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Eur J Cardiothorac Surg 1999;16:S61-S66
© 1999 Elsevier Science NL

Routine minimal invasive vein harvesting reduces postoperative morbidity in cardiac bypass procedures. Clinical report of 1400 patients

^a Department of Cardiac Surgery, Schüchtermann Klinik, Bad Rothenfelde, Germany
^b Department of Pathology, Klinikum Osnabrück, Germany

^* Corresponding author. Department of Cardiac Surgery, Schüchtermann Klinik, Ulmenallee 11, 49214 Bad Rothenfelde, Germany. Tel.: +49-05424-6410; fax: +49-05424-641-653

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusions References

 
Objective: Minimal invasive endoscopic vein harvesting has not gained widespread acceptance although potential improvements in wound healing and patient comfort are undebatable. The main objections to routine application have been impaired graft quality and prolonged operation time. The feasibility of introducing the minimal invasive approach to vein harvesting into a high volume cardiac bypass surgery program was to be investigated in 1400 patients. Methods: Our preferred technique is based on standard videoscopic equipment for endoscopic surgery. No disposables are used. The subcutaneous tissue above the saphenous vein is tunnelled by exclusively sharp dissection. No shear stresses are applied to the vein graft or its side branches. Side branches are closed by clips or bipolar coagulation. The differences between endoscopic and conventional surgical vein harvesting with regard to operation time, graft quality, wound healing disturbances and postoperative pain were compared in two groups of 300 concurrently operated patients. Subsequently, a further 1100 patients underwent endoscopic vein harvesting, giving a total experience of 1400 endoscopic procedures. Results: After a learning curve of approximately 100 procedures for an experienced surgeon, harvesting time using minimal invasive techniques was 16±4 min/graft vs. 10±2 min for the conventional technique (P<0.01). Severe wound healing disturbances requiring re-intervention were observed in 0.1% following endoscopic harvesting, moderate wound healing disturbances were observed in 1.7% of patients. By comparison, conventional harvesting led to severe wound healing disturbances in 5% and to moderate disturbances in 8% (P<0.05). Incidence of peri-operative myocardial infarction as an indirect measure of graft quality was 1.7% with endoscopic vs. 2.3% (n.s.) with conventional technique. Early postoperative mobilisation was faster, pain and need of analgesics were distinctly reduced in patients with endoscopic harvesting. Overall operation time was not significantly prolonged by the described technique. Conclusions: Minimal invasive endoscopic vein harvesting can be developed into a routine procedure resulting in a lower incidence of wound complications, less postoperative pain and much superior cosmetic results. Graft quality appears to be comparable to standard saphenectomy. There is, however, a higher demand of surgical training and expertise.

Key Words: Saphenous vein • Minimal invasive • Endoscopy • Coronary artery bypass • Occlusion rate

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusions References

 
Minimal invasive vein harvesting by endoscopic techniques has become technically feasible during recent years. A variety of techniques have been developed in order to obviate long skin incisions [1–7]. These procedures, however, have raised limited enthusiasm and have not gained widespread acceptance. This is in contrast to the large scale scientific effort towards minimising thoracic incisions [1]. Saphenectomy, however, leads to far longer skin incisions and a much higher prevalence of wound complications and pain than median sternotomy. Although severe morbidity like sepsis or amputation are encountered only in rare instances [8], major complications such as wound dehiscence, excessive drainage, lymphangitis and delayed wound healing are reported in up to 24% of patients resulting in severe patient discomfort and additional cost [8–10]. In spite of this, the operative technique of saphenectomy has not been improved significantly since the advent of coronary revascularisation. Interrupted skin incisions were the only technical proposal for reducing these complications but were not generally accepted. Not before 1996 minimal invasive vein harvesting has been described as an alternative procedure in a few centers. As to our knowledge, the following report describes for the first time the impact of minimal invasive vein harvesting as a routine procedure on a high volume cardiac bypass surgery program.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusions References

 
2.1 Patients
Between January and December 1998, 2158 patients out of a total of 2481 open heart patients underwent coronary revascularisation. Out of these, 1978 were isolated bypass procedures. An average of 2.2 vein grafts and of 0.9 arterial grafts were anastomosed. Coronary mortality was 1.3%. Minimal invasive endoscopic vein harvesting was performed in 1400 patients with increasing frequency during the course of the year. This study period was preceded by an introduction period during 1997. The coordinated introductory tasks of selecting appropriate equipment, standardising our operative technique and providing surgical training for a sufficient number of senior residents all had been concluded before the study period. In 1998, there were no general contraindications to endoscopic vein harvesting except in emergency cases requiring cardiopulmonary resuscitation before extracorporeal circulatory support. In our group of seven senior surgeons, the decision to convert to endoscopic vein harvesting was left at the discretion of the senior surgeon.

