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.     

Total laparoscopic aortic surgery versus minimal access techniques: review of more than 600 patients

In the following paper we describe our experience with a large number of patients in which either a laparoscopic assisted procedure or a total laparoscopic operation was performed. From 1996 until 2005 a total number of 638 aortic patients were operated on using a total laparoscopic or a laparoscopic assisted approach. A total laparoscopic operation was accomplished in 236 cases. A laparoscopic assisted aortic operation was performed in 402 patients. In aneurysm patients a tube graft was more frequently implanted. Thirty-day mortality was significantly higher in patients with a total laparoscopic abdominal aortic aneurysm repair (3.0%) compared to a laparoscopic assisted procedure (1.8%). There was no significant difference in mortality in patients with occlusive disease and a total laparoscopic aortofemoral bypass versus a laparoscopically assisted operation. The same tendency could be observed when analyzing the incidence of major perioperative complications. Again we found no significant difference in patients with occlusive disease yet more severe complications directly related to the operation in patients with a total laparoscopic aneurysm repair. There was a significantly increased complication rate in total laparoscopic aortoiliac repair with a bifurcated prosthesis compared to a tube graft repair: a tendency we could not observe in aneurysm patients with a laparoscopic assisted operation. Our data also show that there is a lot of room for technical improvements such as stapling devices or special grafts to reduce total operating times as well as the period of aortic crossclamping. The routine use of a minilaparotomy can hardly be a solution considering the technical drawbacks such as impaired vision and long term complications like ventral hernias. Compared to open surgery the midterm results of laparoscopic aortic procedures are promising. The time has come to prove that good results can be obtained in more than a few specialized centers.     

Laparoscopy-assisted abdominal aortic aneurysm repair: early and middle-term results of a consecutive series of 122 cases

BACKGROUND: Endoaneurysmorrhaphy with intraluminal graft placement, described by Creech, is the gold standard for abdominal aortic aneurysm (AAA) repair. Endovascular aneurysm repair has gained popularity for its minimal invasiveness and satisfying short-term results, but there are still many concerns about the long-term success of the procedure. Since 1998, laparoscopic surgery has been proposed for AAA treatment. The potential benefits of a minimally invasive procedure reproducing the endoaneurysmorrhaphy results over time have been advocated. In our experience, hand-assisted laparoscopic surgery (HALS) has been routinely used for the open-surgery transperitoneal/retroperitoneal approach and for endovascular aneurysm repair. After 4 years, we are able to define the early and middle-term results of such laparoscopic-assisted treatment. METHODS: From October 2000 to March 2004, 604 consecutive nonurgent AAAs were treated at our institution. Of these, 122 (20.2%) were treated by HALS. Exclusion criteria for HALS were hostile abdomen (previous major abdominal or aortic surgery), bilateral diffuse common iliac and/or hypogastric aneurysms, massive aortoiliac calcifications, and severe cardiac (ejection fraction <35%) and respiratory (P(O2) <60 mm Hg or carbon dioxide >50 mm Hg) insufficiency. Juxtarenal and proximal iliac aneurysms were not a contraindication, nor was obesity. In all patients, we performed a minilaparotomy (7-8 cm) both for laparoscopic hand-assisted dissection and for endoaneurysmorrhaphy. All perioperative data were prospectively recorded. Follow-up consisted of ultrasonography and clinical evaluation after 6 and 12 months and then every year after surgery. RESULTS: The mean laparoscopic and total operative times were respectively 64 +/- 32 minutes and 257 +/- 70 minutes, the mean aortic cross-clamping time was 76 +/- 26 minutes, and the mean autotransfused blood volume was 1136 +/- 711 mL. The overall mortality and morbidity were respectively 0% and 12.2%. Morbidity was surgery related in only two cases (bleeding from an ipogastric artery lesion and a leg graft thrombosis). The mean intensive care unit stay was 14.3 +/- 13 hours. Oral food intake was resumed after 27.4 +/- 15 hours, and patients were discharged after a mean of 4.4 +/- 1.7 days. Operative times were not affected by obesity, suprarenal aortic cross-clamping, or aneurysm size. Both concomitant iliac aneurysms and bifurcated graft implantation (related to longer vascular reconstruction) involved significantly longer operative times. The learning curve of the procedure (comparing the first 30 patients with the last 92 patients) led to significantly shorter endoscopic, cross-clamping, and total operative times (P = .000). The mean follow-up was 28.6 +/- 16 months. Three incisional hernias and one case of bowel occlusion were detected. All these cases (3.4%) required laparoscopic treatment. CONCLUSIONS: The HALS technique is a safe and minimally invasive treatment for AAA; it is useful for limiting the need for conventional open surgery and reducing the length of hospital stay. Despite the lack of randomized studies, HALS seems to be associated with a better postoperative course than standard open surgery. HALS can also be considered as an equivalent of a well-established procedure and as a bridge between open and total laparoscopic surgery.     

