Aly AL-SANEL, Emad BUKHARİ, Charles CANVER, Muhammed TAMİM

Endoscopic saphenous vein harvesting: Results of our initial experience

Amaç: Koroner arter bypass grefti (KABG) ameliyatı sırasında klasik açık cerrahi yöntemle ven hazırlanması, ameliyat sonrasında rahatsızlık, şişlik, deri rengi kaybı, yarada akıntı, yüzeysel yara enfeksiyonu ve yara izi gibi sorunları beraberinde getirir. Son zamanlarda geliştirilen minimal invaziv endoskopik ven greft hazırlanması (EVGH) tekniği dünyada cerrahlar ve hastalar tarafından yaygın bir kabul görmüştür. Bu çalışmada merkezimizde KABG uygulanan hastalarda EVGH ile ilgili ilk deneyimlerimiz değerlendirildi.Çalışma planı: Çalışmaya Aralık 2005 ve Haziran 2006 tarihleri arasında izole KABG uygulanan 32 hasta (6 kadın, 26 erkek; ort. yaş 62±10; dağılım 41-80) alındı. Endoskopik ven greft hazırlanması için dizin medial kısmına standart 2 cm'lik insizyon uygulandı. Ortalama takip süresi 5±3 aydı. Bulgular: Aşırı kanamadan dolayı EVGH'den açık cerrahi yönteme geçilen iki hasta değerlendirmeye alınmadı. Diğer hastalarda safen venlerin endoskopik hazırlığı başarılıydı. Kullanılan bypass grefti sayısı 3.6±0.5 idi. Elde edilen ven yolu uzunluğu ortalama 45.0±12.6 cm idi; bu miktar ilk 10 hastada 38.3±5.7 cm iken, son 10 hastada 50.1±13 cm'ye yükseldi. Dikey insizyon uzunluğu ortalama 4.1±2.0 cm idi. Greft hazırlama süresi ortalama 43.5±9.5 dakika idi; bu süre zamanla azalarak 90 dakikadan 25 dakikaya düştü. Bacak derisi insizyonunu kapama süresi ortalama 6.6±2.9 dakika idi. İşlem sonrasında drenaj kateteri yalnızca iki hastada gerekti. Endoskopik ven greft hazırlanmasına bağlı komplikasyon olarak iki hastada ameliyat sonrası hematom (%6.7), bir hastada yüzeysel ekimoz (%3.3) görüldü. Hastanede kalma süresi ortalama 6.5±0.9 gün idi. Ameliyat sonrasında yara enfeksiyonu görülmedi. Hastaların hepsi erken hareket ve bacak insizyonlarının hızlı iyileşmesinden dolayı işlemden memnun kaldığını belirtti. Sonuç: İlk deneyimlerimiz klasik açık yönteme göre EVGH yönteminin güvenli ve etkili olduğunu bir kez daha gösterdi. Hasta grubumuzun ifade ettiği yüksek derecedeki memnuniyet, KABG sırasında EVGH'nin rutin olarak kullanımını teşvik eder niteliktedir.

Endoskopik safen ven greft hazırlanması: İlk deneyim sonuçları

Background: Traditional open surgical vein harvesting during coronary artery bypass grafting (CABG) is associated with considerable postoperative problems including discomfort, swelling, skin discoloration, wound drainage, superficial wound infections, and scarring. Minimally invasive endoscopic vein harvesting (EVH) technique has been widely accepted by surgeons and patients worldwide. The aim of this study was to review our initial experience with EVH in patients undergoing CABG at our center.Methods: The study included 32 patients (6 women, 26 men; mean age 62±10 years; range 41-80 years) who underwent isolated CABG between December 2005 and June 2006. A standard 2-cm incision at the medial aspect of the knee was used for EVH. The mean follow-up was 5±3 months. Results: Two patients required conversion to open technique due to bleeding and were not included in the evaluation. Endoscopic procurement of the saphenous vein was successful in the remaining patients. The mean number of bypass grafts used was 3.6±0.5. The mean length of vein conduit was 45.0±12.6 cm, which was 38.3±5.7 cm in the first 10 patients and 50.1±13 cm in the last 10 patients. The mean length of vertical incision was 4.1±2.0 cm. The overall mean harvesting time was 43.5±9.5 min. Harvesting time gradually decreased over time (from 90 to 25 min). The average time for closing the leg skin incision was 6.6±2.9 min. A drainage catheter was necessary in only two patients. Complications related to EVH were postoperative hematoma in two patients (6.7%) and superficial ecchymosis in one (3.3%). The mean hospital stay was 6.5±0.9 days. No wound infections were seen postoperatively. No early or late deaths occurred. All the patients expressed remarkable satisfaction with regard to mobilization and early healing of leg incisions. Conclusion: Our initial experience supports the previously shown safety and efficacy of the EVH technique compared to the traditional open technique. High-satisfaction expressed by the patients should encourage the routine use of EVH during CABG.

