ENDOSCOPIC VEIN HARVEST STEP BY STEP - …C1D47DCC... · ENDOSCOPIC VEIN HARVEST STEP BY STEP. ... Below the knee GSV runs along the tibial groove LSV ... leg where the GSV is thought

LT 7900563 Confidential information of MAQUET Cardiovascular. For Internal Use Only. Do not copy or distribute.

ENDOSCOPIC VEIN HARVEST STEP BY STEP

Confidential information of MAQUET Cardiovascular. For Internal Use Only. Do not copy or distribute.LT 7900563

� The Setup

� Positioning the Patient

� Locating the Vein Externally

� A One Inch (2cm) Incision

� Locating the Vein in the Subcutaneous Tissue

� Once the Vein is Found Create a Hood

� Dissection

� Branch Litigation

� Run the Vein

� Distal Litigation

� Remove the Vein

� Preparing the Vein

� Close the Leg Dress the Wound

AGENDA


ROOM SETUP

� Where to put the monitor????

� Include the OR staff in the decision

� Most optimal location would be directly across from the

harvester

� Usually not possible

� At the foot of the bed

� At the head of the bed


OBSTACLES

� The Staff

� New equipment brought into the room

� Believe they have to do a lot more work

� Time Factor

� Takes longer in the beginning

� Will get faster once the harvester is over the learning curve


EQUIPMENT NEEDED

� Video Tower (hospital)

� Bipolar Bovie Generator (hospital)

� Skin knife (hospital)

� Dissection scissors (hospital)

� Retractor (hospital)

� VasoView Kit (from us)

� 7mm Endoscope (from us)

� Bipolar bovie cord (from us)


VIDEO TOWER

� Video monitor (TV Screen)

� Camera Box

� Camera (sterile or placed in sterile bag)

� Light box

� Light cord (sterile)

� CO2 Tank

� CO2 insufflation Tubing (sterile)


BIPOLAR BOVIE

� Dedicated bovie generator

� Bipolar bovie cord

� Bipolar foot pedal


VASOVIEW KIT

� VasoView 6 kit (sterile)


7MM ENDOSCOPE

� Sterile 7mm endoscope

� Light cord adapters +/-


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


FROG LEG

� Heels of feet touching, bent at the knees

� Best if done prior to draping

� Should cushion ankles


BUMP THE LEG

� Elevation of the inner thigh

� Must be uniform

� Much better if subtle


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


GREATER SAPHENOUS VEIN

� Lies beneath the fascia and above

the muscle

� Courses anterior to the medial

malleolus, then medially into the

proximal thigh where it terminates

at the femoral vein

� Contains valves that open and

close in response to muscle

contractions to assist in return of

venous blood

http://www.tricitymed.org/Service/HIC/cardiac/varicose.htm


ANATOMIC LANDMARKS

� GSV (Greater Saphenous Vein) runs between the Gracilis and Sartorius muscles in the thigh

� 2 finger breaths posterior to the medial epicondyle

� Below the knee GSV runs along the tibial groove

� LSV (Lesser Saphenous Vein) is located lateral to the achilles tendon 180 degrees opposite of the GSV, it extends along the midline of the calf to the posterior knee


VEIN PURGING

� Maneuver in which the harvester places their free hand on the lower

leg where the GSV is thought to be and with the other hand they

purge the GSV from the ankle toward the other hand transmitting a

pulse in the vein

� Allows the harvester to feel the pulse and locate the vein


ULTRASOUND

� Some harvesters use ultrasound on the outside surface of the leg

� Typically need training or practice

� Some surgeons have radiology “vein map” prior to surgery

� Common ultrasounds

� site rite

� TEE (trans-esophageal echocardiogram) handheld

probe


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


TWO TYPES

� Longitudinal

� Transverse


LONGITUDINAL INCISION

� Parallel to the vein

� More difficult to locate the vein if the incision is not directly over the

vein

� Allows harvester to extend the incision if needed

� Less likely to leak CO2 from the tunnel


TRANSVERSE INCISION

� Perpendicular to the vein

� More area to locate the vein

� Can not extend the incision-must bridge

� If incision is to large (long) CO2 likely to leak out of the tunnel


WHERE TO PLACE YOUR INCISION

� Above the knee

� At the knee

� Below the knee


ABOVE THE KNEE

� Traditional for new harvester

� Many landmarks available at this location

� May be difficult in large patients


BELOW THE KNEE

� Sometimes easier to locate in large patients

� Not great option for new harvesters as many tiny vein branches

located below the knee

� Allows harvester to obtain 2 full lengths of vein (2 mets lengths, 8

inches, 18 cm)

� Be sure to measure scope prior to making incision so you are not

short


AT THE KNEE

� Distal point of the incision just above the crease of the knee

� Allows for “straight shot” vein harvesting when going up the thigh to

the groin or down the lower leg to the ankle


WHERE YOU SHOULD NOT PLACE YOUR INCISION

� Groin

� Ankle


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


DIFFICULT NO MATTER WHAT THE HARVESTER’S

EXPERIENCE

� No patients anatomy is exactly the same and the GSV does not

always lay in the same location

� Why it is important to use multiple methods to try and locate the

vein ahead of time


BE SYSTEMATIC

� From the center of the incision dissect down to the muscle

� If not found move lateral and work from superficial to deep (skin to

the muscle)