Laparoskopische Aortenchirurgie

The following article describes our technique and results with total laparoscopic aortic aneurysm repair. A distinction must be made between laparoscopic-assisted procedures requiring a mini-incision to perform an anastomosis and total laparoscopic operations where the whole procedure is performed laparoscopically. In addition to aorto-femoral or ileo-femoral bypass procedures, total laparoscopic techniques can be used to perform abdominal aortic aneurysm resections. A transperitoneal left retrorenal access is preferred in most cases. Special laparoscopic clamps, often in combination with balloon catheters are used to occlude the aorta and if necessary the renal arteries. Exactly the same techniques as used in open surgery are transferred to a laparoscopic setting. Either a tube graft repair or a bifurcated graft anastomosed with the iliac bifurcation or the femoral artery is performed to exclude the aneurysm. Laparoscopic techniques can also be used to treat patients with type II endoleakage after EVAR or cases with endotension. Lumbar arteries or the IMA are clipped and if necessary downsizing of the aneurysm can be accomplished by opening the sac of the AAA, evacuating the thrombus material and stitching lumbar arteries from the inside. More recently laparoscopic techniques have been used to reduce the access trauma in debranching procedures. The learning curve of total laparoscopic aortic procedures is still steep, but new instruments, staplers or robotic devices will probably shorten this learning curve in the future. In an increasing number of European countries laparoscopic aortic surgery is becoming a third way to perform aortic repair. In contrast to EVAR it can offer to aneurysm patients the same definitive outcome and long lasting results as open surgery.     

Totally laparoscopic juxtarenal aortic anastomosis: an experimental study

The surgical management of juxtarenal aneurysms necessitates suprarenal aortic clamping and control of the renal arteries. We attempted to reproduce this procedure laparoscopically. Five female piglets were submitted to a totally laparoscopic approach of the aortoiliac segment. After laparoscopic control of the renal arteries and suprarenal clamping, a 6-mm Dacron tube graft was anastomosed to the juxtarenal aorta. After the procedure, a midline laparotomy allowed verification of the patency of the renal arteries and the quality of the anastomosis. Mean operative time was 198 minutes (range, 170-240 minutes). The dissection took an average of 92 minutes (range, 75-110 minutes). The mean suprarenal aortic cross-clamp time was 46.3 minutes (range, 29.1-81.5 minutes), and the mean anastomotic time was 28.9 minutes (range, 16.5-68.1 minutes). This study demonstrates in this animal model the feasibility of juxtarenal aortic anastomosis using a laparoscopic technique. Newly designed instruments should allow a shorter clamping time in the future.     