PDF

___

1) Utley JR, Thomason ME, Wallace DJ, Mutch DW, Staton L, Brown V, et al. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Cardiovasc Surg 1989;98:147-9.
2) DeLaria GA, Hunter JA, Goldin MD, Serry C, Javid H, Najafi H. Leg wound complications associated with coronary revascularization. J Thorac Cardiovasc Surg 1981;81:403-7.
3) Lavee J, Schneiderman J, Yorav S, Shewach-Millet M, Adar R. Complications of saphenous vein harvesting following coronary artery bypass surgery. J Cardiovasc Surg 1989;30:989-91.
4) Aziz O, Athanasiou T, Darzi A. Minimally invasive conduit harvesting: a systematic review. Eur J Cardiothorac Surg 2006; 29:324-33.
5) Allen KB, Griffith GL, Heimansohn DA, Robison RJ, Matheny RG, Schier JJ, et al. Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial. Ann Thorac Surg 1998;66:26-31.
6) Cable DG, Dearani JA. Endoscopic saphenous vein harvesting: minimally invasive video-assisted saphenectomy. Ann Thorac Surg 1997;64:1183-5.
7) Davis Z, Jacobs HK, Zhang M, Thomas C, Castellanos Y. Endoscopic vein harvest for coronary artery bypass grafting: technique and outcomes. J Thorac Cardiovasc Surg 1998;116: 228-35.
8) McGuire DB. The measurement of clinical pain. Nurs Res 1984;33:152-6.
9) Graceley R. Verbal pain assessment: integrated approach to management of pain. In: National Institutes of Health Consensus Development Conference; February 4, 1986; Baltimore, USA. 1986.
10) Utley JR, Leyland SA. Coronary artery bypass grafting in the octogenarian. J Thorac Cardiovasc Surg 1991;101:866-70.
11) L'Ecuyer PB, Murphy D, Little JR, Fraser VJ. The epidemiology of chest and leg wound infections following cardiothoracic surgery. Clin Infect Dis 1996;22:424-9.
12) Allen KB, Shaar CJ. Endoscopic saphenous vein harvesting. Ann Thorac Surg 1997;64:265-6.
13) Griffith GL, Allen KB, Waller BF, Heimansohn DA, Robison RJ, Schier JJ, et al. Endoscopic and traditional saphenous vein harvest: a histologic comparison. Ann Thorac Surg 2000;69: 520-3.
14) Pagni S, Ulfe EA, Montgomery WD, VanHimbergen DJ, Fisher DJ, Gray LA Jr, et al. Clinical experience with the video-assisted saphenectomy procedure for coronary bypass operations. Ann Thorac Surg 1998;66:1626-31.
15) Morris RJ, Butler MT, Samuels LE. Minimally invasive saphenous vein harvesting. Ann Thorac Surg 1998;66:1026-8.
16) Carpino PA, Khabbaz KR, Bojar RM, Rastegar H, Warner KG, Murphy RE, et al. Clinical benefits of endoscopic vein harvesting in patients with risk factors for saphenectomy wound infections undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;119:69-75.
17) Tevaearai HT, Mueller XM, von Segesser LK. Minimally invasive harvest of the saphenous vein for coronary artery bypass grafting. Ann Thorac Surg 1997;63(6 Suppl):S119-21.
18) Kiaii B, Moon BC, Massel D, Langlois Y, Austin TW, Willoughby A, et al. A prospective randomized trial of endoscopic versus conventional harvesting of the saphenous vein in coronary artery bypass surgery. J Thorac Cardiovasc Surg 2002;123:204-12.
19) Bitondo JM, Daggett WM, Torchiana DF, Akins CW, Hilgenberg AD, Vlahakes GJ, et al. Endoscopic versus open saphenous vein harvest: a comparison of postoperative wound complications. Ann Thorac Surg 2002;73:523-8.
20) Black EA, Campbell RK, Channon KM, Ratnatunga C, Pillai R. Minimally invasive vein harvesting significantly reduces pain and wound morbidity. Eur J Cardiothorac Surg 2002; 22:381-6.
21) Meyer DM, Rogers TE, Jessen ME, Estrera AS, Chin AK. Histologic evidence of the safety of endoscopic saphenous vein graft preparation. Ann Thorac Surg 2000;70:487-91.