J Thorac Cardiovasc Surg 2008;136:1379-1380
© 2008 The American Association for Thoracic Surgery
Infiltration of saline solution around the saphenous vein facilitates stripping for coronary bypass surgery
Ahmad Al Khaddour, MD, MS, FRCSa,*,
Andrew Cohen, FRCS, CThb,
Uday Trivedi, FRCS, CThb,
Jonathan Hyde, FRCS, CThb,
Andrew T. Forsyth, FRACSb
a James Cook University Hospital, Middlesbrough, United Kingdom
b Brighton and Sussex University Hospitals, Brighton, United Kingdom
Received for publication October 9, 2007; accepted for publication January 16, 2008.
* Address for reprints: Ahmad Al Khaddour, MD, MS, FRCS, 40 Linden Grove, Middlesbrough TS5 5NE, United Kingdom. (Email: ahmedal{at}doctors.org.uk).
The use of the mayo stripper to harvest the long saphenous vein has been shown to improve morbidity from leg wound incisions. Many studies1,2
have shown that this technique is easy, gives good quality veins for grafting, and is associated with minimal wound problems. We describe this maneuver of saline solution infiltration around the saphenous vein, which facilitates its stripping for coronary bypass surgery.
Technique
Administration of saline solution or anesthetic agent into a surgical wound is a well-described technique.3 We applied this maneuver for stripping the long saphenous vein for coronary bypass surgery.
The surgeon stands on the side of the donor leg with the patient in a supine position; the patient's hip is externally rotated 150°. A 2-cm incision is made over the vein, 3 cm below and lateral to the pubic symphysis, and the vein is dissected to its adventitia. Saline solution is infused just under the skin through the fat above the vein using a 17-guage needle (Figure 1, A
). Gentle massage is applied externally, dispersing the saline solution into the tissue surrounding the saphenous vein. Saline solution is forced between the fat cells, creating a superhydrated cell matrix that protects the integrity of the tissue and vein and also facilitates vein harvesting and sliding of the stripper; saline solution keeps the vein well hydrated, and it dilutes any debris or clots generated by using this technique and facilities washout before wound closure. Saline solution infiltration also makes dissection and creation of a tunnel behind the vein very easy. After tying and dividing the proximal end of the vein, a tunnel is created behind the vein using a clip or digital dissection.
The vein is placed under traction, then the stripper is slid along the vein up to the level of first side branch (Figure 1, B). Another 1-cm longitudinal incision is made above the side branch. The vein is delivered to skin, and the distal end of the side branch is clipped and cut. The procedure is repeated until the required length of vein is achieved. The vein is tied and divided. Then the proximal ends of the side branches are tied.
Methods and Results
We conducted a randomized control trial on 40 diabetic patients. Twenty patients (18 men, 2 women; mean age 66; 5 with insulin-dependent diabetes mellitus, 11 with non-insulin-dependent diabetes mellitus, and 4 with diet-controlled diabetes, mellitus without medications) underwent stripping vein harvesting (SVH), and 20 patients (14 men, 6 women; mean age 61; 9 with insulin-dependent diabetes mellitus, 11 with non-insulin-dependent diabetes mellitus, and 0 with diet-controlled diabetes, mellitus without medications) underwent open vein harvesting (OVH). Pain score was much better in SVH group (Figure 2
). Six patients in the OVH group developed wound problems (3 with serous discharge, 3 with infected discharge) versus 1 patient in the SVH group who developed hematoma but required no treatment. Two patients in the OVH group stayed longer than 15 days due to leg wound infection. Harvest time was 0.83 cm/min in SVH group versus 0.93 cm/min in the OVH group (P = .03). Histologic analysis did not show any intimal injury to the veins in the SVH group. There was no significant difference in contractile response to noradrenaline bath between SVH and OVH groups.
Discussion
Harvesting the long saphenous vein by means of multiple small incisions and use of the mayo strippers is a well-recommended technique.2 We found that SVH was associated with less wound complications and wound pain, required shorter length of hospital stay, and did not add any cost to the procedure. It did not prolong the overall operative time nor compromise the vein quality both morphologically and functionally. We found that this maneuver facilitated vein dissection. It kept the vein very well hydrated and protected its integrity. It facilitated removal of the debris and clots generated after sliding the stripper. Further research is required to evaluate the potential benefits of this maneuver.
References
- O'Regan DJ, Borland JA, Chester AH, Pennell DJ, Yacoub M, Pepper JR. Assessment of human long saphenous vein function with minimally invasive harvesting with the mayo stripper. Eur J Cardiothorac Surg 1997;12:428-435.[Abstract/Free Full Text]
- Athanasiou T, Aziz O, Skapinakis P, Perunovic B, et al. Leg wound infection after coronary artery bypass grafting: a meta-analysis comparing minimally invasive versus conventional vein harvesting. Ann Thorac Surg 2003;76:2141-2146.[Abstract/Free Full Text]
- Horn EP, Schroeder F, Wilhelm S, et al. Wound infiltration and drain lavage with ropivacaine after major shoulder surgery. Anesth Analg 1999;89:1461-1466.[Abstract/Free Full Text]