The initial 300 patients undergoing endoscopic vein harvesting were part of a subgroup study, comparing these patients with 300 concurrently operated non-selected patients undergoing conventional saphenectomy. Demographic patient data and comorbidity for both groups were compared. The minimal invasive vein harvesting procedure in this initial group was performed by one individual surgeon (R.C.).

2.2 Surgical technique
Standard saphenous vein harvesting was performed by one longitudinal uninterrupted skin incision. Vein side branches were closed by clips. Saphenectomy and skin closure were performed by senior residents only. Skin closure was by absorbable intracutaneous suture. Suction drainage was used liberally when harvesting saphenous vein from the thigh. Great care was taken to appropriately compress the leg by bandaging for 24 hours postoperatively.

Our technique for minimal invasive endoscopic saphenectomy is performed with a commercially available endoscopic system (Karl Storz Endoskope, Tuttlingen, Germany) (Fig. 1). The system can be sterilised completely. No disposables are used. Saphenectomy and median sternotomy with preparation of the left internal mammary artery are performed simultaneously. After disinfection, the leg is draped with an incision foil. A longitudinal incision of 3–4 cm length is performed at the medial aspect of the thigh 5 to 10 cm above the knee. We found longitudinal incisions to be superior to transverse incisions, as preparing the first cm of the vein is facilitated. After identification of the greater saphenous vein, the subcutaneous tunnel dissector, carrying an endoscope, is inserted. Surgery is performed under videoscopic view by a standard monitor. The essentials of our technique are as follows.

• The subcutaneous tunnel above the saphenous vein is created exclusively by sharp dissection.

• No blunt dissection is allowed.

• Likewise, it is actively discouraged to use the tunnel dissector, which was originally designed for blunt tunnelling, in this manner. Uncontrolled bleeding and major shear forces onto the vein graft may result.

• All major side branches are closed by clips.

• Bipolar cautery is appropriate for small side branches. The cauterisation of large side branches is avoided as uncontrolled heat transfer towards the vein graft might result (Fig. 2).

• The use of the ring stripper instrument provided by the manufacturer is discouraged as side branches might be disrupted.

View larger version (76K): [in this window] [in a new window]   Fig. 1. The Storz tunnel dissector. The instrument comes in two sizes and carries the endoscopic lens and light source (bottom). No blunt tunnelling with this instrument is allowed.

View larger version (111K): [in this window] [in a new window]   Fig. 2. Saphenous vein side branch on the video monitor. The bipolar electrocautery forceps is used to coagulate this branch.

During the learning curve we especially recommend to add additional incisions during the course of the vein, if difficulties are encountered in identifying side branches. These incisions may be directed at the tip of the tunnel dissector instrument and thus can be very short. During the introductory phase, a compromising strategy can be established, which allows for additional skin incisions in case of time restraints, bleeding or obscured vision.

When additional vein length is required, the tunnel can be brought down to below the knee and the vein can be divided here, again either by ‘Endoloop' or direct ligature via an additional incision. Saphenectomy of the calf is technically more difficult due to the lack of subcutaneous tissue and is not recommended as a routine procedure.

Suction drainage of the tunnel is used liberally, but we do not find it essential. The leg is wrapped immediately after skin closure with elastic bandages in order to prevent hematoma, while the patient is fully heparinised on extracorporeal circulation.

2.3 Operative parameters
In the subgroup analysis comparing the first 300 endoscopic procedures with 300 concurrently operated conventional procedures, the number of leg incisions, the length of incisions, the time required for harvesting per graft, the number of harvested grafts and the incidence of conversion from endoscopic to conventional saphenectomy were recorded. The time for skin closure was excluded as it was felt that the time span relevant for the conduct of the operation was the time required for producing suitable vein grafts.

2.4 Wound complications
Wound healing disturbances were defined as dehiscence, drainage, necrosis, hematoma or abscess. Wounds were assessed daily up to postoperative day 6 and then once a week during the next 3 weeks. Wound complications were classified as severe when further surgical intervention was necessary and as moderate when hematoma, superficial infection or inflammation was seen.

