R Feyrer, U Metzler-Bertram, T Seitz, R Tandler, T Strecker, A Purbojo, T Fischlein, M Weyand
cabg, minimally invasive, saphlite, vein harvesting
R Feyrer, U Metzler-Bertram, T Seitz, R Tandler, T Strecker, A Purbojo, T Fischlein, M Weyand. SaphLITE System, Standard Bridge Technique or Conventional Vein Harvesting: A Randomized Comparison. The Internet Journal of Thoracic and Cardiovascular Surgery. 2004 Volume 7 Number 1.
Background: The value of newly developed techniques for saphenous vein harvesting remains controversial. Which technique offers the most benefits is still unknown. The aim of this study was to compare conventional vein harvesting through a continuous skin incision with two less invasive methods, while focusing on surgical advantages and postoperative results.
Methods: In this prospective study, 110 CABG patients were randomized to vein harvesting by standard continuous skin incisions (group I), conventional bridge technique (group II), and the SaphLITE retractor system (Genzyme) (group III). Particular interest was paid to collect intraoperative data and postoperative clinical results.
Results: The ratio vein length/incision length was 0.89 (Group I), 1.9 (Group II), and 3.3 (Group III). Dissection time per centimeter harvested vein and time for wound closure were found to be 1.23 min (0.77min), 0.89 min (0.57 min), and 0.96 min (0.46 min), respectively.
No wound infection was seen in either group; conduit quality, postoperative pain and mobilization were similar. Hematoma and edema formation were less frequent in groups I and II. The best cosmetic results were seen in the SaphLITE group.
Conclusions: Less invasive vein harvesting techniques, especially use of the SaphLITE retractor system, yield favorable clinical results, particular with respect to the cosmetic appearance. Compared with the conventional approach, the method is suitable for routine vein harvesting, because it has less complications and it is easy and fast to perform. Since the bridge technique does not require special instruments, it has economic advantages.
Presented at The 8 th Annual CTT Meeting 2002 Miami Beach, Florida
Saphenous vein harvesting through long continuous skin incisions has an extended history in cardiac surgery. Over recent years, minimal invasive techniques have begun to gain ground in cardiac surgery. Cosmetic considerations were the primary impetus to develop various methods for minimal invasive vein harvesting. The surgical spectrum encompasses a wide range of techniques, from intermittent skin incisions to totally endoscopic vein harvesting. More and more patients request that such methods are used. Patients' wishes and cosmetic considerations alone cannot justify the introduction of novel methods, however. It is essential to assess not only suitability and feasibility of each individual technique, but also their safety, associated complications, and postoperative results. Finally, cost considerations need to be included when weighing the pros and cons of particular techniques.
This study was designed to cover these aspects. Two minimally invasive approaches – SaphLITE retractor system (Genzyme) and standard bridge technique performed with regular surgical instruments – were compared with conventional vein harvesting through a long continuous incision.
Materials and Methods
110 patients (34 women and 76 men, 46-82 years of age) scheduled for elective coronary bypass grafting were enrolled and randomized. Patients were assigned to one of three groups: conventional open vein harvesting (group I), standard bridge technique (group II), vein harvesting with the SaphLITE system (group III). Severe varicosities, preexisting skin conditions (e.g. psoriasis), and a history of surgical procedures on the lower extremities were exclusion criteria.
Conventional vein harvesting
Exposure through a continuous skin incision over the greater saphenous vein (GSV) from the medial malleolus advancing proximally. Vein dissection, division of side branches between ligatures. Distal and proximal division of the saphenous vein and ligature of both stumps. Placement of a drain, running subcutaneous suture, running intracutaneous suture, sterile dressing, elastic bandage.
Standard bridge technique
4 cm long skin incisions with approximately 4 cm long intervening skin bridges; direct dissection of the exposed vein under vision; exposure and dissection of the vein inside the tunnels using Langenbeck retractors, vein dissector and standard instruments, application of titanium clips to any side branches, insertion of drains in some areas, simple interrupted subcutaneous sutures, running intracutaneous suture, sterile dressing, elastic bandage [fig. 1A].
