It’s early afternoon, a perfect spring day. Outside the UMass Medical Center, employees savor the last of their lunch break, faces tipped toward the sun, legs splayed on the grass.
Inside, in operating room 3, Evelyn Kolat, 74, lies inert, dwarfed by a vast array of surgical instruments, anesthesia paraphernalia, and a heart-lung machine.
2:10 p.m. The OR team proceeds gingerly. Kolat’s heart rhythm is unstable, so Dr. Ellie Duduch, the anesthesiologist, induces sleep slowly. As Dr. Robert Lancey, the surgeon, waits, he takes a last look at her angiogram, noting where blood flow to her coronary arteries is blocked.
2:42 p.m. Stable now, Kolat is deeply asleep. Duduch slips a breathing tube down her throat. Lancey gowns up. Nurses scrub Kolat’s chest and both legs.
Kolat is about to join the nearly 400,000 Americans who have coronary artery bypass surgery every year.
In most of these operations, a long incision – from knee to groin and often ankle to knee as well – is made to “harvest” a vein that will be cut into segments and stitched onto coronary arteries to bypass damaged areas. After surgery, patients often have more pain and infection from leg wounds than from incisions made in the chest through the breastbone to get to the heart. This is in part because fatty leg tissue does not have as good a blood supply as the chest.
But Kolat, like an estimated several thousand patients worldwide, has opted for a new technique – endoscopic vein harvesting, in which a member of the surgical team, usually a physician’s assistant, makes from one to three tiny incisions in the leg, slides a long viewing tube along the outside of the vein, snips off side branches that feed the vein, then slips the vein out.
2:56 p.m. Donna Iddings, a physician assistant, makes the first cut, a one-inch incision inside Kolat’s right knee. Moments later, Lancey, who has done 30 bypass operations in which the vein was harvested the new way, begins slicing open Kolat’s chest.
Endoscopic vein harvesting takes longer – an hour or more, if the physician’s assistant is new at it, versus 20 to 40 minutes for the traditional method. It costs more, too, in part because the disposable endoscopy kits – several are on the market – cost $ 300 to $ 500. Some proponents say that the costs of these kits may be offset by shorter hospital stays and fewer post-operative complications.
Granted the endoscopic technique doesn’t always work perfectly, but surgeons who try it are enthusiastic, as are patients.
Gaston Poudrette, a 64-year-old Leominster man who had the surgery in March, says his leg looks good and healed fast.
At the Lahey Clinic in Burlington, Dr. Richard D’Agostino, who has done seven operations with the technique, thinks “it will become the norm soon. It’s a significant advance.”
Dr. Willard Daggett says it’s clear from his 103 patients at Massachusetts General Hospital and St. Vincent’s Hospital in Worcester that the endoscopic procedure reduces infections, leaves minimal scars and that “patients love it.”
In fact, he says, while endoscopic surgery on the heart itself – using tiny incisions in the chest rather than opening the sternum – has captured more headlines, it is endoscopic vein harvesting that may prove more widely applicable. The minimal heart technique is chiefly for people who need only one coronary artery bypass and so far, the results have not been as good as the standard, open-chest surgery. By contrast, endoscopic vein surgery could help most bypass patients.
It’s so new – many hospitals have only offered it for a few months – that the data are mostly unpublished, but provocative: At the Indiana Heart Institute in Indianapolis, a published study of 112 patients – half were randomly chosen to have the new technique, half the old – showed that only 4 percent of those who had the new procedure got leg infections while 19 percent of the others did, says Dr. Keith Allen. Those who had the new procedure also left the hospital a day earlier.
At Chippenham Medical Center in Richmond, Va., physician assistant Nan Lambert has done more than 100 endoscopic vein surgeries and has compared them to the old technique. Nobody who had the new technique needed antibiotics or special care for leg wounds, but 5.8 percent of the others did.
At Hahnemann University Hospital in Philadelphia, Michael Butler, a physician assistant, has compared 25 patients who got the new technique and 25 who had the old one. Less than one percent of those who got the new procedure had leg infections, but 5 percent of the others did. The first group also had no leg swelling, while 42 percent of the second group did.
3:08 pm Iddings probes Kolat’s incision with her fingers, trying to find the vein. No luck. Lancey saws through Kolat’s sternum, then turns to help Iddings. He can’t find the vein either.
3:13 pm They find it. Lancey returns to Kolat’s chest, using a metal device to spread open the sternum. Iddings inserts a long tube with a camera attached into the leg incision.
3:17pm Trouble. The light doesn’t work. They fix it. Now there’s an image on the TV screen, but it’s bad. They call for new equipment. It comes, but the image is still blurry. Another call for help.
3:34pm Another nurse arrives, takes one look at the image, swears softly, and decides the problem is moisture on the lens of the camera in the endoscope. They clear it. Now the image is beautiful.
3:38 pm Iddings inserts the endoscope and squirts in carbon dioxide to expand the tissue around the vein. Her eyes glued to the TV screen, she begins snipping off the tiny branches that connect to the leg vein.
4:00 pm With the vein nearly free, Iddings makes an incision in Kolat’s leg at the groin, to tie off the end of the vein that will stay in the body.
4:15 pm They pull the vein out. It looks fragile and barely the diameter of spaghetti at one end, smaller than they’d hoped for. Some veins, in fact, are simply too small to use, says Phillip Carpino, a physician assistant at New England Medical Center. But endoscopy can also “shred” veins, he says, especially in smaller, older women. “You have to be careful about the patients you select.”
4:16 pm Lancey mutters about the “poor quality” of this vein but places it on a drape over the patient’s chest and begins the painstaking process of fixing leaks, which he detects by repeatedly injecting a solution into the vein. For the next 41 minutes, he stitches up tears, many of which soon leak again. Finally, he cuts off and discards the worst part, saying “We can’t take a chance on using it if it’s too thin-walled.” He only nods to Iddings, but she understands.
4:56 pm Quickly, she begins slicing open Kolat’s other leg – this time from the groin to the knee. In barely 15 minutes, she’s removed a long stretch of vein. This one looks plump and healthy. The team relaxes palpably.
5:10 pm “Ready to go on bypass,” says surgeon Lancey. The heart-lung machine, already hooked up, will keep Kolat’s blood circulating for the next 93 minutes whirs. Lancey stops the heart with a potassium injection. He works quickly, using two segments of leg vein to bypass two arteries. For the third bypass, he severs one end of the nearby internal mammary artery and connects it to the heart.
6:40 pm Kolat is off the heart-lung machine, her own heart back at work.
7:40 pm It’s over. She’s on her way to intensive care.
Four days later, she’s home, her left leg bearing a long incision, her right leg, two tiny ones. If endoscopy proponents are right, her right leg should be less painful than her left.
But surgery is art as well as science and Kolat refused to bow to mere statistics. The truth is that “neither one hurts!”