Robot-assisted aortoiliac reconstruction: A review of 30 cases

OBJECTIVE: The feasibility of laparoscopic aortic surgery with robotic assistance has been sufficiently demonstrated. Reported is the clinical experience of robot-assisted aortoiliac reconstruction for occlusive disease and aneurysm performed using the da Vinci system. METHODS: Between November 2005 and June 2006, 30 robot-assisted laparoscopic aortoiliac procedures were performed. Twenty-seven patients were prospectively evaluated for occlusive disease, two patients for abdominal aortic aneurysm, and one for common iliac artery aneurysm. Dissections of the aorta and iliac arteries were performed laparoscopically using a transperitoneal direct approach technique, a modification of the Stádler method. The robotic system was used to construct anastomoses, to perform thromboendarterectomies and, in most of the cases, for posterior peritoneal suturing. RESULTS: Robot-assisted procedures were successfully performed in all patients. The robot was used to perform both the abdominal aortic and common iliac artery aneurysm anastomoses, the aortoiliac reconstruction with patch, and to complete the central, end-to-side anastomosis in another operation. Median operating time was 236 minutes (range, 180 to 360 minutes), with a median clamp time of 54 minutes (range, 40 to 120 minutes). Operative time is defined as the time elapsed from the initial incision to final skin closure. Median anastomosis time was 27 minutes (range, 20 to 60 minutes), and median blood loss was 320 mL (range, 100 to 1500 mL). No conversion was necessary, 30-day survival was 100%, median intensive care unit stay was 1.8 days, and median hospital stay was 5.3 days. A regular oral diet was resumed after a mean time of 2.5 days. CONCLUSION: Robot-assisted laparoscopic surgery is a feasible technique for aortoiliac surgery. The da Vinci robotic system facilitated the creation of the aortic anastomosis and shortened aortic clamp time in comparison with our laparoscopic techniques.     

Laparoscopically assisted abdominal aortic aneurysm repair

Background: Laparoscopic surgery decreases postoperative pain and length of hospital stay. Whether laparoscopically assisted abdominal aortic aneurysm (AAA) repair can be safely and reliably performed is unknown. This prospective study was designed to establish the feasibility of laparoscopically assisted AAA repair and its effects on intraoperative and postoperative variables. Methods: With IRB approval, 10 patients with infrarenal AAA requiring a tube graft underwent laparoscopically assisted AAA repair. The procedure consisted of laparoscopic dissection of the aneurysm neck and iliac vessels. Then, through an 8–11-cm minilaparotomy, a standard endoaneurysmorrhaphy was performed. Data included laparoscopic and total operative times, blood loss, fluid requirements, duration of nasogastric suction (NGT), and lengths of intensive care unit (ICU) and postoperative hospital stays. Results: Laparoscopically assisted AAA was completed in nine of 10 patients. The first patient was converted to a standard incision because the aneurysm neck could not be adequately dissected. Laparoscopic and total operative times were 1.8 ± 0.4 and 4.5 ± 0.7 h, respectively. Mean blood loss was 1 ± 0.6 l. Intraoperative fluid requirement was 6.6 ± 1.3 l. The duration of NGT suction was 1.8 ± 1.0 days. The ICU stay was 2.1 ± 0.8 days and hospital stay was 6.7 ± 2.5 days. There were two minor complications and no deaths. Conclusions: Laparoscopically assisted AAA repair is technically feasible with acceptable blood loss, operative time, morbidity, and mortality. Potential advantages may be early removal of the NGT and shorter ICU and hospital stays. Prospective randomized trials are needed to determine if laparoscopically assisted AAA repair is advantageous.     

Totally laparoscopic aortobifemoral bypass grafting in an experimental model: Description of technique with initial surgical results

