Totally laparoscopic abdominal aortic aneurysm repair.

Current experience with totally laparoscopic aortic aneurysm repair is reviewed with particular attention to the techniques of surgery. Vascular surgery has been slow to enter the field of minimally invasive surgery because of the unique difficulties of managing arterial anatomy with minimal access techniques. Laparoscopic instrumentation has undergone a stunning evolution, and surgeon experience with minimally invasive surgery has grown exponentially. This dramatic revolution has allowed several groups to perform laparoscopic aortic vascular surgery. The surgical approach that each group has taken has varied. The approaches have included both laparoscopically assisted and totally laparoscopic aortic surgery with both transperitoneal and retroperitoneal approaches to the aorta. A review of these varied techniques will be discussed and include our experience with totally laparoscopic aortic surgery. This experience includes both transperitoneal and retroperitoneal approaches to infrarenal aortic aneurysms. An extended discussion of our surgical technique for aneurysm bypass is included. Patient selection, patient positioning, and trocar placement are described. The pattern of surgery for both techniques is enumerated, and postoperative care is discussed. However, the world experience with minimally invasive vascular surgery remains small, therefore a wider acceptance will require a prospective, randomized trial that shows an equally as safe surgical approach as provided open vascular surgery. With its acceptance, minimally invasive vascular surgery should show the patient benefits that befall minimally invasive surgery patients.     

Hand-assisted laparoscopic abdominal aortic aneurysm repair.

Hand-assisted laparoscopic aneurysm resection enables the surgeon to use his tactile senses while performing a laparoscopic aneurysm repair. Even more complex procedures that involve suprarenal clamping of the aorta can be performed by using this laparoscopically assisted approach. Twenty-nine laparoscopic patients were compared with a control group of 19 patients who were operated on conventionally. Transperitoneal hand-assisted laparoscopic aneurysm resection with a tube graft or a bifurcated graft was performed. The anastomosis was sutured with conventional instruments using the mini-incision as an access. The time for laparoscopy did not exceed 40 minutes. The incidence of complications did not vary between groups. The mean operating time was 135 minutes in the conventional group versus 180 minutes in the minimal invasive group. Intensive care stay and postoperative hospital stay were significantly shorter after the laparoscopic procedure. An oral diet was resumed significantly earlier, and the time until complete recovery was shortened in the miniaccess group. Hand-assisted laparoscopic aneurysm resection can be performed safely with operating times almost as expeditiously as in open surgery. Because it can be offered to the majority of patients with aortic disease, the technique described has distinct advantages over a total laparoscopic approach and a less steep learning curve.     

Concomitant transabdominal MIDCAB and abdominal aortic aneurysm repair

We present 2 patients who underwent transabdominal minimally invasive direct coronary artery bypass with the right gastroepiploic artery combined with abdominal aortic aneurysm repair. The surgical procedures, both performed through a median laparotomy, proved safe and of limited invasiveness. The one-stage surgical intervention prevented catastrophic complications, such as acute myocardial infarction or rupture of abdominal aortic aneurysm. We believe that concomitant transabdominal minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair should be considered as a single combined surgical strategy in selected patients.     

Totally laparoscopic abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) resection is a major surgical procedure performed frequently. As a minimal access procedure, laparoscopy has been shown in the field of general surgery to improve a patient's postoperative well-being and to shorten hospital stay. The same benefits could be expected from a laparoscopic approach for AAA repair. We report what we believe to be the first totally laparoscopic AAA repair performed according to the principles of endoaneurysmorrhaphy.     

