Totally retroperitoneal laparoscopic aortobifemoral bypass

The classic procedure for aortobifemoral bypass is open surgery. Since the first totally laparoscopic aortobifemoral bypass reported in 1997 by Yves-Marie Dion, laparoscopy has been accepted by several authors as a possible minimally invasive alternative for aorto-iliac occlusive disease. The transperitoneal left retrocolic and retrorenal ways are generally used. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. We report here a totally laparoscopic retroperitoneal approach to performing aortobifemoral bypass. This approach was proposed to a 51-year-old man with aorto-iliac occlusive disease. There was no indication for endovascular revascularization. The patient suffered from 10 metres of bilateral intermittent claudication and lower limb ulcers. During the surgical procedure our patient was placed in a 30-degree right lateral decubitus position. The optical system was first placed in an intra-abdominal position to check the positioning of the trocars in the left retroperitoneal space. The dissection of the retroperitoneal space was performed by CO2 insufflation and by blunt dissection using laparoscopic forceps. The infrarenal aorta was exposed and clamped by laparoscopic clamps. A bifurcated graft was sutured on the left-hand side of the aorta by a running suture. Both prosthetic limbs were tunnelized retroperitoneally to the groin under optical control. The femoral anastomoses were performed by classic open surgery.     

Experimental laparoscopic aortobifemoral bypass for occlusive aortoiliac disease

Objective

To describe a totally laparoscopic technique for aortobifemoral bypass to treat aortoiliac atheromatous occlusive disease.

Design

A feasibility study.

Setting

A university teaching hospital.

Subjects

Six piglets weighing between 70 and 80 kg were submitted to a totally laparoscopic retroperitoneal aortobifemoral bypass, performed through six trocar sites, with abdominal suspension and a gasless technique. No minilaparotomy was performed. After systemic heparinization, the infrarenal aorta was cross-clamped and the aortic bifurcation stapled. An end-to-end aorto–prosthetic anastomosis was performed. Retroperitoneal tunnels were created to allow each limb of the graft to join its corresponding femoral artery by a conventional anastomosis.

Intervention

Totally laparoscopic aortobifemoral bypass.

Main Outcome Measures

Duration of the procedure, intraoperative blood loss and operative complications, bleeding in the immediate postoperative period. Evaluation of the aortic anastomosis at autopsy.

Results

All aortobifemoral bypasses were completed in less than 4 hours. Intraoperative blood loss did not exceed 250 mL. No intraoperative complication was encountered except occasional bleeding at the aortic anastomosis upon releasing the arterial clamp. This was controlled with a collagen sponge (three cases) or extra stitches (two cases). The animals were observed for 15 minutes before sacrifice. Autopsy revealed a normal aortic anastomosis in all cases and a normal progression of the limbs of the graft under the ureters in the retroperitoneal tunnels.

Conclusions

This animal model demonstrates the feasibility of the aortobifemoral bypass through a laparoscopic approach. The retroperitoneal anatomy of the piglet is similar to that of man. Aortic surgery can be conducted as for the standard technique. We used a similar approach to perform the first human, totally laparoscopic aortobifemoral bypass with an end-to-end anastomosis.     

Hand-assisted laparoscopic aortobifemoral bypass grafting

OBJECTIVE: Aortobifemoral bypass grafting is a durable operation for arterial reconstruction in patients with symptomatic aortoiliac occlusive disease. In several small laparoscopic series technically demanding aortic operations have been described that have not gained widespread acceptance or applicability. To simplify the laparoscopic approach to the aorta, we have developed a technique of aortobifemoral bypass grafting that uses hand-assisted laparoscopic surgery (HALS) to minimize the complexity of aortic dissection and reconstruction. METHODS: Five patients with symptomatic aortoiliac occlusive disease underwent successful HALS aortobifemoral bypass grafting. With the use of a specialized sleeve device (Hand-Port), an operative hand was introduced into the laparoscopic field while pneumoperitoneum was maintained. Laparoscopic dissection of the infrarenal aorta was then performed with retraction provided by the operative hand. Proximal aortic anastomosis was performed with an open technique through the same 7.5-cm Hand-Port incision, and femoral anastomoses were performed in the standard fashion. RESULTS: Five hand-assisted laparoscopic aortobifemoral bypass grafts were performed (two end-to-end, three end-to-side proximal anastomoses). Mean operative time was 231 minutes. Mean blood loss was 440 mL. All patients underwent extubation immediately after surgery, were ambulatory on postoperative day (POD) 1, and were tolerating their diet by POD 3. The mean length of hospital stay was 3.8 days. One patient was discharged on POD 5 and started a clear liquid diet after a self-limiting postoperative ileus. All patients were asymptomatic and back to full activity/work by 14.6 days postoperatively, on average (range, 11-20 days). CONCLUSION: The HALS offers the advantages of tactile feedback, flexible retraction, and the introduction of conventional surgical instruments, all of which extend laparoscopic surgery and its established benefits to a wide array of more complex surgical problems, including major vascular surgery. Ease of performance, shorter hospital stays, and faster recovery times all suggest that HALS may become a valuable adjunct to conventional aortobifemoral bypass grafting.     