Our aim was to examine the feasibility of a totally laparoscopic insertion of a bifurcated aortofemoral bypass graft in a canine model and to compare the surgical results with those in control animals undergoing standard grafting and laparoscopic-assisted bypass procedures. Using a six-port approach, we exposed and cross clamped the aorta, tunneled a bifurcated Dacron graft, and performed an end-to-end aortic anastomosis while maintaining pneumoperitoneum by means of CO₂. Proximal anastomoses were performed with 4/0 double-ended continuous Prolene sutures and distal anastomoses were performed through standard groin incisions. Total operating and aortic cross-clamp times were measured as was the total blood loss for each procedure. Clinical outcome was also documented. Eight female laboratory-bred hounds underwent successful totally laparoscopic aortobifemoral bypass grafting, eight underwent open grafting, and eight underwent laparoscopic-assisted bypass. Mean operating time was 193 minutes in the animals undergoing totally laparoscopic insertion vs. 156 minutes in the open group and 180 minutes in the laparoscopic-assisted group. Aortic cross-clamping time was also significantly longer at 87 minutes vs. 43 minutes (p < 0.001)=" in=" the=" totally=" laparoscopic=" group,=" but=" blood=" loss=" was=" less.=" all=" eight=" laparotomy=" and=" laparoscopic-assisted=" dogs=" were=" still=" alive=" with=" no=" complications=" at=" 28=" days,=" whereas=" three=" of=" the=" eight=" in=" the=" totally=" laparoscopic=" group=" showed=" evidence=" of=" temporary=" paraplegia.=" this=" experimental=" study=" demonstrates=" that=" a=" totally=" laparoscopic=" approach=" can=" be=" used=" to=" insert=" a=" bifurcated=" aortofemoral=" bypass=" with=" a=" proximal=" end-to-end=" anastomosis=" but=" currently=" does=" not=" save=" time=" and=" may=" increase=" the=" risk=" of=" neurologic=">Presented at the Twentieth Annual Meeting of the Peripheral Vascular Surgery Society, New Orleans, La., June 10, 1995.     

Surgical repair of aneurysms involving the distal aortic arch

The surgical approach to aneurysms involving the transverse aortic arch usually requires either techniques for perfusion or hypothermic circulatory arrest. A simplified approach may be warranted when the aneurysmal process begins in the distal aortic arch and spares the innominate artery. Between November, 1975, and January, 1984, 32 patients (22 men, 10 women; median age 61 years) underwent repair of aneurysms of the distal aortic arch by simple cross-clamping of the diseased aortic segment. In each, the aneurysm arose distal to the innominate artery and involved the arch at the origin of the left subclavian or left common carotid artery. Proximal control was achieved by cross-clamping the aortic arch between the innominate and left carotid arteries. No shunts or extracorporeal bypass circuits were employed. Proximal hypertension was controlled by sodium nitroprusside infusion. All patients were heparinized. A mean aortic cross-clamp time of 27 +/- 10 minutes was required for Dacron graft replacement in 28 patients and Dacron patch repair in three patients. Surgical repair was accomplished successfully in 32 patients. The 30 day mortality was 3% with an in-hospital mortality of 6%. There were no complications as a result of myocardial infarction or stroke. Paraplegia (three patients) was related to cross-clamp time (less than 30 minutes, 0/18; greater than 30 minutes, 3/13 [p less than 0.001]) and distal extent of the aneurysm (localized, 0/22; extensive, 3/9 [p less than 0.001]). Transient renal failure (two patients) was related to cross-clamp time (less than 30 minutes, 0/18; greater than 30 minutes, 2/13 [p less than 0.001]). This experience supports the use of simple aortic cross-clamping for aneurysms of the distal aortic arch, especially if an expeditious repair can be accomplished.     

Minilaparotomy for aortoiliac aneurysmal disease: experience and review of the literature

Vascular surgery is evolving, as other specialities, toward minimally invasive techniques. Presently, 3 approaches to aortoiliac disease are suggested as minimally invasive. Besides the endovascular procedures, laparoscopic techniques and minilaparotomy are being advocated. Although for aneurysmal disease, we favor a totally laparoscopic approach, criticisms raised over laparoscopy-assisted techniques by those advocating minilaparotomy led us to investigate the benefits of the latter technique. We first evaluated the procedure in 7 patients with infrarenal abdominal aortic aneurysm (AAA). We found the procedure impossible to perform with an 8- to 10-cm incision in 6 of the 7 patients. This led us to evaluate causes of failure of the technique. It appeared to us that most of our complications were related to inadequate exposure. Fifty consecutive computed tomography scans from patients with AAA of surgical size were then reviewed to evaluate the aneurysm lengths and compare them to the reported lengths of skin incision for minilaparotomy. Results were expressed adding a total of 2 cm for proximal and distal clamping. Only 2% of patients would present with aneurysms suitable for treatment through an 8-cm midline incision and 30% through a 10-cm incision. We then reviewed the literature on minilaparotomy. We believe that minilaparotomy should be reserved for those patients with purely aortic disease and the appropriate body habitus.     

