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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3753_Библиотеки_им_академика_М_И_Перельмана
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Endoscopic Vein Harvest Using an Open System (Terumo®) 111
Table 1 Compatible generators
Generator Model Foot Pedal Type Mode Settings range (W)
®
Olympus
ValleyLap™ Force FX Single Bipolar Macro 14–18
ValleyLap™ Force FX-C Single Bipolar Macro 14–18
®
Bovie
ConMed
Olympus
Covidien
UES-40 Dual (Cut/Coag) Bipolar cut 8–12
Aaron®ORIPRO 300 Single Bipolar Macro 8–10
®
System 5000™ Single Bipolar Macro 6–8
®
ESG-400 Dual (cut/coag) Bipolar BiSoft Coag effect 8
®
Force triad™ Single Bipolar Macro 6–7
Video 1 Orientation to Terumo scope (▶ https://doi.org/10.1007/000-a7h)
2.3 Theatre Set-Up
• Plug in the stack system and diathermy and
test the equipment where possible to ensure
Prior to commencing each EVH procedure, get
into a routine of ensuring that the equipment is set
up and ready for use in a timely manner (Fig. 3).
This allows for any issues to be fixed prior to
commencing the procedure and reduces the
chances of issues occurring during the EVH.
Issues occurring mid procedure can make the
EVH more difficult, increase the length of harvest
time and create added and unnecessary stress.
that it is working.
• Set the screen of the stack system up so the
height is level with your head and is opposite
where you are standing. This ensures minimal
strain is placed on your neck and back.
• Ensure all the equipment is set on the appropriate settings, ready for use.
• Ensure there is enough CO
for the EVH.
gas in the canister
2
112 D. Croft et al.
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V-Cautery Switch
V-Cuer
V-Cuer Buon
Wiper Ring
V-Keeper
V-Lock
CO2Line
V-Lock BuonV-Keeper Buon
Wiper
Fig. 2 Equipment orientation
Fig. 3 Theatre set up
Endoscopic Vein Harvest Using an Open System (Terumo®) 113
• Ensure the necessary surgical instruments are
available for use.
– Basic instruments including a Scalpel,
Scissors and Forceps
– A Small Langenbeck
– Artery forceps, such as Mosquitos
– A long-handled artery forcep, such as a
Sawtell
Note: Ideally, learn to harvest the vein by standing on the same side as the leg from which you are
harvesting. Although, only a minor movement,
harvesting from the opposite leg can cause pain in
the lower back from reaching over. When all the
equipment is placed ergonomically, EVH allows
the operator to maintain a better posture and
sustain the body’s three natural curves [2].
2.4 Pre-operative Patient Assessment
When beginning an EVH programme, initial
patient selection is vital. The first 20–30 cases
will be focused on becoming familiar with the
equipment and its application, alongside consolidating the muscle memory and hand–eye coordination required for EVH. Choosing the initial
patients carefully means there will be an
increased chance of a successful harvest and
minimal damage to the conduit. Once the use of
the equipment has been mastered, it will be easier
to utilise the techniques discussed later in the
chapter to adapt to more difficult harvests.
Prior to commencing each EVH ensure you
are aware of the patients past medical history and
carry out a clinical examination of the lower
limbs, including ultrasound assessment if
appropriately trained. If any of these indicate that
a harvest may be more difficult when done
endoscopically, then consider using an alternative method. The quality of the conduit is the
optimum priority and if there is a risk that this
may be compromised by using an endoscopic
approach, then an alternative method should be
utilised until the operator is more experienced.
2.5 Patients Past Medical History
Although the past medical history of the patient
should be reviewed prior to any conduit harvest,
some patient history can indicate whether harvesting the vein using an EVH method may be
more difficult.
• Patients on anticoagulant treatment imme-
diately prior to surgery can mean a greater
chance of bleeding within the tunnel.
• Patients who have had previous trauma to
the lower extremities may develop tissue
fibrosis, which can make manipulation of the
scope difficult or may prevent a tunnel forming. This can be dependent on the type and
location of the trauma.
2.6 Clinical Examination
Clinical examination of a patient’s lower limbs
can also indicate when an EVH may be more
challenging.