Videoendoscopically assisted combined retroperitoneal and pelvic extraperitoneal approach for aortoiliac occlusive disease

Background Laparoendoscopic surgery has emerged as a new method for the management of iliac and aortoiliac occlusive disease. This article describes a combined retroperitoneal and pelvic extraperitoneal approach to aorta and iliac arteries. Methods A review was performed for 15 patients who underwent videoendoscopically assisted vascular bypass procedures between January 1999 and June 2003. A minimal access approach was used for access to the proximal anastomotic site (proximal common iliac or distal aorta) and creation of a tunnel for the prosthetic graft placement up to the distal anastomotic site. Altogether, 11 iliofemoral bypasses, 2 iliobifemoral bypasses and 2 aortobifemoral bypasses were performed. Patients with diffuse stenosis/long-segment occlusion and multiple lesions for whom percutaneous transluminal angioplasty with stenting proved to be unsuitable were included. The outcome parameters measured were intraoperative time, intraoperative blood loss, skin incision length, length of hospital stay, postoperative pain and analgesia requirement, and patency of graft. Results Videoendoscopy was used to complete14 procedures. The mean operating time was 258 ± 49 min (range, 180–300 min) and the mean blood loss was 124 ± 28.23 ml (range, 80–150ml). The mean hospital stay was 6.7 ± 4.46 days (range, 4–9 days). After a mean follow-up period of 14.4 ± 3.55 months (range, 6–20 months), all grafts were patent. Conclusion Videoendoscopically assisted vascular surgery for iliac and aortoiliac occlusive disease by a combined retroperitoneal and pelvic extraperitoneal approach is feasible and appears to confer many advantages of minimal access surgery. However, prospective randomized trials are needed to define clearly any advantages of this approach over conventional surgery.     

Hand Assisted Laparoscopic Surgery of Aortoiliac Occlusive Disease: Initial Results

OBJECTIVES: Open aortobifemoral bypass grafting has been the procedure of choice for many years in patients with symptomatic aortoiliac occlusive disease (AIOD). Hand assisted laparoscopic surgery (HALS) for AIOD could have advantages like faster recovery, faster oral intake and shorter hospital stay compared to the conventional technique. We documented the results of patients who underwent HALS for AIOD in our hospitals. MATERIALS AND METHODS: from January 1999 to December 2002, 33 consecutive patients underwent HALS for AIOD. Peri- and postoperative results were prospectively registered. Three different laparoscopic approaches were applied: transperitoneal, retroperitoneal and apron approach. RESULTS: There were 23 males and 10 females, with a mean age of 59 years (range 39-85). The surgical technique applied was: transperitoneal: 22 patients, retroperitoneal: 7 patients, apron: 4 patients. Per-operative results (median) of the transperitoneal, retroperitoneal and apron approach are: operating time 240, 420 and 263 minutes, cross clamp time 32.5, 40 and 33.5 minutes, blood loss 1150, 2100 and 950 ml, respectively. Postoperatively oral intake was fully resumed in 3, 4.5 and 2 days after performing the transperitoneal, retroperitoneal and apron technique. During the ICU stay patients received artificial respiration for 0, 1 and 0 days, admission to the ICU was 0.5, 1 and 0.75 days for the transperitoneal, retroperitoneal and apron approach. Finally, hospital stay was 8, 12.5 and 7 days after the transperitoneal, retroperitoneal and apron approach. Four patients (12%) had a minor complication, 4 patients (12%) had a major complication; pneumonia with ARDS, sepsis, bypass occlusion and chylo-abdomen. No patients died. CONCLUSIONS: HALS for AIOD is a technically demanding operation with a long learning curve. All three approaches are feasible. In this series of patients, we feel the transperitoneal and apron approach have the most advantages because of the larger working space. Finally, randomized trials will determine if laparoscopic assisted or total laparoscopic aortoiliac surgery has the potential to reduce morbidity for the patient compared to the conventional technique.     