Hand-assisted laparoscopic aorto-aortic bypass: initial experience in a porcine model

Videoscopic surgical techniques have been developed to reduce morbidity of open aortic reconstructions. The advantage of hand-assisted laparoscopic surgery (HALS) technique is the introduction of the surgeon's hand into the peritoneal cavity. The aims of this study were to assess the feasibility and to examine the learning curve, limitations, and pitfalls of the HALS technique to perform aortic reconstruction in a porcine model for training purposes. HALS aorto-aortic 8 mm polytetrafluoroethylene (PTFE) interposition grafts were placed in 12 pigs. Proficiency was judged by measuring operative time points, satisfactory completion of the operation, and the need to convert to open procedure. The strength of the relationship between order number in which a procedure was performed and the various surgical time point measures was described with the Spearman rank correlation. HALS aortic grafting was successful in the last 8 pigs. The first 2 pigs required conversion to open repair, and the graft of the third and fourth animals occluded early. Median operative time was 115 minutes (range: 75 to 205), median intestinal retraction time was 28 minutes (range: 10 to 40), median aortoiliac dissection time was 30 minutes (range: 20 to 60), and median aortic cross-clamp time was 48 minutes (range: 35 to 82). The Spearman rank correlations and p values between the order of the procedure and the intestinal retraction time, aortoiliac dissection time, clamping time, and total operative time were -0.62 (0.06), -0.47 (0.17), -0.69 (0.03), and -0.83 (0.03), respectively. HALS facilitates intestinal retraction and completion of laparoscopic aortoiliac dissection. It offers adequate exposure in pigs for aortic grafting and allows open sutured aortic anastomosis. The learning curve for HALS aortic surgery in a porcine model is short and within reach of surgeons with standard laparoscopic surgery skills, since no laparoscopic suturing is required. Training on this porcine model may be an efficient and safe way to introduce surgeons to HALS for aortoiliac reconstruction.     

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.     

Laparoscopically assisted abdominal aortic aneurysm repair: First 20 cases

Purpose: Laparoscopic surgery decreases postoperative pain, shortens hospital stay, and returns patients to full functional status more quickly than open surgery for a variety of surgical procedures. This study was undertaken to evaluate laparoscopic techniques for application to abdominal aortic aneurysm (AAA) repair. Methods: Twenty patients who had AAAs that required a tube graft underwent laparoscopically assisted AAA repair. The procedure consisted of transperitoneal laparoscopic dissection of the aneurysm neck and iliac vessels. A standard endoaneurysmorrhaphy was then performed through a minilaparotomy using the port sites for the aortic and iliac clamps. Data included operative times, duration of nasogastric suction, intensive care unit days, and postoperative hospital days. Pulmonary artery catheters and transesophageal echocardiography were used in seven patients. For these patients data included heart rate, pulmonary artery systolic and diastolic pressures, mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index, and end diastolic area. Data were obtained before induction, during and after insufflation, during aortic cross-clamp, and at the end of the procedure. Results: Laparoscopically assisted AAA repair was completed in 18 of 20 patients. Laparoscopic and total operative times were 1.44 ± 0.44 and 4.1 ± 0.92 hours, respectively. Duration of nasogastric suction was 1.3 ± 0.7 days. Intensive care unit stay was 2.2 ± 0.9 days. The mean length of hospital stay was 5.8 days excluding three patients who underwent other procedures. There were two minor complications, one major complication (colectomy after colon ischemia), and no deaths. For the eight patients who had intraoperative transesophageal echocardiographic monitoring, no changes were noted in heart rate, pulmonary artery systolic pressure, pulmonary capillary wedge pressure, and cardiac index. Pulmonary artery diastolic pressure and central venous pressure were greatest during insufflation without changes in end-diastolic area. Volume status, as reflected by end-diastolic area and pulmonary capillary wedge pressure, did not change. Conclusions: Laparoscopically assisted AAA repair is technically challenging but feasible. Potential advantages may be early removal of nasogastric suction, shorter intensive care unit and hospital stays, and prompt return to full functional status. The hemodynamic data obtained from the pulmonary artery catheter and transesophageal echocardiogram during pneumoperitoneum suggest that transesophageal echocardiography may be sufficient for evaluation of volume status along with the added benefit of detection of regional wall motion abnormalities and aortic insufficiency. Further refinement in technique and instrumentation will make total laparoscopic AAA repair a reality. (J Vasc Surg 1998;27:81-8.)     