• Large legs can mean the vein is located
deeper in the leg and means an increased
chance of fatty tissue falling into the tunnel,
which can reduce your vision. You could
consider harvesting the vein in the calves of
these patients, if the LSV is suitable.
• Small legs can mean the vein is located more
superficially within the leg. This makes
manipulation of the scope within the tunnel
difficult when dissecting the fat from the vein
and can lead to significant bruising on the
surface of the skin.
• Fragile patients can mean fragile tissues and
fragile veins, which are more prone to damage. These veins commonly may also have
tiny, hair-like tributaries, which can easily
become avulsed by the endoscope.
114 D. Croft et al.
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2.7 Ultrasound
Using ultrasound prior to harvesting the LSV has
been shown to reduce both the length and
quantity of incisions and reduce the harvesting of
unsuitable conduit, in multiple studies [3]
(Fig. 4). Ultrasound is also non-invasive and
relatively easy to use once trained. In EVH, preoperative ultrasound also has the added benefitof
providing an accurate location of the LSV, at the
medial aspect of the upper calf, where the initial
EVH incision is made. Identifying the LSV for
EVH can sometimes be difficult in the absence of
ultrasound when compared to the use of landmark techniques commonly used for open vein
harvest. Ultrasound can also identify a superficial
or deep LSV, which can make EVH more challenging. The use of ultrasound in EVH therefore
has two advantages.
Pre-operative ultrasound aids in identifying
the location of optimum LSV by:
• Confirming the presence of the LSV and
that it has not been removed during a previous
surgery.
• The diameter of the LSV—Studies have
reported that the most optimum LSV size for
CABG surgery as measured by ultrasound is
(2–5 mm) [3].
• Highlighting any calibre changes or
bifurcations.
• Identifying any varicosed of unusable segments, due to dilation or tortuosity or whether
there is just one small area effected.
• Identifying any thrombosed segments,
which should be avoided.
Pre-operative ultrasound can be used to assess
EVH difficulty by:
• Providing a means of locating the LSV for
the initial incision at medial aspect of upper
calf. This can be marked using an indelible
skin marker (Fig. 5).
• Identifying whether the LSV is superficial
or deep, which can make the harvest more
difficult.
• Identifying whether the vein is located
posteriorly.
• Identifying locations where the vein takes a
sudden change in direction, or a large
tributary which may distort the location of the
true LSV once carrying out EVH. These
locations can be marked using an indelible
skin marker. Large tributaries can also be
more difficult to seal effectively using the
diathermy. Tips to overcome this are discussed later in the chapter.
• Identification of ‘red-herring
’ veins.In
some patients, superficial veins may run near
the true LSV. Early identification reduces the
chances of following a vein other than the
LSV. Again, indelible skin markers can be
used to identify the course of the true vein, so
the practitioner ensures they stay on course.
• Identifying any varicose veins, which are
fragile and thin walled areas of vein and are
more likely to perforate and cause bleedi ng
within the tunnel.
2.8 Other Points to Note
• Calf vein can be more difficult to harvest,
especially in patients with smaller legs. This is
because in the calf the LSV runs along the
medial aspect of the tibia and manipulation of
the scope against the bone can be difficult. In
the calf, the Saphenous nerve is also more
likely to be present in very close proximity to
the LSV and extra care and dexterity is needed
to preserve its inte grity and prevent nerve
damage.
• Consider choosing cases that require less
segments of vein. Beginning to learn EVH by
harvesting just one segment of vein would be
ideal, however, two segments is reasonable.
More than two segments can take a significantly longer time until the user builds up the
dexterity required to confidently harvest.
• If there is a risk of conduit damage and
there being no further conduit available, then
consider using an alternative method to EVH
until more experienced.
Endoscopic Vein Harvest Using an Open System (Terumo®) 115
Fig. 4 Identifying the LSV using ultrasound scanning
116 D. Croft et al.
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Fig. 5 Marking the vein after identification
Assemble equipment
3 Intra Operative Procedure
1. Attach the light source to the endoscope.
3.1 Patient Positioning
Position the patient supine with legs slightly bent
and externally rotated using appropriate pressure
relieving devices under the knees and heels,
allowing access to the long saphenous vein
(LSV) medially.
