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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 Cardiac Surgery—Tips, Tricks and Traps; Endoscopic Vessel Harvesting … 71
Fig. 1 Surgical instruments required for minimally invasive endoscopic vessel harvesting by means of a non-sealed
system. In the box, detail of the vessel sealing system fitting in the dedicated tunnel in the endoscopic retractor
to prevent injuring the brachial plexus. As such,
we recommend that the angle between the chest
and the abducted arm should be 80° or less. This
could be even more important in aged patients
with a history of arthritis, or in patients with a
history of shoulder interventions/stabilization.
Moreover, it is highly recommended to firmly fix
the arm to the armboard, in order to avoid
unnecessary movement or sliding of the arm
during harvesting maneuvers (See Fig. 2 and
Video 1).
between the brachioradialis (BRM) and flexor
carpi (FCM) muscles. Dissection of this plane is
extended proximally under direct vision, by
gently lifting the self-retaining retractor (generally 3-4 cm more from the incision edge). Aim of
the surgical exposure is to achieve full mobilization of the RA as a pedicle graft (Fig. 4A, B).
Hence, fascia is opened and dissection of surrounding tissues superiorly, laterally, medially
and inferiorly to the RA is performed.
Impedance-controlled bipolar radiofrequency
vessel sealing system (LigaSure Maryland,
Medtronic, Minneapolis, MN, USA) is used to
4.2 Surgical Exposure
divide the pedicle from surrounding tissues until
at least 3-4 cm have been harvested under direct
Beginning 1 cm above the radial styloid prominence, a longitudinal incision of approximately
2-3 cm is performed along the course of the RA
(Fig. 3). A self-retaining retractor is used to
spread subcutaneous tissue and expose the fascia
visualization (Fig. 4C), then a specifically
designed reusable endoscopic retractor (Karl
Storz, Tuttlingen, Germany) can be inserted
and used to harvest the remaining RA
endoscopically.
72 F. Rosati et al.
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Fig. 2 Left arm positioning: white arrow highlights the
use of a rolled pad underneath the wrist in order to
white star shows drapes used to firmly secure the left arm
to the surgical armboard
adequately hyperextend and expose the RA while the
Video 1 Endoscopic Radial Artery Harvesting with a non sealed approach (▶ https://doi.org/10.1007/000-a7b)
Endoscopic Cardiac Surgery—Tips, Tricks and Traps; Endoscopic Vessel Harvesting … 73
Antecubital Fossa
Edge of
Brachioradialis Muscle
Fig. 3 Schematic left arm anatomy: black dashed lines
depict the course of the edge of the brachioradialis muscle
(upper line) and the flexor carpi muscle (bottom line). Red
dashed line highlights the course of the left RA from the
Radius Styloid
Edge of Flexor Carpi
Muscle
wrist until the antecubital fossa. The short white dotted
line shows the initial incision line, 1 cm above the radius
styloid and extended proximally for 2–3cm
Fig. 4 Left RA is fully isolated as a pedicle before
starting endoscopic maneuvers. A and B: the vessel
sealing system during the “open” phase is used to divide
Tips, tricks and traps: To manage RA side
branches, use of hemoclips must be avoided as
they may dislodge or be torn off by the endoscopic retractor, leading to unnecessary bleeding.
The ideal position of the self-retaining retractor is
side branches and avoid the use of hemoclips; C: Left RA
is fully isolated as a pedicle. Note the self-retractor with
the handle positioned towards the elbow
as depicted in Fig. 4, with the handle placed
towards the antecubital fossa in order to enhance
visualization of the dissection tunnel and move
the initial dissection as far as possible under
direct vision. We strongly recommend following
74 F. Rosati et al.
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the exact sequence of dissection as described
above: first proceed by opening the fascia
between the BRM and FCM as far as possible
proximally, then, laterally, dividing RA side
branches and surrounding tissue from the side of
the BRM; next,medially, dividing all side branches and dissect surrounding tissue at the level of
the FCM; lastly, divide surrounding tissue inferiorly to the RA. If RA dissection is started
medially, traction from the lateral side branches
may pull the RA under the BRM, and make the
procedure more challenging. Satellite veins at
both sides of the RA should be kept as references
and surrounding tissue should be divided beyond
them (Fig. 4A, B). Pay particular attention when
moving the dissection laterally at the level of the
wrist: here, the superficial radial nerve might be
close, so we strongly recommend avoiding
unnecessary traction or digging. Also, the use of
a vessel loop around the RA is not helpful, and
may, in fact, be dangerous. It is mandatory to
correctly prepare and visualize the four dissec-
tion planes in order to maintain a “parachute”
reference during endoscopic maneu vers.
4.3 Endoscopic Harvesting
As suggested above, we recommend starting by
dividing the fascia between BRM and FCM until
the antecubital fossa is reached. The endoscopic
retractor is slid superior to the muscular fascia in
order to divide subcutaneous tissue above the RA
course (Fig. 5).