2.5 Pain assessment
A visual numeric rating scale was used to assess postoperative leg pain [11]. The patient was asked to adjust a graded analog ruler. Scaling was from 0 (no pain) up to 10 (unbearable pain). Postoperative pain was assessed by patients on a daily basis during the first six days and once a week for the next three weeks. Routine peri-operative analgesic therapy consisted of non-steroidal antiphlogistics during the first postoperative week in combination with continuously administered opioids during the first postoperative 24 h in all our patients.

2.6 Graft quality
The Pathologist (R.K.) was asked to demonstrate histologic correlates of iatrogenic graft damage. For this purpose, early in this series, 15 unselected vein grafts underwent stained light microscopy examination for mechanical or thermal damage. The vein grafts came from patients in whom a planned coronary anastomoses could not be performed due to unsuitable coronary vessels. In addition, the pathologist was provided with samples of intentionally torn side branches and heat damage as reference samples.

A peri-operative rise in cardiac related enzymes, new Q-waves or R-wave reduction in postoperative electrocardiograms as well as new wallmotion abnormalities were considered as early graft failure. No serial postoperative angiograms were performed.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusions References

 
The introduction of endoscopic saphenectomy into a routine program was achieved with increasing training status of surgical senior residents and better familiarity with the procedure, leading to an increased acceptance of the procedure during 1998. It should be noted that 3 operating theatres were available. An annual frequency of 827 open heart - cases per year and theatre is an indicator of a busy time schedule and might support our finding that little extra time is needed once the technique is established and training achieved. Overall operation time did not differ significantly between both procedures (151±27 min. for endoscopic saphenectomy vs. 145±31 min. for conventional saphenectomy). Number and length of incisions as well as harvesting time per graft are shown in Table 1 . An average of 2.17 vein grafts was used in patients with endoscopic harvesting vs. 2.2 grafts in conventional procedures. An average of 0.9 arterial grafts was additionally used resulting in a revascularisation rate of 3.1 grafts per patient for both groups. Conversion from endoscopic to conventional saphenectomy was necessary in 1.6% of the patients. In 18 patients, a multitude of side branches leading to a difficult and time consuming harvesting procedure made this necessary. In 5 patients conversion was necessary because of superficial course or varicose abnormalities of the saphenous vein.

View larger version (13K): [in this window] [in a new window]   Fig. 3. Minimal invasive harvesting time per graft. Personal learning curve during the first 100 saphenectomies in 1997 by a single surgeon.

View larger version (12K): [in this window] [in a new window]   Fig. 4. Intensity of postoperative pain. Patients were asked to adjust a scaled ruler according to the individually experienced pain. Score 0 means no pain and score 10 unbearable pain.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusions References

 
Postoperative morbidity and patient discomfort due to wound complications at the vein harvesting site appear to be a neglected issue in cardiac surgery. These complications seem to be widely accepted as unavoidable, and well-described morbidity rates of up one fourth the cardiac bypass surgery population suffering from wound complications received only scarce attention. In our patients we observed a complication rate of 11% after conventional saphenectomy, which reflects the reported incidence of wound healing disturbances within the literature [5,6]. With the advent of endoscopic technology for minimal invasive vein harvesting a dramatic progress in this field might be achieved. We observed a reduction of the wound complication rate to below 2% with endoscopic saphenectomy. Pain scoring has proven that the much shorter skin incision and the avoidance of continuous skin incisions in the knee area contribute to patient comfort and quality of life. Our results corroborate the experience of Davis [3]. Allen and Davis observed a quicker recovery and mobilisation in the first postoperative week [3,4]. The pain scoring results of Allen [4] are different from our findings, but the time of pain scoring was not identical in both studies. Undoubtedly, with increasing time elapsed since the operation, the patient discomfort tends to be forgotten and final results of wound healing tend to give equal outcomes. Our findings of significantly improved early patient comfort appear to be significant in view of the strong forces urging towards shorter hospital stays.

Two main objections against techniques of endoscopic vein harvesting must be considered. A significantly longer overall operation time would place a heavy burden on the resources of personnel and operating room time of most surgical departments. The fact that endoscopic harvesting could be established in a routine program of more than 800 annual heart-lung-machine-operations per theatre may be used as an indicator that the procedure can be integrated. The time required per graft is 60% longer than for the conventional procedure, however, the overall operative time was prolonged by only 10 min, which was not statistically significant.