Total laparoscopic aortobifemoral bypass.

AIM: To assess the feasibility of aortobifemoral bypass by a laparoscopic approach. MATERIAL AND METHODS: During November 2002 through July 2003 a total of 21 patients with aorto-iliac occlusive disease underwent total laparoscopic aortobifemoral bypass surgery. RESULTS: The median operative time was 240 (range 150-420) min with a median aortic cross-clamp time of 60 (30-120) min. Operating time was reduced with experience. The median blood loss was 500 (100-2500) ml. One conversion to open surgery for acute dilation of the small bowel was necessary. Post-operative complications occurred in five patients (coagulation problems, disseminated intravascular coagulation secondary to thrombosis of the left limb, cerebro-vascular accident, dyspnoea, lymph leak) and there was no peri-operative death. Median hospital stay was 7 (5-30) days. CONCLUSION: Aorto-bifemoral bypass using a total laparoscopic approach can be performed safely. As all new techniques, a learning curve is observed. This new technique should be evaluated in a larger randomised trial to assess its clinical value in comparison to conventional surgery.     

Robot-assisted laparoscopic aortobifemoral bypass for aortoiliac occlusive disease: a report of two cases

This article describes the use of robotic technology in laparoscopic aortobifemoral bypass grafting. In two patients with disabling intermittent claudication on the basis of severe aortoiliac occlusive disease, laparoscopic aortobifemoral bypass grafting was performed with a proximal end-to-side anastomosis constructed with robotic arms that had been mounted on the operating table and were controlled from a separate console. No complications occurred. Operating times were 290 and 260 minutes, and aortic anastomosis times were 48 and 37 minutes, respectively. Blood loss was less than 200 mL in both cases. A normal diet was resumed on the second postoperative day, and the patients were discharged home on postoperative days 4 and 6. To our knowledge, this is the first report on robot-assisted laparoscopic aortobifemoral bypass in the world literature.     

Totally laparoscopic aortobifemoral bypass: a review of 22 cases

OBJECTIVE: Laparoscopic aortobifemoral bypass (LABF) has been performed for diffuse aortoiliac occlusive disease in a few large centers. We hypothesize that in selected patients LABF can be performed safely and is a viable, minimally invasive approach to aortoiliac occlusive disease. METHODS: We conducted a retrospective review of all individuals undergoing LABF over a 2.5-year period in a community-based vascular surgery practice. RESULTS: From January 2002 to August 2004, LABF was performed successfully in 20 of 22 patients. The age of the patients ranged from 49 to 75 years, with 11 male and 11 female subjects. LABF required a median duration of 267 minutes (range, 199 to 365 minutes) to complete. Median aortic cross-clamp time was 89.5 minutes (range, 64 to 14 minutes) with an aortic anastomotic time of 37 minutes (range, 30 to 56 minutes). Blood loss averaged 0.69 +/- 0.081 L. Median intensive care stay was 1 day, and hospital stay was 4 days. The median duration of postoperative intravenous narcotics via patient-controlled analgesia pump was 2 days. No patients received epidural analgesia. Nearly all patients began a liquid diet 1 day and a solid diet 4 days after surgery. Complications occurred early in our experience and included one death secondary to mesenteric infarction possibly caused by excessive visceral traction. There was one pelvic abscess, one ureteral injury, and two limb occlusions necessitating thrombectomy and revision. The last six patients had uneventful operative procedures and recoveries. Of the two LABF failures, one patient required open conversion because of inadequate aortic exposure and the other required a short upper midline incision to complete the aortic anastomosis. Compared with conventional open aortobifemoral bypasses performed concomitantly during this period, selected LABF patients required fewer narcotics, experienced less bowel dysfunction, and were discharged home sooner. CONCLUSIONS: Aortobifemoral bypass can be performed through a minimally invasive laparoscopic approach. Although technically demanding with a steep learning curve, experience should reduce the significant complication rate. Compared with a conventional open aortobifemoral bypass, advantages include less pain, minimal postoperative bowel dysfunction, and a shorter hospital stay.     

