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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®) 121
Artery clip
Fig. 12 Grabbing the LSV
Fig. 13 Tributary on right
button (this will advance from the right-hand
side) so the tributary sits in the slit between the
bipolar tips of the V cutter (Fig. 13).
Ensure the ground electrode on the V cutter is
placed against the tunnel wall. Slowly advance
the V cutter button forwards whilst pressing the
diathermy foot pedal until the tributary is cauterised and cut. Similarly, if there is a left
sided tributary, rotate the harvester anticlockwise
and the V cutter will advance from the left
(Fig. 14).
122 D. Croft et al.
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Fig. 14 Tributary on left
• If haemostasis is not achieved at this point,
then spot cautery can be used. This is done by
releasing the vein from the V keeper and
positioning the ground electrodes of the V
cutter into the area of the tunnel wall that is
bleeding. Move the blue cautery switch across
laterally and hold whilst pressing the foot
pedal to cauterise the area, releasing after 2 s.
• The grey wiper ring on the handle of the
harvester operates a wiper blade which cleans
the endoscope lens if required.
• There is the option to cauterise and cut by
performing tributary isolation. This is achieved
by releasing the LSV from the V keeper and
capturing the specific tributary. If the tributary
is on the right, insert into the V keeper with the
V lock at the bottom. For a left sided tributary
insert the vein with the V lock at the top. Follow the previous steps for rotating the harvester and advancing the V cutter.
• Continue the harvesting process until all the
tributaries have been cauterised and cut.
Release the vein from the V keeper and turn
off the CO
and light source. The vein can
2
now be divided proximally in the thigh or
distally (if the lower leg vein is harvested) and
then pulled out through the incision.
• After ligating or clipping the tributaries, flush
the vein as per institutional protocol to remove
any potential clots. Evacuate any blood from
the tunnel before closing the skin incision
with a subcuticular suture and the stab incision with an interrupted suture (See Video 3).
Note: There may be occasions when extending
the incision is necessary to access tethered
tributaries at the entrance of the tunnel. Similarly
have a low threshold to open certain points along
the harvest site if difficulties arise.
4 Traps, Tips and Tricks
4.1 Bleeding
If haemostasis is not achieved internally by spot
cautery, bleeding within the tunnel may obstruct
the view of the operator. In this case remove the
harvester from the tunnel and apply pressure to
the area externally for approximately 3 to
Endoscopic Vein Harvest Using an Open System (Terumo®) 123
Video 3 Harvest of LSV (▶ https://doi.org/10.1007/000-a7f)
5 minutes then continue (Fig. 15). A suction
catheter attached to a cell salvage system can be
used to evacuate blood from the tunnel (Fig. 16).
If bleeding persists then it may be necessary to
insert a drain (as per surgeons’ guidance or local
protocol).
Tips to avoid bleeding
During the dissection, advance the dissector
forwards then backwards, this allows the tunnel
to inflate with CO
thus enabling a better visual
2
field and will reduce the risk of damage to the
vein, bleeding or fat disruption.
During harvesting keep the vein in the middle
of the tunnel and avoid dragging the harvester on
the bottom, this will avoid bleeding and fat
disturbance.
4.2 Large or Bifurcating Tributaries
These can sometime tether the vein and it can be
difficult to dissect. Manipulation of the dissector
within the tunnel manually can enable the operator to accurately direct the tip of the dissector
around such tethered tributaries. Large tributaries
may sometimes bleed after cauterising and
cutting which can obstruct the view of the
operator, therefore leaving them till the end when
all other tributaries have been divided, may
prevent this. Note: It may be helpful to perform
tributary isolation to have better exposure of the
large tributary. Alternatively, the operator can
divide the tributary by performing a stab incision
and grab the large tributary with an artery clip.
4.3 Fat in Tunnel
Fat disru ption, particularly at the beginning of the
harvest when inserting the harvester or producing
a false tunnel, can obstruct the view and cause
endless problems with the harvesting process. If
this occurs the harvester will need to be removed,
cleaned of fat debris and reinserted. It is important
to disrupt as little fat as possible ensuring a clean
dissection and thus a fat free tunnel.
Tip
To ensure minimal fat disruption keep the cone
tip in the plane between the vein and fat during
the posterior and anterior dissection.
Fat stuck to the tip of the harvester can
sometimes be removed by extending the V
124 D. Croft et al.
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Fig. 15 Dealing with branch bleeding
keeper in the hope it will become dislodged from
the end of the harvester to allow the harvesting
process to progress (See Video 4).
4.4 Superficial Saphenous Vein
In our experience, these veins tend to be difficult to dissect due to their adherence to the
anterior tunnel wall. Performing a posterior dissection first can make the anterior dissection
easier. Thin legs and vein adherence can be
challenging to dissect as too much pushing
may cause damage to the vein and there is a
danger of perforating the skin with the tip of the
dissector.