Stapled aortic anastomoses: a minimally invasive, feasible alternative to videoscopic aortic suturing?

Widespread applications of totally laparoscopic aortic reconstructions have been limited by the long cross-clamp time required to suture the aortic anastomosis despite improvement in instrumentation. The authors' hypothesis was that a "one-step anastomosis concept" using an intraluminal stapler would allow shorter cross-clamp time but similar patency and imperviousness as videoscopic suturing techniques. An intraluminal stapler (Endopath-ILS, Ethicon) with a modified anvil was used to perform videoscopic-assisted thoracic aorta-to-iliac artery bypass with a 21 mm by 8 mm polytetrafluoroethylene (PTFE) graft in 22 sheep through a minimally invasive approach using a 5 cm thoracotomy. The graft-to-iliac artery anastomoses were hand sutured through a flank incision. Twelve sheep were used to establish the technique and 10 subsequent animals constituted the study group. Aortic cross-clamp time, imperviousness, and need for additional sutures were recorded and compared to previously reported data using videoscopic suturing in pigs. Patency was assessed by comparing lower limb arterial pressures. Macroscopic and microscopic examinations of the anastomoses were performed at different time-points within the first 3 months. Videoscopic-assisted stapled anastomoses were also performed on atherosclerotic aortas of 3 human cadavers. Stapled anastomoses between the thoracic aorta and PTFE graft were completed in 8 of 10 animals. Two animals were euthanized after stapler failure and anastomotic bleeding. Sutures to strengthen the anastomosis had to be used in 4 cases. Mean aortic cross-clamp time in 8 successful cases was 4.3 +/-2.9 minutes (range 2-11 minutes) and was significantly shorter than clamp time of videoscopic suturing technique (48.7 +/-9.4 minutes, p < 0.0001). Imperviousness was good or excellent in 4 animals and fair in 4 animals. All anastomoses were patent at the end of the procedure. Examination of the anastomosis of the 2 failed interventions showed medial aortic tear surrounding the anastomosis in 1 case and misfired staples in the other. No graft occlusion was noted during follow-up ranging from 0 to 12 weeks. At the time of harvest, no bleeding was noted after epinephrine and volume infusion to increase mean arterial pressure to 200 mm Hg for 15 minutes. Macroscopic examination of the anastomoses revealed adequate healing with circumferential stapling of the prosthesis to the aortic wall and no stenosis or thrombus except in 1 false aneurysm (1/7, 14%). Surface electron microscopy showed cells coverage of the anastomosis surface. When applied on human cadaver thoracic and abdominal aorta with atherosclerotic changes, clamping times of less than 5 minutes were achieved. However, imperviousness tested with saline was poor. An automatic stapling device allows performance of a graft-to-aorta anastomosis through a minimally invasive approach with shorter clamping time than a videoscopic suturing technique. However, the current technique of aortic stapling is unreliable and further improvements are needed.     

