[[300 Technical Outline of Coronary Artery Bypass Grafting]] # Endoscopic Vein Harvest - Make incision slightly anterior to marked vein site - Try to keep incision not much larger than diameter of Harvest Port - Use Metzenbaum scissors to develop tract anterior to vein cephalad and caudal to incision for 2-3 cm in either direction - Harmonic scalpel may be useful to deal with smaller branches - Attach camera to Getinge Vasoview scope - Keep the camera oriented constantly to aid in directional awareness - Insert scope with dissector tip through harvest port fitted with appropriate seal - Turn on optics and white balance - Slide dissector tip gently through incision anterior to vein while watching on screen - When sufficient progress has been made with dissector, slide Harvest Port over scope into the incision up to the hub - Inflate the port balloon with air in a syringe - Attach CO2 insufflation line to the Harvest Port - Slide dissector tip anterior to the vein, and anywhere from 9 to 3 o'clock, creating a space that the CO2 will fill - Note side branches, compare to those marked on the skin during [[Sonosite Ultrasound for Greater Saphenous Vein]] - Whenever a branch is seen dissect it out with the tip to increase length of visible branch away from Greater Saphenous Vein - Slide dissector tip immediately below branch, and back up to the level of the Greater Saphenous Vein - Retract dissector tip back to position before branch - Slide dissector tip immediately on top of branch - Progress until dissector tip can be palpated (and light can be seen) through the skin at inguinal crease - Do not neglect branches at this level: make sure that the vein will be free to be pulled up through skin when the time comes - Slide Dissector Tip back to the Harvest Port - Repeat process for posterior of vein and tissues between 9 and 3 o'clock - Vein should now appear as a structure surrounded by CO2, "suspended" only by branches - Dissect out as best possible, thin, diaphenous sheets of tissue on all sides of vein - Consider small heparin dose at this time. [^a] - Remove Scope with Dissector Tip from Harvest Port - Unscrew Dissector Tip from scope, carefully set aside, and clean scope tip with anti-fog solution - Insert Scope into Vasoview system until the notch in the base locks over light source - Insert Hemopro 2 tip into appropriate port of the Vasoview base, but don't let the tips of this instrument protrude past the far end at this time, as it will interfere with passage of the instrument into the tract surrounding the vein - Note that this port is opposite to the slide control of the c-ring - Attach power source into the back end of the Hemopro - Remove seal from Harvest Port with a Kelly clamp, replace with seal appropriate to Vasoview system - Insert the Vasoview/Scope system into the Harvest Port - Detach the CO2 line from the Harvest Port and connect it into the insufflation port of the Vasoview system. - Attach a syringe of anti-fog solution to the irrigation port of the c-ring - Carefully use the Vasoview system to sever/coagulate the branches of the vein - Extrude the c-ring, usually ahead of the branch you wish to take - Turn the Vasoview system clockwise or counterclockwise as desired while keeping the camera in correct orientation. This will apply tension on the branch by pushing the saphenous vein away from the direction of the branch. - As the Hemopro instrument port is 180 degrees away from the c-ring, this orients the instrument perfectly to take the branch - Push the Hemopro instrument out, with the curve of the instrument concave towards the Greater Saphenous Vein - Apply the Hemopro as far away on the branch as possible to avoid thermal injury, but realize that inside the curve of the instrument, the tips are shielded to avoid propagation of heat more than 1 millimeter - Push the slide control of the Hemopro to close the tips. Further pressure will activate the heat source. - If possible, when the Hemopro tips have closed over the branch, relax some of the c-ring torque pulling on the branch. This lessens the chance that the branch will part before the instrument has had a chance to thoroughly cook the ends. - Consider leaving large branches to the very end of the harvest - If there is bleeding, it will be less likely to interfere with the remainder of the harvest if this is done at the end - With a large branch, even after it has parted and the Saphenous Vein has pulled away, keep the instrument heated and pushed up against the side of the channel to maximize cautery of the branch remnant - I will sometimes activate the Hemopro without clamping the branch to heat up the tips, then apply the instrument to the large branch so that it gets some "pre-cooking" before the real heat is generated to increase coagulation before severing the branch. - At various points during the Vasoview phase of the procedure, it can be very useful to enlarge the channel around the vein by performing "Tunneloplasty" - The fascia anterior to the vein is seen inside the channel - A tip of the open Hemopro clamp is dug into the the fascia, then the tips are closed and power applied - This line is the fascia is extended as desired, and the CO2 opens up the tunnel - At this point, the Greater Saphenous Vein should be free from all branches to the desired length - It is important to confirm this - Deploy the c-ring on top of the furthest extent of the vein to be harvested - The c-ring is rotated clockwise to the undersurface of the vein, and the Vasoview is systematically drawn back until the port is seen on the camera - Any intact branches would interfere with this transit of the c-ring - The process is repeated with the c-ring rotated on the counter-clockwise to the undersurface of the vein - The camera is focused on the furthest extent of the vein to be harvested while the skin overlying that portion is dimpled with a finger, and seen from the inside by the camera. - The area directly over the vein is marked - An eleven blade is inserted here and the orientation of the tip towards the vein is noted on the camera. A slit is made just large enough to admit a tonsil clamp. - Keeping eyes on the television screen, a tonsil clamp is quickly inserted, and the vein is clamped using the tips of the instrument - It pays to be consistent so as to avoid losing orientation. I face the concavity of the curved tonsil tips towards the vein I will be cutting. - The clamp is pulled with the vein out of the "Stab and Grab" incision - A tonotomy scissors is used to cut the vein, leaving enough tissue in the clamp to satisfyingly ligate with a strong silk tie - Leave the tie uncut - Release the tonsil while holding the vein stump - Apply two medium clips to the stump past the tie - Cut the tie - Let the vein stump retract into the thigh - Ask the scrub nurse to use a finger to temporarily occlude the "Stab and Grab" incision so CO2 will not escape - Pick up the free end of the vein with the c-ring and pinch it against the Vasoview sytem by retracting the c-ring into the housing gently - Pull the entire system and the vein through the port - Remove the port over the vein - Take any remaining branches that had been hidden by the walls of the port in the immediate vicinity of the initial incision - The Harmonic Scalpel can be borrowed from the team member harvesting arterial conduit to help in this portion. - Further vein can be harvested by repeating this process down the leg - This can be done before or after taking the thigh portion - If only a few centimeters are desired, this can be done through the incision with retraction from an Army-Navy and the distal Vein taken after ligation with orange cysto clips - Before attending to closure of the incision, the vein should be throughly flushed with heparinized saline in advance of [[Preparation of Venous Conduit]] - If the field is sanguineous, closure of the incision can be deferred until after reversal of anticoagulation with protamine. - The surgeon is often keenly aware of which particular side branch is the source of truly concerning bleeding, and it is a simple matter to make a small incision in that area and directly control it. - An olive tip Yankauer can be used to suck out the wound, plus or minus some irrigation, then the wound rolled dry with external application of force - A blake drain can be dragged into the wound through the "Stab and Grab" using an Alley chest tube passer or other long clamp, then brought out through another stab incision, or fed in through a stab incision using ring forceps. These adjuncts are highly unusual. - The tight ACE wrap bandage will help with hemostasis - Most often, the harvest is dry enough to close immediately after [[Preparation of Venous Conduit]] - Primary incision - 2-0 Vicryl Dermis Layer - 3-0 V-lock Subcuticular - "Stab and Grab" - Dermabond or plain band-aid [^a]:The manufacturer recommends a 5000 unit heparin dose prior to taking the branches to prevent clot formation. I have not found this necessary.