Tip
When it is difficult to advance the dissector
through the fat it may be necessary to adopt a
twisting action side to side to aid
advancement whilst applying external counterpressure at the tip of the dissector. In these situations, have a low threshold to perform an open
vein harvest.
4.5 Orientation
The camera can inadvertently twist which will
produce an incorrect position of the vein on the
monitor. To avoid this the operator must maintain correct positioning of equipment during
the harvesting process to ensure optimum orientation of the image (Fig. 17).
4.6 CO2Blockage
Fat and debris may occlude or impair CO
insufflation, if this occurs remove the harvester
2
Endoscopic Vein Harvest Using an Open System (Terumo®) 125
Fig. 16 Use of suction
and clean the end with a damp swab. The CO
tube on the harvester may also be evacuated by
using a 20 ml syringe of air.
4.7 Thermal Spread
Dissect enough tributary length to avoid the
spread of thermal damage when cauterising and
cutting tributaries.
4.8 Twisted/Tangled Vein
If the vein becomes twisted around or tangled
within the V Keeper, then release the V Lock and
carefully free the vein. Once freed, recapture the
vein in the V Keeper and continue with the
harvest. In the event of a tangled or twisted vein
around the V Keeper, where the view is
2
obstructed by blood or debris, open the leg to
safely free the vein under direct vision.
5 Post-operative Complications
5.1 CO2Embolus
Although rare, carbon dioxide insufflation during
EVH can enter a tributary or damaged saphenous
vein. This is potentially fatal and can cause CO
bubbles to collect in the right atrium (which may
be visible on trans-oesophageal echocardiogram
(TOE)) and may result in changes to the
haemodynamic status of the patient. In such
circumstances discontinue CO
immediately and treat the haemodynami c status
of the patient accordingly [4].
insufflation
2
2
126 D. Croft et al.
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Video 4 Traps, tips and tricks (▶ https://doi.org/10.1007/000-a7j)
Fig. 17 Correct orientation
Endoscopic Vein Harvest Using an Open System (Terumo®) 127
5.2 Saphenous Nerve Injury
In the thigh there can be altered sensation and
increased pain from injury to the medial femoral
cutaneous nerve. Similarly, the medial surface of
the lower leg can be affected when harvesting
LSV from below the knee. These symptoms are
temporary and should resolve in approximately
6 months [5].
As with open vein harvesting haematoma and
infection are post-operative complications and
treatment will follow institutional guidelines.
References
1. Zenati MA, Bhatt DL, Bakaeen FG, Stock EM,
Biswas K, Gaziano M, Kelly RF, Tseng EE,
Bitondo J, Quin JA, Hossein Almassi G, Haime M,
Hattler B, DeMatt, E, Scrymgeour A. GD Huang 2019
Randomized trail of endoscopic or open vein-graft
harvesting for coronary-artery bypass. 2019;380:132–
41.
2. Health and Safety Executive.:Back Pain. https://www.
hse.gov.uk/msd/backpain/index.htm. Accessed 21
May 2021.
3. Cohn JD, Korver KF. Optimizing Saphenous vein site
selection using intraoperative venous duplex ultrasound scanning. Ann Thorac Surg. 2005;79:2013–7.
4. Lin TY, Chiu MK, Wang MJ, Chu SH. Carbon
dioxide embolism during endoscopic saphenous vein
harvesting in coronary artery bypass surgery. J Thorac
and Cardio Surg. 2013;126(6):2011–105.
5. Raja SG, Sarang Z. Endoscopic vein harvesting:
technique, outcomes, concerns and controversies.
J Thorac Dis. 2013;5 Suppl 6:630–7.
Further Reading
6. 888627_VS-PLUS-Brochure_USletter_MAR2018_
FINAL-LR.pdf (terumo-cvs.com)
Endoscopic Mitral Valve Surgery
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Using the External Clamp
Patrick Perier
Abstract
Fear change and it will destroy you, embrace
change and it will enlarge you.
Elizabeth Moon in the Speed of Dark
Minimally “invasive” mitral valve surgery has
become along the years more and more
accepted by the surgical community, and
more and more demanded by the patients. In
Germany, isolated mitral valve repair is performed minimally invasively in more than
50% of the cases. Many different approaches
are existing: direct Vision, totally endoscopic
operation, peripheral cannulation, central cannulation, depending on the surgeon’s preferences. One differentiation is the use of
external clamp or endo aortic occlusion. We
will concentrate in this article on the description of our use of the external clamp. Emphasis has to be placed on the advantages of the
totally endoscopic approach: limited incision,
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_8. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
P. Perier (&)
Herz und Gefäß Klinik, Salzburger Leite 1, 97616
Bad Neustadt/Saale, Germany
e-mail: pperier@club-internet.fr
no rib spreading to ensure limited postoperative pain and a quick recovery. Moreover;
everyone in the operating room can follow the
operation, which strengthens the links
between the members of the team, but also
this allows to train in a very effective way.