Laparoscopic-assisted abdominal aortic aneurysmectomy

PURPOSE: The technical elements and early results of laparoscopic-assisted abdominal aortic aneurysmectomy are described. METHODS: From February 1997 to May 1999, 60 patients underwent elective laparoscopic surgery for infrarenal abdominal aortic aneurysm. Patients ranged in age from 53 to 87 years (mean age, 70.6 years). The mean aneurysm size was 5.7 cm (range, 4.4-8.0 cm). All patients underwent aortography and computed tomography scanning preoperatively. Patients were not deemed candidates for the procedure when visceral arterial abnormalities requiring surgical treatment were present or an aortic aneurysm neck shorter than 0.5 cm was found. A risk-stratification system was used as a means of quantitating risk factors and excluding high-risk patients. Aortic reconstruction was performed with retroperitoneal laparoscopy, with the patient in a modified right lateral decubitus position. An Endo TA 30 and an Endo TA 60 laparoscopic staplers (US Surgical, Norwalk, Conn) were used in occluding the common iliac arteries and aneurysm sac. Laparoscopic hemoclips were used as a means of occluding the lumbar arteries and other branches of the aneurysm sac. An aortobifemoral or aortobi-iliac bypass grafting procedure was performed by means of the laparoscope to position the graft and visualize the end-to-end aorta-to-graft anastomosis, with distal anastomoses performed through counter incisions. RESULTS: Three patients died within 30 days of surgery (mortality rate, 5.0%). Complications included left ureteral injury (1), postoperative myocardial infarction (1), ileofemoral deep venous thrombosis (1), acute renal failure (2), colon ischemia (1), and infected graft limb requiring revision (1). The mean operative time was 7.7 hours, and the mean aortic cross-clamping time was 112 minutes. Compared with a contemporary consecutive series of 100 patients undergoing open transabdominal or retroperitoneal aneurysmectomy performed by the same group of surgeons, the laparoscopic patients had decreased length of stays in the intensive care unit and the hospital, with less need for ventilator support, earlier resumption of a regular diet, and an earlier return to normal activity. At the follow-up examinations, all bypass grafts were patent. CONCLUSION: Laparoscopic-assisted aneurysmectomy is safe and effective and can be performed with good results. The longer operation time required is well tolerated in patients who are at good and moderate risk. Prior training in laparoscopic aortic surgery is necessary for surgeons to obtain the required level of expertise needed to perform these procedures. With these caveats, the results of our study suggest that laparoscopic-assisted aortic aneurysmectomy is appropriate for moderate-to-good risk (American Society of Anesthesiologists class of III or lower) operative candidates meeting standard criteria for aneurysm resection in whom preoperative computed tomography scan and biplane arteriography demonstrate a proximal aneurysm neck of 0.5 cm or larger and no need for visceral or internal iliac artery reconstruction. A randomized trial would be required to confirm the benefits of this procedure over open aneurysmectomy.     

Laparoscopic hybrid techniques for ectopic or accessory renal arteries debranching in complex endovascular aneurysm repair

The aim of this study was to report an assisted or totally laparoscopic approach for renal revascularization in patients with congenital renal vascular anomalies during endovascular abdominal aneurysm repair (EVAR). In three patients with an ectopic main or a large accessory renal artery (>3mm) arising from the aneurysm, laparoscopic exposure of the target renal artery and the ipsilateral iliac bifurcation was performed. In two patients a small incision was made over the area between the iliac bifurcation and the renal target vessel in order to facilitate the anastomotic procedure. In the third patient a totally laparoscopic bypass between a big left inferior renal polar artery and the left common femoral artery was carried out. In all patients the aneurysm was successfully excluded using an endovascular graft. Technical success was achieved in all three patients. The mean total operative time was 126 min (range 110-152 min). The mean hospital length of stay (HLS) was 3.5 days. Renal function of the patients remained unchanged. All bypasses were found to be patent and endoleaks was not observed at 6-month follow-up. Laparoscopic assisted or totally laparoscopic renal revascularization may increase the applicability of EVAR in complex abdominal aortic aneurysms.     