Our findings of uncompromised graft quality are valid only, if surgical training and expertise are adequate. There is no doubt, that the demands on the surgeon with regard to technical expertise and patience are far higher than in conventional saphenectomy. Graft quality after endoscopic saphenectomy remains the key issue. There is a potential for doing harm to the saphenous graft by rude harvesting techniques, resulting from inadequate training or unsuitable instrumentation. Long-term results of graft quality and patency rates are not yet available. A number of authors have claimed equivalent graft quality compared to conventional saphenectomy. Cable [2] has investigated endothelial integrity after endoscopic harvesting by means of light and electron microscopy as well as by superperfusion bioessay of luminal endothelial secretion and has confirmed the preservation of endothelial integrity. Compared to this study, our results from light microscopic control investigations can only be judged as an indication that no major harm occurred to the vein segments. In our study, early graft failure may serve as an indirect indicator of graft quality. The incidence of peri-operative myocardial infarction was equally low with both techniques in the study. We had to acknowledge that routine repeat coronary angiograms could not be performed on grounds of lack of funding. It might well have to be accepted, that nowadays a large scale randomised study including control angiograms early and late postoperatively might be generally impossible for economic reasons. In this situation, our favourable results of uncompromised early postoperative courses in 1400 patients might be used as an indicator, that endoscopic vein harvesting can be performed without incurring unacceptable risks from presumed inferior graft quality.

	5. Conclusions

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusions References

 
Minimal invasive endoscopic vein harvesting can be performed as a routine procedure. Judged by the unchanged incidence of peri-operative myocardial infarctions, graft quality appears to be unimpaired. The harvesting procedure can be incorporated into the operative time schedule without unduly lengthening operating room time. A higher level of surgical training and expertise is required, but this is by far outweighed by a reduced incidence of wound infection, less postoperative pain and a much superior cosmetic result.

	Footnotes

 
Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3– 5, 1998.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 5. Conclusions References

 

1. Reichenspurner H, Boehm D, Welz A, Reichart B. Minimally invasive cardiac surgery – a fashion or an accepted surgical concept?. Z Kardiol 1998;87:594-603.[Medline]
2. Cable D, Dearani J, Pfeifer E, Daly R, Schaff H. Minimally invasive saphenous vein harvesting: endothelial integrity and early clinic results. Ann Thorac Surg 1998;66:139-143.[Abstract/Free Full Text]
3. Davis Z, Jacobs H, Zhang M, Thomas C, Castellanos Y. Endoscopic vein harvest for coronary artery bypass grafting: technique and outcomes. J Thorac Cardiovasc Surg 1998;116:228-235.[Abstract/Free Full Text]
4. Allen K, Griffith G, Heimansohn D, Robison R, Matheny R, Schier J, Fitzgerald E, Shaar C. Endoscopic versus traditional saphenous vein harvesting: a prospective, randomised trial. Ann Thorac Surg 1998;66:26-32.[Abstract/Free Full Text]
5. Tevaearai H, Mueller X, von Segesser L. Minimally invasive harvest of the saphenous vein for coronary artery bypass grafting. Ann Thorac Surg 1997;63(6):119-121.
6. Lumsden A, Eaves F, Ofenloch J, Jordan W. Subcutaneous, video-assisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg 1996;4(6):771-776.[Medline]
7. Cusimano R, Dale L, Butany J. Minimally invasive cardiac surgery for removal of the greater saphenous vein. Can J Surg 1996;39(5):386-388.[Medline]
8. Lee KS, Reinstein L. Lower limb amputation of the donor site extremity after coronary artery bypass graft surgery. Arch Phys Med Rehabil 1986;67:564-565.[Medline]
9. DeLaria G, Hunter J, Goldin M, Serry C, Javid H, Najafi H. Leg wound complications with coronary revascularization. J Thorac Cardiovasc Surg 1981;81:403-407.[Abstract]
10. Utley J, Thomason M, Wallace D. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Surg 1989;30:147-149.
11. Lui WHD, Aitkenhead AR. Comparison of contemporaneous and retrospective assessment of postoperative pain using the visual analog scale. Br J Anaesth 1991;67:768-771.[Abstract/Free Full Text]

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