Tips, tricks and traps: the initial dissection
plane should be maintained and lim ited to the
fascia. In most instances, the RA, around the
mid-portion, tends to dive underneath the BRM:
Edge of Flexor Carpi
Muscle
Fig. 5 Endoscopic view: the red-triple line depicts the
course of the left RA in its mid-portion tending to run
underneath the BRM. The black dotted line highlights the
Edge of
Brachioradialis Muscle
fascia between BR and FC muscles that should be divided
as the first step of the endoscopic harvesting
Endoscopic Cardiac Surgery—Tips, Tricks and Traps; Endoscopic Vessel Harvesting … 75
Edge of
Brachioradialis Muscle
Fig. 6 Endoscopic harvesting at the level of the BRM
(lateral) side: red-triple line shows the course of the left
RA with the two satellite veins (blue dashed lines). Note
the edge of the BRM gently lifted by the endoscopic
here, it is important to proceed proximally by
dividing the fascia along the BRM edge, as the
dissection plane moves slightly medially. While
the RA may seem “invisible” at this level, correctly dividing the fascia will lead to the antecubital fossa where the RA tends to superficialize
and become clearly visible again. It is very
important to avoid division of any muscular
structure that may bleed after heparin is given for
cardiopulmonary bypass increasing the risk of
bleeding and hematoma.
Once the fascia is opened, the retractor is
pulled distally, the dissection plane between the
RA and the BRM (RA lateral side) is visualized
endoscopically, then dissection of the RA itself is
started with the goal of reaching the antecubital
fossa (Fig. 6).
retractor and the RA running underneath. The vessel
sealing system is providing division of lateral sidebranches towards the BRM
Tips, tricks and traps: in most instances, the
RA runs underneath the BRM, making endoscopic harvesting challenging. This is particularly true for muscular forearms. By using the tip
of the endoscopic retractor to gently lift the
BRM, a proper visualization of the lateral dissection plane is achieved (Fig. 6). Advancing
with small bites of the vessel sealing system can
be considered to avoid damaging the RA at this
level. Do not move the dissection plane towards
the FCM: it should be kept intact since the FCM
and RA attachments pull the RA towards the
midline, improving exposure, especially in difficult cases.
Similarly, once the previous part is completed,
dissection is started at the FCM side from distal
to proximal until the antecubital fossa is reached.
76 F. Rosati et al.
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Edge of Flexor Carpi
Muscle
Fig. 7 Endoscopic harvesting at the level of the FCM
(medial) side: red-triple line shows the course of the left
RA with its medial satellite vein (blue dashed line). Note
During this stage, residual branches at the level
of the inferior aspect of the RA are also divided
(Fig. 7). It is mandatory to assess the presence of
any residual side branches by means of a pigtail
vessel dissector (Fig. 8).
Tips, tricks and traps: normally the FCM is
smaller compared to the BRM, and does not
“bulge” as much. Attention should be paid when
approaching the antecubital fossa while performing dissection of the inferior aspect of the
RA: in some circumstances, large collateral veins
can be visualized close to the division between
the RA and ulnar artery. Dissect cautiously and,
if extra-length is not required, stop at this level.
Caution should be taken when endoscopically
harvesting the right RA. Since we preferentially
use the non-dominant arm, operators will become
more familiar with the anatomy of the left arm, in
which the lateral side of the RA is visualized at
the level of the right side of the endosco pic view.
Thus, during harvesting maneuvers, especially
the edge of the FCM (black dashed line) which is less
bulging of the contralateral BRM
during the fascia opening phase, the dissection
line is moving from right to left proceeding from
the wrist towards to the antecubital fossa, in
order to avoid the BRM. Conversely, the opposite direction will be taken if the right RA is
harvested: an automatic tendency to slightly
move from right to left should be avoided
keeping in mind that the BRM side (lateral side)
of the right RA is positioned to the left side of the
screen thus, the ideal direction will be from left
to right proceeding from the wrist to the antecubital fossa (Fig. 9).
Otherwise, we recommend following the
same steps normally used for the left RA.
4.4 Radial Artery Endoscopic
Retrieval
Once heparin is given, operators can proceed to
retrieve the full length of the RA. As reported by
Endoscopic Cardiac Surgery—Tips, Tricks and Traps; Endoscopic Vessel Harvesting … 77
Fig. 8 Pigtail dissector to check the presence of any residual branches
the factory, a proper sealing is guaranteed for up
to 7 mm vessel diameter, and, as such, a single
incision could be performed safely in each
patient: the RA is divided at its proximal end
(antecubital fossa) and the graft is then retrieved
through the same distal incision at the level of the
wrist (single-incision approach) (Fig. 10).
Tips, tri cks and traps: if operators are not
confident in directly dividing the RA by using
the vessel sealing system proximally or if the
angle between the RA and the vessel sealing
system does not provide a safe direct approach, a
counter incision (2 cm max) could be performed
at the level of the antecubital fossa above the tip
of the endoscopic retractor. Then a blunt dissection is performed under endoscopic control
and a tape is passed around the RA. Now, the
graft can be divided directly at the level of the
wrist and gently pulled from the proximal incision (counter-incision approach). In this context,
it is extremely imp ortant to check for any residual side branches before proceeding with the
single incision or double incision techniques for
graft retrieval.