The feasibility of hand-assisted laparoscopic aortic bypass using a low transverse incision

Background: Hand-assisted laparoscopy can be used to perform aortoiliac reconstructive procedures. This study aimed to evaluate the safety and feasibility of a hand-assisted aortofemoral bypass in patients with occlusive disease using a low abdominal transverse incision to reduce postoperative respiratory problems. Methods: In 18 patients, a modified Pfannenstiel incision was performed. A hand-assist device was inserted, and the aorta was exposed using transperitoneal laparoscopy. Tunneling was performed under laparoscopic control. The anastomosis was always performed proximally to the inferior mesenteric artery. In three patients, the proximal anastomosis had to be performed laparoscopically. The indication for surgery was occlusive disease in 16 patients and a combination of an aneurysm and aortoiliac occlusion in 2 patients. Results: Conversion was required in one patient (1/18). In 13 patients (13/18), the total operating time did not exceed 180 min, and 61% of the patients (11/18) could be discharged by postoperative day 5. None of the patients died perioperatively (0/18). Complications were observed in six patients (6/18). Only one of these patients had respiratory problems (1/18). The remaining five patients had local complications such as wound healing problems. The anastomosis was sutured laparoscopically in three patients (3/18). Conclusions: Hand-assisted laparoscopy can be performed safely using a low transverse abdominal incision. In our experience this laparoscopic access can reduce the incidence of postoperative respiratory problems and incision-related complications.     

Recent surgical treatment for patients with true aortic arch aneurysm

From december 1996 to april 1999, 25 patients with true aortic arch aneurysm underwent aortic arch aneurysm repair using selective cerebral perfusion. There were 17 males and 8 females ranging in age from 62 to 79 years (mean 71 years). Orikaesi method was used in the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. This technique allowed us a simple approach to the lesion and the easy additional stitch. The average duration of extracorporeal circulation, aortic crossclamping, selective cerebral perfusion were 269 minutes, 140 minutes, and 122 minutes, respectively, under 19.3 degrees C of lowest esophageal temperature. There were no cases complicated with postoperative low output syndrome and cerebrovascular accident, and no hospital mortality. Replacement of the aortic arch using selective cerebral perfusion is a safe procedure with acceptable hospital mortality.     

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.     

Video-assisted aortic surgery

BACKGROUND: There are several laparoscopic techniques that can be used to perform a total or video-assisted aorto-femoral bypass grafting procedure. Major drawbacks of laparoscopic aortic surgery are the long operating times and the steep learning curve required for these procedures. Hand-assisted laparoscopy is a novel technique that allows surgeons to use their hands and laparoscopic instruments in the operative field while maintaining a pneumoperitoneum. STUDY DESIGN: A prospective nonrandomized study was conducted in a community medical center. Any patient with aortoiliac occlusive disease or an abdominal aortic aneurysm who was determined to be suitable for a laparoscopic aorto-femoral bypass grafting procedure was included in the study. The main outcomes measured were: operating time, aortic cross-clamp time, incision size, complications, conversion rate to an open procedure, length of stay in the ICU, and postprocedural hospital stay. A concurrent control group of 20 patients was compared with the minimally invasive group. RESULTS: Forty-one consecutive patients were scheduled for the laparoscopic operation. Conversion to an open procedure was necessary in three patients. There were two major complications, including the development of renal failure in one patient who died 28 days postoperatively. The mean postprocedural hospital stay was 4.5 +/- 2.5 days (range 2 to 15 days). The mean operating time was 163.1 +/- 38.7 minutes, including an aortic cross-clamp time of 38.3 +/- 9.7 minutes. Postoperative hospital stay and the time required in the ICU were significantly shorter after the laparoscopic procedure compared with a conventional bypass grafting procedure. CONCLUSIONS: Hand-assisted laparoscopy is a minimally invasive technique with operating times and outcomes similar to those of conventional procedures. The possibilities of this technique in patients with aortoiliac disease should be evaluated in a prospective randomized study.