Retroperitoneal laparoscopic bilateral lumbar sympathectomy

The first retroperitoneal lumbar sympathectomy was performed in 1924 by Julio Diez. The classic procedure for sympathectomy is open surgery. We report a unilateral laparoscopic retroperitoneal approach to perform bilateral lumbar sympathectomy. This approach was performed for a 43-year-old man with distal arterial occlusive disease and no indication for direct revascularization. His predominant symptoms were intermittent claudication at 100 metres and cold legs. The patient was placed in a left lateral decubitus position. The optical system was placed first in an intra-abdominal position to check that the trocars were well positioned in the retroperitoneal space. The dissection of retroperitoneum was performed by CO2 insufflation. The inferior vena cava was reclined and the right sympathetic chain was individualized. Two ganglia (L3-L4) were removed by bipolar electro-coagulation. The aorta was isolated on a vessel loop and careful anterior traction allowed a retro-aortic pre-vertebral approach between the lumbar vessels. The left sympathetic chain was dissected. Two ganglia (L3-L4) were removed by bipolar electro-coagulation.     

Femorofemoral crossover bypass for noninfective complications of aortoiliac surgery

Between 1973 and 1989, 39 femorofemoral crossover bypasses were performed to treat unilateral noninfective complications of aortoiliac surgery. The initial revascularization procedure, performed an average of 79.5 months previously, was an aortobifemoral bypass in 29 cases, an aorto- or iliofemoral bypass in six cases, an inlay graft for abdominal aortic aneurysm and aortoiliac endarterectomy in two cases each. The indications for femorofemoral crossover bypass included prosthetic occlusion in 35 cases, thrombosed false aneurysm in two, and further degradation after endarterectomy (iliac stenosis and occlusion in one case each). There was no operative mortality. One patient with acute ischemia upon admission and another with distal gangrene required below-knee and forefoot amputations, respectively. No amputations were required during the rest of the follow-up period. Three repeat aortobifemoral bypasses were performed because of occurrence of aortic or inflow vessel lesions. Primary and secondary actuarial five year patency rates for femorofemoral crossover bypasses were 59.7% and 78.4%, respectively. Femorofemoral crossover bypass can extend the benefits derived from direct aortoiliac surgery with low mortality and morbidity in the absence of associated aortic pathology (false aneurysm at the aortic implantation site or severe obstructive lesions). kg]Key wordsPresented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Laparoscopic end-to-end aortobifemoral bypass with reimplantation of the inferior mesenteric artery

Background: Colic ischemia is a serious complication that can occur after abdominal aortic surgery. It has been described in two patients after laparoscopic aortic surgery. The goal of the current experiment was to determine the feasibility of inferior mesenteric artery (IMA) reimplantation during laparoscopic aortobifemoral bypass (LAFB). Methods: Six piglets were submitted to the laparoscopic approach according to the ``apron' technique previously described. The infrarenal aorta was clamped and an LAFB was performed using a dacron graft. The IMA was reimplanted in the body of the graft with a running 5-0 polypropylene suture. Results: Mean operation and dissection times were 282.5 min (range, 270–310 min) and 123 min (range, 110–140 min), respectively, with a mean blood loss of 108 ml (range, 80–150 ml). Aortic clamping and anastomotic times were 123 min (range, 110–135 min) and 33 min (range, 24–45 min), respectively. The IMA reimplantation took 55 min (range, 45–70 min). At autopsy, all anastomoses were patent with no stenosis nor leak. Conclusion: Laparoscopic IMA reimplantation during laparoscopic aortobifemoral bypass is feasible. Received: 10 July 1998/Accepted: 15 November 1998     

Treatment of failed lower extremity bypass grafts with new autogenous vein bypass grafting

During the last 9 years we performed 111 bypass procedures for lower extremity ischemia, which occurred after failed infrainguinal bypass grafting. An all autogenous reversed vein bypass was achieved in 103 of 111 operations (93%). Five-year primary and secondary patency of bypasses placed as treatment for one or more failed prior bypass(es) was 57% and 71%, respectively, as compared to 80% and 83%, respectively, for 5-year primary and secondary patency of simultaneously placed first time leg bypasses. Five-year limb salvage for bypass procedures performed as treatment for failed bypass was 90%, which was identical to that achieved for first time bypasses.     

