West self-retaining retractor for large subcutaneous layers
Procedure
Position the leg so it is slightly bent at the knee and externally rotated, to enable access to the medial aspect of the leg.
Approximately, 1cm superior to the edge of the medial malleolus, cut the skin with a curved scalpel blade to make an incision of 2-3cm.
Non-toothed forceps and McIndoe’s scissors to dissect longitudinally in the incision underneath the subcutaneous fat to find the saphenous vein.
The vein should be identified within the incision. If the nerve is seen, the vein should be very close to it, even hiding in fatty tissue. The whole length of the vein in the incision should be dissected free for use in the graft.
Once the LSV is found, insert Mayo curved scissors inside the wound with the closed tip pointing superficially and the scissors resting on the top of the vein to bluntly dissect and create a tunnel.
Once tunnel is created on top of the vein, insert the Mayo scissor’s bottom blade into the tunnel with its tip pointing superficially (tenting the skin away from the vein and deeper structures), and then cut the skin and subcutaneous structures.
Follow the vein by tunnelling and cutting, keeping the vein in sight and directly below the incision.
Look into the tunnel before cutting to see the course of the vein.
Avoid jagged cutting by placing the corner of the wound against the corner formed by the two scissor blades, and then making a single cutting motion.
Once the required length of vein is exposed, dissect it from the surrounding fascia, and ligate its tributaries.
Start at one end, usually the distal. Use a non-toothed forceps to lift up the thin layer of fascia off superior or lateral aspects of the vein and cut into it with McIndoe scissors.
The same scissors is then pushed into the window created and used to push the fascia away from the vein.
A closed Dunhill artery forceps may be used to lift the vein from its underlying fascia and spread open to create a window.
Retract the vein with closed instruments (closed forceps, or artery forceps) and push away the fascia all around it using another closed instrument. Use scissors if necessary to cut the fascia.
Once the first tributary is encountered, insert the closed forceps under the tributary and bluntly dissect away the fascia around it.
The tip of the artery forceps lifts up the tributary and ligate it.
Use a tie or ligaclips to ligate and cut the tributary with scissors.
Continue until all the tributaries are ligated.
When the saphenous nerve is encountered, create a plane between the nerve and the vein using blunt or sharp dissection.
If the nerve is wrapping or crossing over the vein, separate the vein from the nerve, and continue dissection and tributary ligation.
When the vein cut and is being removed , slide it under the nerve, thus preserving the nerve.
Once the vein can by freely lifted from its bed, clip the distal end.
Make an opening to insert a cannula and inject heparinised blood to distend the vein and identify any leakage.
Once identified, ligaclip it or use 7-0 prolene to transfix the leaking point.
The distal end is marked with a suture, or cannulated secure with a tie. Ensure the entire length of the vein within the incision is used.
The proximal end is then clipped and divided. The vein segment is now completely free, place it in a bowl of heparinised blood until needed.
The distal and proximal stumps are tied with 2-0 silk and ligaclips.
Instructions to give heparin are given, if using cardiopulmonary bypass.
Haemostasis along the wound is achieved by clipping veins where identified, or diathermy (bipolar).
Close wound in at least two layers – subcutaneous fat (which might need two layers of absorbable suture) and skin (using absorbable subcuticular suture). Ensure no dead space is left between layers.
If using a drain, place it under the deepest layer. Turn on suction after close the deep layers.
When closing the subcutaneous layer, do not catch the subcuticular layer which leads to puckering of the skin.
Take care to avoid the ligated tributaries when passing the needle.
The wound is then dressed with a self-adhesive absorbent dressing. A crepe bandage is wrapped around with some tightness.