clinical utility of this system has not yet been fully evaluated in terms of feasibility of the harvesting technique and late results. In our protocol to develop an endoscopic SV harvesting system, we considered the following points to be minimum requirements.
- 1. The length of three SV grafts (almost 45 cm in the Japanese population) must be harvested within 30 min.
- 2. There must be no injury to the harvested SV.
- 3. Complete hemostasis of the side branches must be obtained.
- 4. The SV harvest must be performed by a single surgeon.
There are several original instruments in our endoscopic SV harvesting system to fulfill the requirements such as the optical sheath, the tunnel retractor, vessel dissector, and GCC forceps. With the optical sheath, clear endoscopic visualization of the SV and surrounding tissue may be obtained through the translucent cap of the optical sheath and the initial subcutaneous space along the anterior surface of the SV can be created within a few minutes very safely. The tunnel retractor is utilized to retract the overlying tissues to provide a reasonable field in which to dissect the SV and also the tunnel retractor holds the endoscope securely in place through the endoscope channel at the top. This allows the surgeon to concentrate on manipulating the hand instruments during the operation without the need of assistance. The vessel dissector enable to dissect the SV and its branches gently and quickly without injury with its sliding hook mechanism. With the GCC forceps, the minor branch of the SV can be divided with simultaneous cauterization of the distal stump in one maneuver. Although we could not satisfy all of the items which we considered as requirements for endoscopic SV harvest. Although the average harvesting time of SVG (skin to skin) was 54±18 min in this study, we found that more than 40 cm of the SV was available for bypass grafting within 40 min in our most recent patients. Microscopic examination of the remaining portion of 105 segments of SVG showed no evidence of injury to the vein. To harvest the SV within a reasonably short period of time, it seems to be effective to decrease endoscopic clipping or ligation of side branches. Therefore, we clipped only the distal side of major branches of the SV, and cauterize the distal side of minor branches using GCC forceps which divide and cauterize in one maneuver. The proximal side of the branch is carefully ligated, after harvesting the SV, on the table. This ensures a more secure hemostasis of the SV graft. Although there was no evidence of injury to the harvested SV, long-term follow-up of the implanted SV graft is necessary in terms of late pathological change and patency. Wound pain in the early postoperative period and sensory abnormalities around the wound in the late postoperative period seem to be reduced and mostly acceptable to all 40 patients. Although slight erythema and edema was observed in two patients, there was no evidence of infection, wound dehiscence or drainage required. This condition disappeared within 4 weeks in both patients. During the same period of time saphenectomy was performed with open surgical technique in 192 patients. The major complication (infection, wound dehiscence, drainage required) was observed in six patients (3.1%) and minor complication (erythema, edema) was observed in nine patients (4.7%) in the patients with open surgical technique. The cosmetic appearance of the wound in the late postoperative period also seems to be better than that resulting from surgical harvest. Improvement in infection rates are expected since there are fewer incisions and less tissue dissection. Obesity can be one of the risk factors for wound infection in cardiac surgery [17]; therefore, obese patients may be good candidates for endoscopic saphenectomy. To avoid unnecessary dissection (especially in the obese patients) and more efficient harvest of the SV, we believe preoperative evaluation of the anatomical location and quality of the SV by echography is very important. In summary, the Saitama–Olympus technique for endoscopic harvesting of the SV is a clinically feasible surgical technique with a unique potential for significantly reducing morbidity and wound scarring in CABG patients.
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References
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|---|
- Benetti FJ, Ballester C, Sani G, Doonstra P, Grandjean J. Video-assisted coronary bypass surgery. J Card Surg 1995;10:620-625.[Medline]
- St. Goar FG, Stevens JH, Burdon TA, Siegel LC, Pompili MF, Peters W, Reitz BA. Closed-chest CABG clinical characteristics: potential for procedural synergy in managing CAD. JACC 1996;27(SupplA)(Abstract):392A..
- Robinson MC, Gross DR, Zeman W, Stedje-Larsen E. Minimally invasive coronary artery bypass grafting: a new method using an anterior mediastinotomy. J Card Surg 1995;10:529-536.[Medline]
- Soper JN, Brunt LM, Kerbl K. Medical progress laparoscopic general surgery. N Engl J Med 1994;330:409-419.[Free Full Text]
- Peters WS, Austral AS. Minimally invasive cardiac surgery by cardioscopy. J Cardiac Thorac Surg 1993;2:152-154.
- Landreneau RJ, Hazelrigg SR, Mack MJ, Dowling RD, Burke D, Gavlick J, Perrino MK, Ritter PS, Bowers CM, DeFino J, Nunehuek SK, Freeman J, Keenan RJ, Ferson PF. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoraeotomy. Ann Thorac Surg 1993;56:1285-1289.[Abstract]
- Slaughter MS, Olson MM, Lee Jr. JT, Ward HB. A 15-year wound surveillance study after coronary artery bypass. Ann Thorac Surg 1993;56:1063-1068.[Abstract]
- Wipke-Tevis DD, Stotts NA, Skov P, Carrieri-Kohlman V. Frequency, and correlates of impaired healing of saphenous vein harvest incisions. Heart Lung 1996;25:108-116.[Medline]
- L'Ecuyer PB, Murphy JR, Fraser VJ. The epidemiology of chest and leg wound infections following cardiothoraeic surgery. Clin Infect Dis 1996;22:424-429.[Medline]
- Daily PO, Freeman RK, Dembitsky WP, Adamson RM, Moreno-Cabral RJ, Marcus S, Lampere JA. Cost reduction by combined carotid endartereetomy and eoronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;111:1185-1193.[Abstract/Free Full Text]
- Wittens CHA, Pierik RGJM, van Urk H. The surgical treatment of incompetent perforating veins. Eur J Vasc Endovasc Surg 1995;9:19-23.[Medline]
- Conrad P. Endoscopic exploration of the subfascial space of the lower leg with perforator vein interruption using laparoscopic equipment: a preliminary report. Phlebology 1994;9:154-157.
- Dion YM, Katkhouda N, Rouleau C, Aucoin A. Laparoscopy-assisted aortobifemoral bypass. Surgical Laparoscopy Endoscopy 1993;3:425-429.[Medline]
- Lumsden AB, Eaves III FF. Vein harvest in endoscopic plastic surgery. In: Bostwick J, Eaves III FF, Nahai F, editors. Endoscopic Plastic Surgery. St. Louis MO; Quality Medical, 1995:535–545..
- Rosenthal D, Tucker JG, Atkins CP, Walters AS, Newman CL, Lamis PA, Clark MD. Extraluminal endoscopic-assisted ligation of venous tributaries for infrainguinal in situ saphenous vein bypass: a preliminary report. Cardiovasc Surg 1996;4:512-514.[Medline]
- Cusimano RJ, Dale L, Butany JW. Minimally invasive cardiac surgery for removal of the greater saphenous vein. Can J Surg 1996;39:386-388.[Medline]
- Kyo S, Kanako K, Nishikiori Y, Shimamura Y, Kasai H, Yokote Y, Konou R, Omoto R. Endoscopic harvesting of saphenous vein for coronary artery bypass grafting: development of new technique. Circulation 1996;94(Suppl I)(Abstract):I–476..
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Abstract
1. Introduction