Totally laparoscopic abdominal aortic aneurysm repair

On the basis of our previous animal and clinical experience with laparoscopic intra-abdominal vascular reconstructions, and due to the prevalence of abdominal aortic aneurysms (AAA), we have recently broadened our scope to tackle more difficult aortic surgery laparoscopically. We present a case report of our first clinical experience with laparoscopic AAA repair using specialized laparoscopic vascular instrumentation. The patient was an 84-year-old hypertensive male with a 7-cm asymptomatic infrarenal abdominal aortic aneurysm that was discovered incidentally. He presented with postcoronary artery bypass grafting and had moderate chronic obstructive pulmonary disease (COPD). A spiral computed tomograph (CT) angiogram revealed an adequate infrarenal neck and aneurysmal involvement of the proximal iliac arteries. An eight-port transabdominal technique was used with the patient in the supine position. Proximal and distal control was achieved without difficulty. The aneurysm was excluded using endoscopic stapling devices, and an aortobiiliac reconstruction was performed with a 16 × 9-mm bifurcated dacron graft. Estimated blood loss was 1000 ml, and the operative time was approximately 7 hours. The patient was ambulating without assistance on postoperative day 3. Total hospitalization was 7 days (delayed secondarily to postoperative ileus). Minimal quantities of narcotics were required for analgesia. At 6-months follow-up, the patient has palpable peripheral pulses and no complications related to surgery. This case report shows that a completely laparoscopic approach to the abdominal aortic aneurysm is possible using instrumentation specifically designed for laparoscopic vascular surgery. The exact role that laparoscopic techniques will hold in vascular surgery remains to be determined because these procedures are time consuming and technically difficult. Received: 2 December 1997/Accepted: 4 March 1998     

Total laparoscopic juxtarenal abdominal aortic aneurysm repair

OBJECTIVES: This study describes our experience of total laparoscopic juxtarenal abdominal aortic aneurysm (JAAA) repair. METHODS: Between February 2002 and October 2007, we performed 148 total laparoscopic AAA repairs, including a subset of 13 patients who underwent a laparoscopic JAAA repair. Median age was 70 years (range, 50-81years). Median aneurysm size was 55 mm (range, 50-80 mm). Eight patients were in American Society of Anesthesiologist class II, and five were in class III. We used laparoscopic transperitoneal left retrorenal approaches and suprarenal clamping in all patients. RESULTS: We implanted tube grafts in nine patients and bifurcated grafts in four. No conversions to open repair were required. Median operative time was 260 minutes (range, 180-355 minutes). Total median aortic clamping time was 77 minutes (range, 36-105 minutes). Median suprarenal clamping time was 24 minutes (range, 9-37 minutes). Median blood loss was 855 mL (range, 215-2100 mL). No patients died. One patient had a postoperative coagulopathy with hemorrhagic syndrome. Five patients had moderate systemic complications, including four renal insufficiencies without dialysis and one grade I ischemic colitis. Liquid diet was reintroduced after 1 day (range, 1-7 days). Most patients were ambulatory by day 3 (range, 2-17 days). Median lengths of stay were 48 hours (range, 12-336 hours) in the intensive care unit and 10 days (range, 4-30 days) in the hospital. With a median follow-up of 19 months (range, 1-36 months), patients had complete recovery without graft anomalies. CONCLUSION: Total laparoscopic JAAA repair is feasible and worthwhile for patients. Prior experience in laparoscopic aortic surgery is essential to perform these challenging procedures. Despite these encouraging results, a greater experience is required to ensure the benefit of this technique compared with open repair.     

Infrarenal aortic aneurysm repair by retroperitoneal approach combined with laparoscopic cholecystectomy: two case reports

Simultaneous repair of abdominal aortic aneurysm and treatment of cholelithiasis by the transperitoneal approach is controversial because of the risk of prosthesis infection. We report two patients who underwent a successful combined procedure using a retroperitoneal approach for the aortic aneurysm repair and a laparoscopic approach to the cholecystectomy. This combined approach reduces the risk of infection of the aortic prosthesis and is associated with a rapid return of normal peristalsis.     

Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair

PURPOSE: Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure. METHODS: Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality. RESULTS: Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups. CONCLUSION: Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.     

Technique for iliac artery reconstruction in abdominal aortic aneurysm repair.