Robot-assisted Laparoscopic Aortobifemoral Bypass for Aortoiliac Occlusive Disease: Early Clinical Experience

BACKGROUND: Robotic technology may facilitate laparoscopic aortic reconstruction. We present our early clinical experience with laparoscopic aortobifemoral bypass, aided by two different robotic surgical systems. METHODS: Between February 2002 and April 2004, we performed eight robot-assisted laparoscopic aorto-bifemoral bypasses for aortoiliac occlusive disease. All patients were male; median age was 55 years (range: 36-64). Dissection was performed laparoscopically and the robotic system was used to construct the aortic anastomosis. RESULTS: A robot-assisted anastomosis was successfully performed in seven patients. Median operative time was 405 min (range: 260-589), with a median clamp-time of 111 min (range: 85-205). Median blood loss was 900 ml (range: 200-5800). Median anastomosis time was 74 min (range 40-110). In two patients conversion was necessary, one due to bleeding of an earlier clipped lumbar artery after completion of the anastomosis, the other because of difficulties with the laparoscopic exposure of the aorta. On post-operative day 3 one patient died unexpectedly as a result of a massive myocardial infarction. Median hospital stay was 7.5 days (range: 3-57). CONCLUSION: Our initial experience with robotic assisted laparoscopic surgery (RALS) shows it is a feasible technique for aortoiliac bypass surgery. However, laparoscopic aortoiliac surgery demands considerable experience and operative times need to be reduced before this technique can be widely implemented.     

经腹膜后隙途径腹腔镜活体供肾切取32例

目的 探讨经腹膜后隙途径腹腔镜活体供肾切取的技术和效果。方法 32名供者中，男性15名，女性17名。29例取左肾，3例取右肾。供者全身麻醉，取侧卧位，共选3个穿刺点，第1个穿刺点选在12肋缘下2cm与骶棘肌外侧缘1cm交叉点，第2个穿刺点选在第1个穿刺点向前8～10cm，或肋缘下2cm与腋前线交叉点，第3个穿刺点位于髂棘上2cm与腋中线交叉点，分别插入12mm、10mm和5mm的Trocar。以自制水囊扩张器扩张腹膜后隙，游离供肾和输尿管，前6例用直线切割缝合器切断肾动脉和静脉，后26例用带锁的塑料夹夹闭切断肾动脉和静脉，在第1个穿刺点向下的延长切口将肾取出。结果 32只供肾切取顺利，手术耗时60～180min，出血量20～200ml，供肾热缺血时间3～8min，冷缺血时间25～50min。3只肾静脉较短，分别为1cm、1．5cm和2cm，另有1只供肾动脉内膜损伤。移植术后第1d，受者的尿量为2800-10 100ml，无移植肾功能恢复延迟发生。结论 经腹膜后隙途径腹腔镜活体供肾切取是安全、可行的，对供者创伤小，所获供肾的质量较好，但要求有熟练的腹腔镜技术。     

Revascularization with the branched graft in middle aortic syndrome

A case of middle aortic syndrome which was thought to be the thoracoabdominal type of Takayasu's disease was successfully treated with the branched graft bypass. Patient was a 23 year-old woman with hypertension and abdominal pain. The preoperative angiography revealed aortic stenosis from the celiac axis to the left renal artery. The operative procedures were as follows; patient was positioned in supine with her left shoulder and arm raised. Eighth intercostal thoracotomy and midline laparotomy was performed with the thoracoabdominal incision. The branched graft was made previously with woven Dacron (phi 18 mm) and three EPTFEs (phi 8mm). The woven Dacron of the graft was used for the bypass from the descending thoracic aorta to the infrarenal abdominal aorta, and the branched EPTFEs of the graft were used for the bypasses to the common hepatic artery, the superior mesenteric artery and the right renal artery in this order. The bypasses were placed along the anatomical courses in the retroperitoneal space. Postoperatively, the blood pressure dropped and the abdominal pain disappeared. The plasma renin activity decreased and the renal function improved. Two months after operation the bypasses were patent by the angiography and now six months after operation she has returned to her social life healthily. The approach to the aorta and its abdominal branches by thoracotomy and laparotomy and bypass with the three branched graft was useful for middle aortic syndrome.     

