Ann Thorac Surg 2002;74:1715-1717
© 2002 The Society of Thoracic Surgeons
How to do it
Skeletonization of the right gastroepiploic artery using an ultrasonic scalpel
Tohru Asai, MDa*,
Shigeki Tabata, MDa
a Division of Cardiovascular Surgery, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
Accepted for publication May 1, 2002.
* Address reprint requests to Dr Asai, Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Seta-tsukinowacho, Ohtsu, Shiga 520-2192, Japan
e-mail: toruasai{at}belle.shiga-med.ac.jp
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Abstract
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A new method to skeletonize and harvest the right gastroepiploic artery using an ultrasonic scalpel is presented. The technique is simple and safe, and it causes less bleeding. It is possible not only to harvest the artery faster, but to obtain large spasm-free arterial conduits for coronary artery bypass grafting.
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Introduction
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The right gastroepiploic artery (GEA) has been proposed as an alternative conduit for myocardial revascularization and acceptable late results were reported [1, 2]. We found that skeletonization made GEAs markedly enlarged conduits. Skeletonization reportedly prevents spasm, facilitates visual inspection, and facilitates sequential anastomosis [3]. However, skeletonization using electrocautery, scissors, and hemoclips is cumbersome and time consuming. Furthermore, there is a higher risk of injury during skeletonization of GEA compared with that of the internal mammary artery (IMA). We have developed a simple and safe technique of harvesting skeletonized GEA by using an ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH).
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Technique
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For the operation, median sternotomy is extended about 5 cm caudal from the xiphoid process. Before harvesting the IMA, the peritoneal cavity is opened. The GEA is inspected and palpated to confirm it as a suitable conduit. After skeletonizing IMAs, the GEA is encircled with vessel loops at every 5 cm distance. The anterior layer of the greater omentum is then incised throughout the necessary graft length using the ultrasonic scalpel with coagulating shears (Fig 1).
While gently pulling up the vessel loops, all arterial branches with the surrounding tissues are put between the vibrating tip and the tissue pad and simply divided approximately 2 mm from the GEA trunk (Fig 2).
During dissection, we rarely encounter bleeding from the satellite vein or fragile arterial branches. After systemic heparinization, the distal end of the graft is divided, papaverine solution is instilled in it, and a hemoclip is applied. The skeletonized GEA is then wrapped with a papaverine-soaked sponge. Without using intravenous calcium-channel blocker, the GEA becomes a significantly dilated conduit (Fig 3).
In our initial series of off-pump coronary bypass operations, all GEAs (20 conduits) were used in an attached fashion. None of them were used as free grafts. The sites of GEA graftings were the distal right coronary artery in 2 patients, the posterior descending artery in 17 patients, and the left ventricular branch in 5 patients. Among them, GEA were sequentially grafted to the posterior descending artery and the left ventricular branch in 4 patients. Simultaneously, other sites in the left coronary artery territory were grafted with skeletonized bilateral IMAs. Early postoperative angiography demonstrated all GEAs were patent (24 of 24 anastomoses) without anastomotic stenosis (Fig 4).
The right and the left IMAs were also all patent (20 of 20 anastomoses and 24 of 24 anastomoses, respectively).
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Fig 1. (A) The anterior layer of the greater omentum is incised just above the right gastroepiploic artery (GEA) using the Harmonic Scalpel (Harmonic Scalpel, Ethicon Endo-Surgery, Cincinnati, OH) with coagulating shears. (B) The transection demonstrates GEA is protected from thermal damage by the tissue pad of the Harmonic Scalpel.
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Fig 2. (A) Vessel loops are pulled up gently; thus all arterial branches and veins are divided approximately 2 mm apart from the gastroepiploic artery (GEA) by the Harmonic Scalpel (Harmonic Scalpel, Ethicon Endo-Surgery, Cincinnati, OH). (B) The transection shows that the whole surrounding tissues are divided from the GEA.
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Fig 3. The skeletonized gastroepiploic artery becomes a markedly dilated arterial conduit without any spasm after the preparation.
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Fig 4. Coronary angiogram demonstrating a widely patent gastroepiploic artery grafted to the posterior descending artery.
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Comment
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GEA has been used as an alternative graft for coronary artery bypass. Encouraged by recent reports with late results [1, 2], GEA has become a more widely used conduit. However, the conventional pedicled GEA preparation method frequently causes vasospasm of the vessel, as well as inaccurate evaluation of GEA size and vessel quality. Although the skeletonization of GEA was proposed to mitigate these disadvantages [3], the method requires meticulous work with scissors, electrocautery, and hemoclips. It is a cumbersome and time-consuming process that sometimes causes bleeding and carries a higher risk of vessel injury. Our new technique makes GEA skeletonization easier and faster. We have rarely encountered bleeding from arterial branches and veins. This method facilitates accurate evaluation of GEA size and vessel quality and makes sequential grafting easier if necessary.
The Harmonic Scalpel (Ethicon Endo-Surgery) has recently been more widely used by cardiac surgeons [4]. Skeletonization of IMAs [5] and harvesting of radial arteries [6] are reportedly safe and reliable methods. In contrast to IMAs and radial arteries, the GEA has many fragile branches and a large satellite vein. However, in our previous experience the Harmonic Scalpel (Ethicon Endo-Surgery), which has a dissecting hook used for IMA harvesting, was found to cause inadequate coagulation and frequent bleeding from arterial branches and veins. A new method using the Harmonic Scalpel (Ethicon Endo-Surgery) with coagulating shears could resolve this problem. Our series of 20 conduits demonstrated minimal bleeding and no thermal damage to GEAs by gross observation. There were no graft stenoses or failures in early postoperative angiograms. Although we are aware that midterm follow-up of the graft is necessary, we conclude that this technique will facilitate more frequent usage of skeletonized GEA. With maximal dilation of the GEA using our technique, and with proper target selection, we would expect better late patency.
In conclusion, our new technique of harvesting skeletonized GEA using the Harmonic Scalpel (Ethicon Endo-Surgery) is simple and safe, and it provides large spasm-free arterial conduits.
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References
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- Pym J., Brown P., Pearson M., Parker J. Right gastroepiploic-to-coronary artery bypass. The first decade of use. Circulation 1995;92(Suppl 9):II45-II49.
- Suma H., Isomura T., Horii T., Sato T. Late angiographic result of using the right gastroepiploic artery as a graft. J Thorac Cardiovasc Surg 2000;120:496-498.[Abstract/Free Full Text]
- Gagliardotto P., Coste P., Lazreg M., Dor V. Skeletonized right gastroepiploic artery used for coronary artery bypass grafting. Ann Thorac Surg 1998;66:240-242.[Abstract/Free Full Text]
- Tanemoto K., Kanaoka Y., Murakami T., Kuroki K. Harmonic scalpel in coronary artery bypass surgery. J Cardiovasc Surg (Torino) 1998;39:493-495.[Medline]
- Higami T., Yamashita T., Nohara H., Iwahashi K., Shida T., Ogawa K. Early results of coronary grafting using ultrasonically skeletonized internal thoracic arteries. Ann Thorac Surg 2001;71:1224-1228.[Abstract/Free Full Text]
- Psacioglu H., Atay Y., Cetindag B., Saribulbul O., Buket S., Hamulu A. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998;65:984-985.[Abstract/Free Full Text]
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Abstract
Introduction