3-4 cm long skin incisions with 8–18 cm long intervening skin bridges over the course of the GSV. Direct dissection of the exposed vein under vision, additional exposure using the lighted retractor system, further dissection inside the tunnel using long standard instruments and vein dissector, clipping of some side branches and only division of others. Remaining open branches on the venous conduit are ligated after harvesting. Drain insertion in some areas, simple interrupted subcutaneous sutures, running intracutaneous sutures, sterile dressing, elastic bandage [fig 1B].
The following intraoperative parameters were recorded or calculated:
Total length of incision, length of individual incisions, number of incisions, length of skin bridges, length of vein, ratio length of vein to length of incision, time for harvesting, wound closure time, time to harvest one cm of vein, wound closure time per cm of vein, cross-over to different technique, quality of harvested vein (as assessed by the surgeon), complications.
Until patients were discharged, the following parameters were evaluated using a pre-defined scale of 0-3: Hematoma formation, edema, infection, skin edge redness/necrosis, pain, mobilization, cosmetic appearance.
In group I (conventional harvesting), the ratio of vein length to incisional length was .89, in group II (bridge technique) 1.9, and in group III (SaphLITE) 3.3 [fig. 2]. The time for dissecting one cm of vein was 1.23 min in group I, .89 min in group II, and .96 min in group III. The time required for wound closure was 0.77 min in group I, .57 min in group II, and .46 min in group III [fig. 3]. There were no cross-overs to the open technique. Conduit quality was not significantly different between groups. In group I, one case of skin edge necrosis and one case of a localized wound infection were observed. One grade 3 hematoma and one case of grade 3 edema were seen in group I, none in groups II and III. A mild degree of edema formation occurred in all three groups, localized hematomas as well as postoperative discomfort were similar. Patients were mobilized without obvious differences between the groups. The cosmetic results were assessed in descending order as follows: group III, group II, group I. Group I and II vein harvesting costs were comparable; the costs were considerably higher in group III [fig. 4].
Over recent years, new techniques for minimal invasive vein harvesting in coronary artery surgery appeared at a breathtaking rate. Despite lacking clinical data, some methods were advertised for routine use. The following issues need to be addressed prior to introducing a new technique: Is the method as safe as conventional techniques, i.e. does it have an identical complication rate? Is the technique suitable and is its routine clinical use feasible? If these criteria are fulfilled: Which reasons support the introduction of the particular method?
This study was designed to consider the above issues. Two minimal invasive vein harvesting techniques were compared with the conventional method.
Using the SaphLITE system, the harvested vein length per cm incisional length compares favorably with the conventional approach and also with harvesting through intermittent skin incisions. Surgical trauma and possible subsequent complications are therefore significantly reduced. On the other hand, the risk of postoperative bleeding is increased, because the side branches inside the tunnel can not always be adequately ligated. This problem is solved by consistent use of postoperative compression.
The time required for vein harvesting is not significantly different between the groups. After overcoming the learning curve, the new methods can be performed as quickly as the conventional technique. In most cases, the somewhat abbreviated time required for wound closure is not clinically relevant, because harvest site wound closure and coronary bypass grafting are usually performed simultaneously.
In comparison with the conventional approach, the minimal invasive techniques have similar complication rates; in fact, extensive hematomas and edema occur less frequently. Major complications were not seen with any method. Because of the methods' identical safety, patient safety concerns are no issue.
The crucial advantage of minimal invasive techniques, the SaphLITE system in particular, is their cosmetic result. A markedly shortened incision means excellent cosmetic appearance and high patient satisfaction as well. In this era of growing importance of patient acquisition, this factor should not be ignored.
The economic impact of the new methods require comment. The costs of the standard bridge technique approximate those of open vein harvesting, but the expenses associated with the retractor system are clearly higher. Even if growing case numbers make the initial investment pay for itself, the per case costs will still be significantly higher because of higher running costs. This is where a balance between cosmetics and economics needs to be found.
Dr. Richard Feyrer (MBA)Zentrum fuer HerzchirurgieUniversitaet Erlangen-NuernbergKrankenhausstr. 12D-91054 Erlangen, Germany+49 9131/85 33217+49 9131/85 36088 e-mail: firstname.lastname@example.org