完全腹腔镜下主-双股动脉旁路术治疗主、髂动脉硬化闭塞症

目的探讨完全腹腔镜下主一双股动脉旁路术治疗主、髂动脉硬化闭塞症的安全性和可行性。方法2008年11月～2012年11月,完全腹腔镜下主一双股动脉旁路术连续治疗7例主、髂动脉硬化闭塞症。7例均为男性,年龄52—70岁,平均60．6岁。Rutherford分级3级5例,4级I例,5级1例。主、髂病变TASC分级C级2例,D级5例。全麻,先用完全腹腔镜技术经左侧结肠后肾后入路游离肾下腹主动脉,再将“Y”形涤纶人工血管近端与之行端侧吻合,人工血管远端经腹膜后隧道引出至相应侧腹股沟,直视下分别与双侧股动脉吻合。结果5例顺利完成腹腔镜下主一双股动脉旁路术,2例中转开腹（肠系膜下动脉断端的钛夹脱落出血1例,结肠损伤1例）。手术时间420～840rain（中位数585min）,主动脉吻合时间40～150min（中位数65rain）,术中出血量400—1500ml（中位数800m1）。未中转的5例均在术后12—40h恢复进食,术后顺利康复出院。结肠损伤患者术后结肠漏二次开腹手术,结肠漏治愈,术后46天死于呼吸衰竭。一过性左肾积水1例,治愈。吻合口近端腹主动脉残留重度狭窄1例行支架治疗治愈。无症状的部分左肾梗死1例。6例随访2—51个月,平均11．2月,均健在,超声随访移植物均通畅,静息痛和间歇跛行症状均消失。结论完全腹腔镜下主一双股动脉旁路术治疗主、髂动脉硬化闭塞症是安全、可行的。在学习曲线中及时中转保证手术安全是必要的。     

后腹腔镜下腔静脉后输尿管扩张段离断矫正术病例报道并文献复习

目的 报道后腹腔镜途径治疗下腔静脉后输尿管离断矫正术的初步经验.方法 患者21 岁,男,无任何不适,体检超声检查发现右肾轻度积液、右输尿管上段扩张,静脉肾盂造影(IVU)、逆行插管肾盂造影提示腔静脉后输尿管.患者取左侧卧位,建立后腹膜间隙,常规于肋弓下置三个鞘卡,离断扩张处输尿管后端端无张力吻合.结果 手术经后腹腔镜完成,用时170 min,出血20 ml,术中及术后无并发症发生.结论 后腹腔镜下于扩张处离断输尿管矫正术可以作为下腔静脉后输尿管首选治疗方案.     

Outcome of concomitant renal artery reconstructions in patients with aortic aneurysm and occlusive disease

The question remains as to whether patients presenting with aortoiliac occlusive disease (AIOD) or abdominal aortic aneurysms (AAAs) have similar outcomes when concomitant renal artery reconstructions are performed. In this study, we analyzed our experience with simultaneous aortic and renal reconstructions using a retroperitoneal approach. Over a 5-year period, all patients with either AAAs > 5 cm or symptomatic AIOD who were found to have high-grade renal artery stenosis and who underwent aortic reconstructions with concomitant renal revascularization were analyzed through our vascular surgery registry. Morbidity and mortality were quantitatively evaluated. Data were analyzed using the chi-square test. A total of 1,133 patients with AAA (n = 832) and AIOD (n = 301) underwent aortic reconstructions. Two hundred thirty-one patients had 283 concomitant renal revascularizations, including bypass, reimplantation, and endarterectomy, for high-grade (> 70%) renal artery stenosis via a left retroperitoneal approach. The mortality rate of AAA repair with and without renal revascularization was 2.3% (4/178) and 1.5% (10/654), respectively, and that of aortobifemoral bypass for AIOD with and without renal revascularization was 5.7% (3/53) and 2.8% (7/248), respectively. Of the 7 deaths in patients requiring aortic and renal reconstructions, 4 occurred in patients with bilateral renal revascularization. Transient renal insufficiency, ischemic colitis, and cardiopulmonary failure occurred in 5.6%, 2.2%, and 9.6% of patients with AAA repair and in 5.7%, 0%, and 9.4% of patients with AIOD. Two patients developed acute occlusion of their renal bypasses; one was successfully revised, whereas the other led to a nephrectomy. In patients with AAAs, AIOD, and high-grade renal artery stenosis, simultaneous aortic and renal reconstructions can be performed through a retroperitoneal approach with a limited and acceptable mortality. With concomitant renal and aortic procedures, patients with AIOD have a higher mortality when compared with those with AAAs, although this difference is not statistically significant.     