Keywords
Heart valveMitral valve repairMitral valve
Valve diseaseSurgeryMinimally
invasive approach
Minimally invasive mitral valve surgery started
in 1996 when Alain Carpentier performed the
first successful video assisted mitral valve repair
[1]. Pioneers like Fred Mohr [2] and Hugo
Vanermen [3] have further developed the technique which progressively has become a routine
approach for mitral valve surgery in many centers. In Germany, more than half of the operation
on isolated mitral valve regurgitation are performed minimally invasively. The presumed
benefits of this approach for both mitral valve
repair and mitral valve replacement include
improved cosmetic, but also a reduction in postoperative pain, blood loss, blood transfusi on,
hospital stay, and time to return to normal
activity; of course, there is no risk of sternal
infection. Numerous studies have confirmed the
safety of this approach, and the excellent midterm outcomes [4]. It has been shown that mitral
External clamp
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_8
129
130 P. Perier
valve repair can be performed with the same
efficiency as a standard sternotomy, and with the
same rate of repair [5].
Minimally invasive mitral valve surgery is a
spectrum, with different varieties of incisions,
means of cannulation and means of visualization.
Schematically it can be divided in two groups. In
the first group, direct vision is used. It is the most
popular, but it is associated with a longer incision
and most often a rib-spreading retractor is needed. This minimizes the full advantage of minimally invasive approach. In the second group,
endoscopic guidance (whether traditional or
robotic) with improved visualization allows to
further reduce invasiveness and trauma, thus
enhancing the advantages of minimally invasive
surgery [6, 7]. The recent development of 3-D
visualization has greatly improved the comfort,
the precision and has led to a decrease in the
operating and ischemic time.
To achieve good results and master this
approach, a learning cu rve is necessary which
may create a reluctancy to adopt this technique
[8–10].
Two different methods of cross clamping the
aorta is a vailable: the endo-aortic balloon
occlusion or the external trans thoracic cross
clamping which is the subject of this chapter.
There is little evidence to choose one option or
the other, and in end effect it is more a question
of personal inclination [11].
1 Arguments for the External
Clamp
Surgeons performing minimally invasive mitral
valve repai r usually adopt one way of clamping
the aorta external or internal and stick to this
method. Since the beginning of our experience,
we have chosen to use the external clamp for its
ease of use. Other elements are to be taken into
consideration, among which the economic aspect
plays is key. It is a fact that the price of the endoaortic balloon system is significant, whereas for
the external clamp, apart from the clamp bought
once for all, the only expenses are a 4-0 suture
and a cannula for the injection of the
cardioplegia.
Another point that will become increasingly
important is the environmental impact. The
amount of waste in the operating room after
using an endo clamp is considerably greater
(Fig. 1) than after using an external clamp
(Fig. 2) as shown in the attached pictures, and
that is not considering the negative impact on the
environment of the manufacture of this material.
In comparison, the carbon footprint of the external clamp is negligible.
The external clamp is always ready for use. In
contrast over the years, due to technical failures,
the production of the endo-balloon has been
stopped several times, sometime for a long period, obliging its users to switch to another
method. The reliability of the device is
questionable.
2 Preoperative Decision Making
Process
Once the indication for mitral surgery has been
retained, it is necessary to decide if the patient
can be operated minimally invasively, and this
depends on the level of expertise.
In advanced centers where minimally invasive
mitral valve surgery is routinely performed, all
patients referred for mitral surgery are operated
minimally invasively with or without concomitant tricuspid repair, atrial fibrillation ablation or
ASD. The contraindications are patients with
previous right thoracotomy, severe peripheral
vascular disease, or particularly important bar of
calcium of the posterior annulus, which may be a
relative contraindication. A previous sternotomy
is not a contraindication.
For surgeons with less experience, the selection of patients is crucial, and a step-by-step
strategy is mandatory to ensure a safe outcome
with a good result. Easy patients should be
tackled first, isolated mitral valve dysfunction
like annular dilatation, mitral valve replacement,
easy prolapse of the posterior leaflet. The
Endoscopic Mitral Valve Surgery Using the External Clamp 131
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Fig. 1 Waste in the OR after the use of an endo-clamp
difficulty of the cases may be progressively
increased, and then it is possible to add ablation,
then tricuspid repair and then a combination of
the three.
3 Preoperative Radiological
Examinations
A computed tomographic angiography from the
neck to the thighs may be performed. It will assess:
– The ascending aorta (dimensions and quality)
– The presence of significant mitral
calcifications
– The most appropriate intercostal space to
access the mitral valve.
– The descending and abdominal aorta
– The iliac and femoral vessels ruling out
aneurysm, severe arteriosclerotic disease, or
dissection.
In our center, we do not perform this examination routinely, except for patients above
75 years of age, or patients with history of
peripheral vascular disease.
4 Anesthesia and Positioning
of the Patient
A routine anesthesia is performed. The only
particular point for minimally invasive surgery is
the question of intubation: single lumen or double lumen tube. There are advantages to both
approaches. With the single lumen tube, one has
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