2. Apply sterile camera cover to camera.
3. Attach the camera head to the endoscope
and adjust the focus to ensure clear vision.
4. Set light source at 30%.
5. Attach insufflation tubing ensuring it is not
occluded (set to 2.0 L per minute and a
pressure of 10 mmHg).
Endoscopic Vein Harvest Using an Open System (Terumo®) 117
Procedure
The LSV is usually harvested endoscopically just
below the medial aspect of the knee ascending in
the direction of the thigh particularly if two
segments of vein are required (Fig. 6). If a third
segment is required or vein above the knee is
unsuitable for harvesting the direction of the
dissection and harvest descends downwards from
the knee to the ankle (Fig. 7).
In our experience at Blackpool, we give a
single 5000 IU bolus of intravenous heparin
prior to the initial incision at the leg, as we have
occasionally observ ed macroscopic intraluminal
clot within the LSV during harvesting .
Make a transverse or oblique incision
approximately 2 cm at the appropriately identified point along the leg.
Locate the LSV using direct vision and dissection, once exposed isolate with a sling, tie or
tape.
Now open the Terumo VirtuoSaph
®
Plus
Endoscopic Vessel Harvesting System. Insert the
endoscope into the dissector, attach the insufflation
tubing and switch on the CO
using the camera
2
head controls. Perform a white balance. You are
now ready to commence the dissection process.
Dissection
• Using the tip of the dissector locate the LSV at
the incision site (isolated by the sling/tie or
tape) and advance the tip through the fat
anteriorly to the vein (Fig. 8).
• NB If using trocar, slide this over the dissector
before inserting into the incision.
• Continue the same process poste riorly then
dissect all the tributaries along the way.
Ensure a sufficient tributary length is dissected
to allow safe cut and cautery (Fig. 9).
• Disconnect the insufflation tubing and remove
the dissector from the endoscope as the dissection process is now complete.
• Insert the endoscope into the harvester and
connect the bipolar diathermy cable to the
appropriate machine and setting, ensuring you
have the bipolar foot pedal nearby ready for
use. Connect the insufflation tubing to the
handle of the harvester and switch on the CO
.
2
Fig. 6 Initial dissection up the thigh
118 D. Croft et al.
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Fig. 7 Dissection down the calf
Fat
Fig. 8 Anterior dissection of the fat plane
• You are now ready to commence the harvest
process. (see Video 2).
Note: Be aware of the proximity of the saphenous nerve in relation to the vein especially when
dissecting, and ensure it is not caught in the V
Keeper when harvesting.
Harvest
• Ensure the V keeper is closed, the V cutter
retracted and insert the harvester through the
incision into the tunnel (Use a Langenbeck to
lift open the incision OR rotate the harvester
180° to prevent the V cutter from catching the
LSV
Endoscopic Vein Harvest Using an Open System (Terumo®) 119
Tributary
Fig. 9 Dissection of the tributaries
Video 2 Dissection of LSV (▶ https://doi.org/10.1007/000-a7g)
skin during insertion. If there is a tributary
near the entrance of the tunnel obstr ucting the
insertion of the harvester, it may be necessary
to cauterise and cut the tributary to allow
initial insertion.
• Rotate the harvester, whilst advancing through
the tunnel, to avoid tributaries and tissue until
the end of the dissected vein is reached. Ensure
the harvester is positioned over the vein
throughout. Advance the V keeper, open the V
120 D. Croft et al.
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Fig. 10 Open V lock
Fig. 11 Position vein in V keeper
lock and position the vein into the V keeper
(please note the direction of insertion into the
V keeper then close the V lock and retract the
V keeper ensuring the vein is free of the
saphenous nerve (Figs. 10 and 11).
• Leave the clip in situ and begin moving the
harvester towards the knee until a tributary is
encountered. Be aware of the vein buckling as
there may be a tributary present which is
buried amongst the fat and not visible on the
monitor.
• If there is a tributary located on the right of the
• At this point perform a stab incision in the
thigh using endoscopic guidance, insert an
artery clip and grab the vein (Fig. 12).
LSV seen on the monitor, rotate the harvester
clockwise to allow the tributary to become taut
and advance the V cutter using the V cutter
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