Total laparoscopic esophageal bypass using a colonic conduit for corrosive-induced esophageal stricture

Background

The colon and the stomach are the most commonly used conduits for esophageal replacement in patients with esophageal strictures resulting from corrosive ingestion. The replacement surgeries have traditionally been performed by an open approach. While laparoscopic replacement surgery using a stomach conduit has been previously reported, a total laparoscopic bypass using a colonic conduit has not been previously described. We herein describe the surgical technique and results of laparoscopic esophageal bypass using a colonic conduit.

Methods

Patients with corrosive stricture involving the esophagus with the proximal level at the hypopharynx, or those with concomitant gastric scarring, were selected. The surgery was performed with the patient in a supine position using five abdominal ports and a hockey stick/transverse skin crease neck incision. The main steps include colonic mobilization and assessment of the adequacy of the marginal vascular arcade, creation of a retrosternal tunnel, preparation of the colonic conduit, neck dissection, delivery of the colonic conduit into the neck and cervical pharyngo/esophagocolic anastomosis, and intra-abdominal cologastric and ileocolic anastomosis.

Results

During the study period, 39 patients with corrosive stricture of the esophagus were managed surgically at our center with either gastric or colonic bypass. Of these, 22 patients underwent an open procedure (12 retrosternal colonic bypasses and 10 retrosternal gastric bypasses) and 17 patients underwent a laparoscopic procedure (13 retrosternal gastric bypasses and 4 retrosternal colonic bypasses). Patients with stricture at the hypopharynx (n = 2) or those in whom the stomach was contracted (n = 2) were considered for a laparoscopic esophagocoloplasty. The average duration of surgery of these latter four patients was 370 (380, 320, 360, and 420) min and the mean estimated blood loss was 100 mL. All patients could be ambulated on the first postoperative day and were allowed oral liquids by the 7th postoperative day. Compared with patients who underwent an open colonic bypass, there was significantly less need for analgesics. At a median follow-up of 5 (range 3–6) months, all patients are euphagic to solid diet and have excellent cosmetic results.

Conclusion

Laparoscopic colonic bypass is an achievable, safe, and effective procedure for the management of corrosive strictures of the esophagus.     

Intraoperative and early postoperative results after laparoscopic implantation of aortofemoral bifurcation prostheses

PURPOSE: The evaluation of multiple intra- and early postoperative parameters in patients undergoing laparoscopic aortobifemoral bypass grafting. METHODS: The charts of 22 patients who underwent laparoscopic aortobifemoral grafting between February 2nd, 1996 and April 30th, 1999 were retrospectively reviewed. RESULTS: All patients were men. The mean age was 54 +/- 7.2 years with the mean body weight being 76.3 +/- 10.9 kg and the Body-Mass-Index (BMI) 23 +/- 2.8. Claudication was present in 20 patients; one patient had rest pain and one patient suffered from tissue loss. The mean Ankle-Brachial-Index (ABI) was 0.57 +/- 0.1. In four cases conversion to open technique became necessary. The mean operation time was 316 +/- 73 min and the mean aortic cross-clamp time was 73 +/- 20 min. The mean intraoperative blood-loss reached 689 +/- 461 ml. The mean duration of postoperative ventilator support was 6.0 +/- 5.8 hours and the patients left the ICU after 2.2 +/- 3.2 days. Oral intake was allowed after a mean of 2.6 +/- 2.9 days and the central venous lines were removed after 3.8 +/- 3.9 days. The administration of analgetic drugs was required for 2.9 +/- 3.9 days. The mean length of stay in the hospital was 9.6 +/- 5.5 days. CONCLUSIONS: Laparoscopic aortobifemoral bypass grafting is feasible in a selected group of patients. Despite relatively long operation times and the use of a pneumoperitoneum, we did not encounter significant cardiopulmonary adverse effects.