The aim of this retrospective study was to evaluate the technique for iliac artery reconstruction in abdominal aortic aneurysm repair, when external and internal iliac arteries were required to reconstruct individually. Among 203 elective infrarenal abdominal aortic aneurysm repairs, 22 patients (10.8%) required individual reconstruction of bilateral or unilateral iliac arteries, including 56 external or internal iliac arteries. Mainly, three types of procedures were performed: (1) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner, and the internal iliac artery was attached to the side of the external iliac artery, (2) the external iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end manner and the internal iliac artery was bypassed with the use of a straight prosthetic graft extending from the limb of the bifurcated graft, and (3) the internal iliac artery was anastomosed to the end of the bifurcated graft limb in an end-to-end fashion, and the external iliac artery was sewn to the side of the graft limb. In these three types of procedures, the third technique was the easiest and simplest anatomically.     

Midline retroperitoneal versus midline transperitoneal approach for abdominal aortic aneurysm repair

PURPOSE: The purpose of this study was to compare the midline retroperitoneal approach with the midline transperitoneal approach for abdominal aortic aneurysm (AAA) repair with respect to operative details, gastrointestinal complications, and wound complications. METHODS: From January 1990 through January 1998, 128 patients underwent elective aortic reconstruction for infrarenal AAA. Of these, 64 patients (the transperitoneal group) underwent conventional transperitoneal midline aortic exposure, whereas the remaining 64 patients (the retroperitoneal group) underwent retroperitoneal midline exposure of the aneurysm. RESULTS: Preclamp time, that is, the time from skin incision to aortic clamping, was significantly shorter in the transperitoneal group than in the retroperitoneal group (P <.001). However, the midline retroperitoneal approach was associated with decreased incidence of ileus (P <.01), earlier resumption of oral intake (P <.01), and decreased wound pain (P <.01), in comparison with the transperitoneal approach. Furthermore, there was no incidence of wound complications such as abdominal bulge or wound pain in any of the patients in the postoperative period or over the long term. CONCLUSIONS: The midline retroperitoneal approach for AAA was associated with fewer postoperative gastrointestinal and wound complications than the midline transperitoneal approach. Over the long term, there was no wound complication such as abdominal bulge and wound pain in any of the patients.     

Quality of life before and after endovascular and retroperitoneal abdominal aortic aneurysm repair

PURPOSE: This study was undertaken to evaluate changes in quality of life and to compare conventional outcomes in patients undergoing endovascular and open retroperitoneal abdominal aortic aneurysm (AAA) repair. METHODS: Between October 2000 and May 2003, 129 patients underwent elective AAA repair, endovascular repair in 22 patients and open retroperitoneal repair in 107 patients. The Short-Form Health Survey, 12 items (SF-12) was administered preoperatively and at 3 weeks, 4 months, and 1 year after discharge. Quality of life, hospital and intensive care unit stay, perioperative complications, discharge disposition, readmission, and hospital cost were statistically evaluated. RESULTS: For the total group, significant differences were observed for both Physical Component Summary scores (P<.001) and Mental Component Summary scores (P=.001) between time points. There were no significant differences for either Component Summary score between open and endovascular procedures for any time period. Number of weeks required to return to baseline functional status was similar after either open or endovascular repair (7.22 vs 5.47 weeks, respectively; P=.09). Mean hospital and intensive care unit stay was 4.4 and 1 days, respectively, for open repair versus 1.9 and 0 days, respectively, for endovascular repair (P<.0001). No significant difference between groups was observed in terms of perioperative complications, discharge disposition, or hospital readmission (P> or =.54). Mean total hospital cost for endovascular repair was 1.60 times that for open repair (mean difference, $11,662; P<.0001; 95% confidence interval, $17,799-$5525). CONCLUSIONS: Hospital stay is significantly shorter after endovascular AAA repair. However, hospital cost is almost twice that for open retroperitoneal repair. Perioperative complications, discharge disposition, and hospital readmission are not statistically different between the two groups. Effect on health-related quality of life is similar after either open retroperitoneal or endovascular AAA repair.     

Endovascular, transperitoneal, and retroperitoneal abdominal aortic aneurysm repair: results and costs.

