Minimally invasive no touch (MINT) procedure for harvesting the great saphenous vein (GSV), endoscopic asval technique and assisted pin stripping of superficial GSV, hydrodissection-based endoscopic vein harvesting (EVH) system, venous hydrodissector, retractor and tip adapter for use with flexible cystosope and adapted cystoscope system
A method of atraumatically hydrodissecting and maintaining endothelial function and structure of a vascular target includes forming an incision in tissue proximate one end to realize an insertion space, inserting a distal end of a cannula and/or endoscope into the insertion space and while visualizing the vascular target, ejecting a hydrodissecting fluid from the distal end of the cannula and/or endoscope to substantially separate or dissect the vascular target from the surrounding tissue, while advancing the distal end through the space as it is enlarged by the hydrodissecting fluid, to a distal target end of the vascular target. The hydrodissecting fluid is formulated to minimize or prevent formation of microthrombi in the hydrodissected vascular target. The hydrodissecting fluid is a water-based vascular graft treatment solution and can include any of a balance salt solution, a metallic salt solution, such as Plasma-Lyte® A, a vascular graft treatment solution, such as Duragraft® solution, L-Arginine, aspirin and low molecular weight heparin.
1 . An endoscopic hydrodissector for atraumatically hydrodissecting a vascular target, the hydrodissector comprising:
a handle;
an elongate endoscopic tube attached to or integral with the handle at a proximal end of the elongate endoscopic tube with
a working port or opening at a distal end of the elongate endoscopic tube;
a hydrodissecting shell with a distal end and a proximal end, the hydrodissecting shell configured for attachment to an outer surface of the elongate endoscopic tube, wherein
a fluid ejection port is arranged at the distal end of the hydrodissecting shell in fluid-flow connection to a fluid conduit or channel in an inner volume of the hydrodissecting shell that is in fluid-flow connection to a fluid supply for supplying hydrodissecting fluid for ejection from the fluid ejection port to hydrodissect and substantially separate the vascular target from tissues surrounding the vascular target, creating a substantially hydrodissecting fluid-filled space therebetween;
wherein the working port or opening of the elongate endoscopic tube and the fluid ejection port of the attached hydrodissecting shell are inserted into an incision space formed by making an incision into the tissue proximate a proximal end of the vascular target and
controlled to move through the incision space and create a created space by hydrodissecting to separate the vascular target from the tissues surrounding the vascular target and enlarging the created space as the elongate endoscopic tube with working port or opening and hydrodissecting shell with the fluid ejection port to traverse the created space to the distal end of the vascular target; and
wherein the hydrodissecting fluid is formulated to minimize or prevent formation of microthrombi in the endothelium of the hydrodissected vascular target.
2 . The hydrodissector of claim 1 , wherein the fluid is formulated with a vascular graft treatment solution to maintain endothelial function and structure of the vascular target.
3 . The hydrodissector of claim 2 , wherein the hydrodissecting fluid further includes at least one of aspirin and low molecular weight heparin.
4 . The hydrodissector of claim 1 , wherein the hydrodissecting fluid supply provides sufficient pressure and velocity to the hydrodissecting fluid ejected to effect the hydrodissection.
5 . The hydrodissector of claim 1 , further comprising a short blunt tip (SBT) cannula with an insertion end, a fluid seal end, and a side port, wherein the insertion end is inserted partially into the incision to form a fluid barrier to prevent or minimize fluid leakage and the side port acts as as the hydrodissecting shell input port.
6 . The hydrodissector of claim 1 , wherein at or near the working port or opening at the distal end of the elongate endoscopic tube, an image capture assembly or device is provided for direct visualization while the elongate endoscopic tube and attached hydrodissecting shell are navigated under direct vision to hydrodissect the vascular target and divide branches using a cautery device that extends from the the working opening.
7 . The hydrodissector of claim 1 , wherein the elongate endoscopic tube embodies a rigid cannula.
8 . The hydrodissector of claim 7 , wherein the fluid supply is maintained in a housing, separate from the hydrodissecting shell, wherein the hydrodissecting shell is detachably connected to an outer surface of the cannula and wherein the hydrodissecting fluid is ejected from the fluid ejection port arranged in a distal end of the hydrodissecting shell proximate the working tip.
9 . The hydrodissector of claim 8 , wherein the elongate endoscopic tube includes a bending portion comprising a first end and a second end, wherein the first end is attached to or integral with a truncated end of the flexible, elongate endoscopic tube and wherein the second end is attached to or integral with the working tip.
10 . The hydrodissector of claim 9 , wherein the handle includes a manipulating means coupled or connected to the bending portion, to control articulation of the bending portion and a position of the working tip with the ejection port and thereby a direction to which the fluid is directed to effect hydrodissection.
11 . The hydrodissector of claim 9 , wherein the hydrodissecting shell is detachably connected to the outer surface of the elongate endoscopic tube such that the working tip is positioned proximate the distal end of the hydrodissecting shell when the hydrodissecting shell is detachably connected to the elongate endoscopic tube.
12 . The hydrodissector of claim 6 , further comprising a portable display detachably connectable to the image capture device for capturing and displaying an image signal to support atraumatic hydrodissection.
13 . A method of atraumatically hydrodissecting a vascular target from a proximal end to a distal end, or vice versa, while maintaining an endothelial function and structure of the vascular target, comprising the steps of:
forming an insertion space in tissue proximate the proximal end of the vascular target and
inserting a distal end of a cannula with an endoscope arranged in an inner volume thereof, into the insertion space wherein the cannula with endoscope includes a working tip with an image pick-up device and an input port for connecting to a fluid supply means and a hydrodissecting port for ejecting a hydrodissecting fluid;
visualizing the vascular target and cannula with endoscope with an image signal captured by the image pick-up device while advancing the cannula with endoscope and working tip to the distal end of the vascular target while ejecting the hydrodissecting fluid to substantially separate or dissect the vascular target from the surrounding tissues and creating a created space, which is enlarged as the cannula with endoscope and working tip are advanced towards the distal end of the vascular target;
wherein the hydrodissecting fluid is formulated to minimize or prevent formation of microthrombi in the endothelium of the hydrodissected vascular target.
14 . The method of claim 13 , wherein the hydrodissecting fluid is a water-based vascular graft treatment solution that comprises water and one or more of a balanced salt solution, metallic salt solution, vascular graft treatment solution, L-Arginine, aspiring and low molecular weight heparin.
15 . The method of claim 13 , further including, after hydrodissecting the vascular target, dividing and/or sealing branches of the vascular target and substantially closing the incision space and the created space while some portion of hydrodissecting fluid is maintained as a tumescent fluid in or is otherwise introduced to the created space and remains in the created space during harvesting wherein side branches of the hydrodissected vascular target are separated from the vascular target under direct vision.
16 . The method of claim 13 , wherein during harvesting all side branches extending from the vascular target are divided and sealed and the distal and proximal ends of the vascular target are ligated to atraumatically extract the vascular target from the created space.