Incision is sutured in usual fashion after distal
ligation of the RA at the level of the wrist. In
case sneaky bleeding is present after protamine
administration, a small drain can be used and
removed following clinical judgement in the
first/second postoperative day.
5 Endoscopic Saphenous Vein
Harvesting Technique
5.1 Preliminary Details
The course of the great saphenous vein must be
marked in every patient by means of ultrasound
to identify:
78 F. Rosati et al.
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Edge of
Brachioradialis Muscle
Edge of Flexor Carpi
Muscle
Fig. 9 Endoscopic view of the right RA: the red-triple line depicts the course of the right RA in its mid-portion tending
to run underneath the BRM (left side). The black dotted line highlights the fascia between BR and FC muscles
A
Fig. 10 Radial artery (red-triple line) is directly divided proximally: note the vessel sealing system crossing the radial
course (A) and the proximal radial artery stump (B) left after completing the retrieval procedure
B
Endoscopic Cardiac Surgery—Tips, Tricks and Traps; Endoscopic Vessel Harvesting … 79
Fig. 11 The course of the saphenous vein is mapped by means of ultrasound. Note the orange tourniquet at the level of
the thigh (white arrow) in order to increase saphenous vein diameter for a better visualization (blue dashed circle)
– the site of the initial incision;
– anatomical/pathological variations;
– large side-branches (in experienced hands)
Before mapping, to increase the size of the
vein and improve visualization, a tourniquet
should be at the level of the thigh (Fig. 11).
Tips, tricks and traps: the best exposure is
provided by placing rolled sheets under the
knees, with both legs externally rotated, and
knees slightly bent in a “frog-like” position. Both
knees must be completely supported to avoid
position-related neurological complications.
5.2 Surgical Exposure
A2–3 cm longitudinal incision is made over the
course of the SV above the knee. A self-retractor
is used to enhance exposure, and the subcutaneous tissue is divided, thereby mobilizing the
first 4-5 cm of saphenous vein. Similarly to the
RA exposure, impedance-controlled bipolar
radiofrequency vessel sealing system (LigaSure
Maryland, Medtronic, Minneapolis, MN, USA)
may be used at this stage to gently dissect surrounding tissues and side branches.
Tips, tricks and traps: the tissue surrounding
SV does not provide stabilization like the muscular structures around the RA. As such, counter
traction and stability is crucially provided by a
vessel loop passed around the vein. We strongly
recommend gently lifting the self-retractor in
order to isolate the SV along its course as far as
possible under direct visualization. As sugges ted
previously, at this stage, the use of hemoclips
should be avoided (Fig. 12).
5.3 Endoscopic Harvesting
A specifically designed reusable endoscopic
retractor can be gently inserted through the
“open” incision once the SV is isolated. As tissue
surrounding SV is mainly composed of subcutaneous fat, dissection is mostly performed by
80 F. Rosati et al.
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Fig. 12 Saphenous vein is fully isolated as a pedicle
through a 3 cm incision above the knee (left side).
A vessel loop (yellow string) is passed around the
saphenous vein in order to provide stabilization during
harvesting maneuvers. Note the operator working position
gently advancing the endoscopic retractor, while
the vessel sealing system can be used to perform
smooth dissection and seal side branches.
Tips, tricks and traps: it is strongly recommended beginning the ESVH above the knee,
and proceeding with the endoscopic phase
towards the groin. This is particularly helpful for
beginners since the course of the vein is more
linear and side branches usually originate perpendicular to the main axis without vertical side
branches that might be damaged while advancing
the endoscopic retractor. Moreover, the “froglike” position allows the operator to work from
the patient’s feet without conflicts between their
maneuvers, patient’s knees and the scrub nurse
(Fig. 13). This setting can usually provide a
20–25 cm segment (from above the knee to the
groin). If extra-length is required, the operator
can invert his/her position and proceed towards
the knee from the same incision (Fig. 13—right
box). Before inverting position s and beginning
endoscopic maneuvers, the SV must be isolated
at the incision site under direct visualization. At
with the handle of the self-retractor used to enhance
visualization and isolating the graft as far as possible. The
vessel sealing system is used also at this stage to divide
side branches thus avoiding the use of hemoclips
the level of the knee, the SV receives vertical
collaterals from subcutaneous tissue. Hence,
advancing the endoscopic retractor might be
challenging and should be done carefully.
Alternatively, an incision may be made 3 cm
below the knee over the course of the SV: this
can either be a starting point for endoscopic
harvesting or an additional incision in case extralength is required. The operator can proceed
distally towards the ankle, but they should work
from the side of the patient’s hips. It is still
necessary to keep the legs in a “frog-like” position. In cases where a short segment is required,
the operator, according to surgeon’s preference,
could start endoscopic harvesting from the ankle
and proceed proximally towards the knee. We
suggest positioning the patient’s ankle at the very
edge of the surgical table and starting 2-3 cm
above the incision you would have normally
done for the standard “open” approach. These
precautions avoid conflicts between harvesting
instruments against medial malleolus and/or the
edge of the table.
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