PURPOSE: Contemporary treatment of abdominal aortic aneurysms (AAA) includes transabdominal (TA), retroperitoneal (RP), and endovascular (EV) repair. This study compares the cost and early (30-day) results of a consecutive series of AAA repair by means of these three methods in a single institution. METHODS: A total of 125 consecutive AAA repairs between February 1993 and August 1997 were reviewed. Risk factors, 30-day morbidity and mortality rates, and hospital stay and cost were analyzed according to method of repair (TA, RP, EV). Cost was normalized by means of a conversion factor to maintain confidentiality. Cost analysis includes conversion to TA repair (intent to treat) in the EV group. RESULTS: One hundred twenty-five AAA repairs were performed with the TA (n = 40), RP (n = 24), or EV (n = 61) approach. Risk factors among the groups (age, coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease, and cigarette smoking) were not statistically different, and thus the groups were comparable. The average estimated blood loss was significantly lower for EV (300 mL) than for RP (700 mL) and TA (786 mL; P>.05). Statistically significant higher cost for TA and RP for pharmacy and clinical laboratories (likely related to increased length of stay [LOS]) and significantly higher cost for EV in supplies and radiology (significantly reducing cost savings in LOS) were revealed by means of an itemized cost analysis. Operating room cost was similar for EV, TA, and RP. There were six perigraft leaks (9.6%) and six conversions to TA (9.6%) in the EV group. CONCLUSION: There were no statistically significant differences in mortality rates among TA, RP, and EV. Respiratory failure was significantly more common after TA repair, compared with RP or EV, whereas wound complications were more common after RP. Overall cost was significantly higher for TA repair, with no significant difference in cost between EV and RP. EV repair significantly shortened hospital stay and intensive care unit (ICU) use and had a lower morbidity rate. Cost savings in LOS were significantly reduced in the EV group by the increased cost of supplies and radiology, accounting for a similar cost between EV and RP. Considering the increased resource use preoperatively and during follow-up for EV patients, the difference in cost between TA and EV may be insignificant. EV repair is unlikely to save money for the health care system; its use is likely to be driven by patient and physician preference, in view of a significant decrease in the morbidity rate and length of hospital stay.     

Laparoscopically assisted abdominal aortic aneurysm repair.

Since the advent of laparoscopy, the sweeping changes seen in general surgery have not been paralleled in vascular surgery. However, the application of laparoscopic techniques to intraabdominal vascular procedures has now progressed from the animal laboratory to the clinical arena. Initial experience with laparoscopically assisted aortic bypasses for occlusive disease has led to the development of procedures for aneurysmal disease. This article reviews the current clinical experience in the evolving technique of laparoscopically assisted abdominal aortic aneurysm repair.     

Laparoscopic-assisted abdominal aortic aneurysm repair

Since the advent of laparoscopy, the sweeping changes seen in general surgery have not been paralleled in vascular surgery. There have been case reports of laparoscopic-assisted aortobifemoral bypass for occlusive disease. Because aneurysmal disease comprises the majority of aortic surgery, we pursued animal and cadaveric feasibility studies for laparoscopic-assisted abdominal aortic aneurysm (AAA) repair. We present a case report of the first clinical case performed under Institutional Review Board protocol using this technique. The patient was a 62-year-old male with a 6-cm infrarenal AAA. After obtaining a pneumoperitoneum, a modified fish retractor was used to exclude the bowel. Ten 11-mm ports provided access to laparoscopically dissect the neck of the aneurysm and the iliac vessels. Then, a 10-cm minilaparotomy was performed and standard vascular clamps were inserted via the port incisions. Standard aneurysmorraphy was performed with a polytetrafluoroethylene (PTFE) tube graft. Laparoscopy conferred three major benefits: better visualization of the aneurysm neck, less bowel manipulation, and avoidance of hypothermia. This case report illustrates the feasibility of laparoscopic-assisted aneurysm repair. Controlled human studies will define the role of laparoscopy in AAA surgery.