AGENDA

� The Setup






� Dissection


� Run the Vein


� Remove the Vein




WHAT IS A HOOD

� A pocket create by dissection anterior to the GSV that is large

enough to allow the BTT (blunt tip trocar) to slide into the tunnel

atraumatically


HOW TO CREATE A HOOD

� Direct visualization with a retractor

� Dissect with the scissors under direct visualization


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


ANTERIOR

� Under direct visualization lay the scope and dissection tip onto the

anterior surface of the vein and look at the video monitor

� Locate the dissection tip

� Important to maintain camera orientation

� Once in a few inches (10 cm) slide the BTT (blunt tip trocar) into the

tunnel and infuse with up to 25cc of air

� Make sure your CO2 insufflation tubing is connected to the BTT and

set the CO2 insufflator at a flow of 3-5 liters/minute and a pressure

of 10-12 mm/Hg and start the insufflator

� Continue to make an anterior pass dissecting tissue away from the

vein until you have reached the groin/ankle or stopping point


ANTERIORPhoto Courtesy of James Kueler


POSTERIOR

� Pull the scope and dissection tip back to the BTT

� Gently slide tip posterior to the vein

� Make a posterior pass dissecting the tissue away from the vein to

the groin/ankle or stopping point


POSTERIOR Photo Courtesy of James Kueler


SIDE (BRANCH)

� Pull the scope back to the BTT

� Choose a lateral side of the vein and make a pass dissecting tissue

away from the vein

� Dissect tissue away from any branches encountered

� Repeat for the other side


SIDE (BRANCH)Photo Courtesy of James Kueler


MOST IMPORTANT THING

� MAINTAIN CAMERA HEAD ORIENTATION!





� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


HARVESTING CANNULA

� Remove the dissection tip from the scope

� Insert the scope into the harvesting cannula

� Change the BTT seal to the harvesting cannula seal

� Hook up the bipolar bovie cord to the harvesting cannula and to the

bovie and make sure settings on the bovie are correct

� Test the bovie by using a saline soaked lap

� Advance harvesting cannula into the BTT and into the tunnel slowly

� Advance harvesting cannula to the distal end of the vein

� Advance the C-Ring onto the vein


BRANCH/TISSUE ENCOUNTERED

� Make sure the C-Ring is on the GSV distal to the branch as the C-

Ring protects the GSV

� Open the bisector blade and advance the bisector

� Rotate the bisector if necessary to capture the vein

� Make sure there is adequate distance between the GSV and the

bisector

� Initiate coagulation by stepping on the bovie footpedal

� Discontinue bovie after a second or if blanching is noted

� Close the bisector blade

� Pull bisector back into the cannula

� Move to the next branch/tissue


BRANCH LIGATION Photo Courtesy of James Kueler


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


CONFIRMATION THAT ALL BRANCHES AND TISSUE HAS BEEN

LIGATED

� Advance harvesting cannula to the distal end of the vein and extend

C-Ring onto vein

� Pull the cannula back slowly while maneuvering the C-Ring

confirming that there are no branches or tissue attached to the vein

on any side


RUN THE VEINPhoto Courtesy of James Kueler


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


OPTIONS

� Stab and grab

� Endoloop

� “Turn and Burn”


STAB AND GRAB

� The hallmark

� Advance harvesting cannula into the tunnel to the distal end of the

GSV

� Confirm camera head orientation is correct

� Locate the light (if you can) on the outside surface of the leg

� Push down on outer surface of the leg at the light and look at video

monitor to see that you are pushing in directly above the vein

� Use an 11 blade knife in the same location to make a tiny “stab

hole” in the skin above the GSV

� Put a close clamp into the “stab hole” above the vein

� Open the clamp and capture the GSV in the clamp and retract the

GSV above skin level


STAB AND GRABPhoto Courtesy of James Kueler


NONTRADITIONAL

� Endoloop

� “Turn and Burn”


� The Setup






� Dissection


� Run the Vein


� Removing the Vein



AGENDA


VEIN REMOVAL

� Remove harvesting cannula and BTT

� Dissect and clip remaining tissue around the vein at the incision site

� Ligate the vein


� The Setup






� Dissection


� Run the Vein


� Remove the Vein



AGENDA


PREPARE THE VEIN IN THE USUAL FASHION

� Bipolar cautery does not seal the branches on the vein side

� Must tie or clip the branches as they typically would


� The Setup






� Dissection


� Run the Vein


� Remove the Vein


� Close the Leg and Dress the Wound

AGENDA


CAN NOT RECOMMEND HERE

� Dress the leg and wound same way they have been doing it prior to

EVH

� Things we see?


QUIZ

Now it’s time to check the knowledge you’ve retained…

PROPERTIES

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Documents

ENDOSCOPIC VEIN HARVEST STEP BY STEP - …C1D47DCC... · ENDOSCOPIC VEIN HARVEST STEP BY STEP. ... Below the knee GSV runs along the tibial groove LSV ... leg where the GSV is thought