Robotic-assisted laparoscopic dissection of the infrarenal aorta and iliac artery: a technical description and early results

We report our initial experience with a novel robotic-assisted dissection of the infrarenal aorta and iliac arteries for the treatment of aortoiliac occlusive disease and abdominal aortoiliac aneurysm. Seven patients underwent the procedure using the da Vinci Surgical System. Transabdominal, retroperitonal dissection of the aorta and iliac arteries was completed using the robotic system; then, a mini-laparotomy and hand-sewn aorta-to-graft anastomosis were performed. There was no mortality in this series of patients. This novel technique may overcome the difficulty of aortic dissection in a purely laparoscopic aortic surgery and serves as a bridging step toward totally robotic-assisted aortic surgery.     

Robot-assisted laparoscopic aortic reconstruction for occlusive disease-a case report

Aortobifemoral bypass is the standard method for revascularization of aortoiliac occlusive disease but is associated with significant morbidity and mortality. Laparoscopic aortic reconstruction eliminates the large incision but is limited by the cumbersome nature of laparoscopic instrumentation. A robotic system (da Vinci Computer-Enhanced Robotic Surgical System, Intuitive Surgical, Mountain View, CA) has been developed that allows the surgeon to suture in the same manner as in open procedures. The authors report the first case of an aortic reconstruction for occlusive disease performed using the da Vinci system. A 53-year-old woman presented with gangrene of the left great toe. Angiography revealed distal aortic occlusive disease and occlusion of the common iliac arteries bilaterally. Dissection of the aorta was performed by a transabdominal-retroperitoneal approach modified from Dion (J Vasc Surg 26:128-132, 1997). With use of laparoscopic techniques, the abdominal contents were retracted to the patient's right side while the kidney and ureter remained in the retroperitoneum. The aorta was isolated from the bifurcation proximally to the left renal vein. The patient was anticoagulated, and the aorta was clamped below the left renal artery and proximal to the bifurcation. The da Vinci robotic system was placed on the patient's right side, and an extruded polytetrafluoroethylene (ePTFE) graft was passed into the retroperitoneum. While seated at a computer console viewing the operative field on a screen, the surgeon used robotic instruments to fashion an arteriotomy and complete an end-to-side aortic anastomosis using ePTFE suture. The left groin was opened and the aortic graft passed down to the groin. The reconstruction was completed by performing a left-to-right femoro-femoral bypass in standard, open fashion. The procedure was completed in 8 hours with an aortic clamp time of 65 minutes and a 500 cc blood loss. The patient was extubated in the operating room, ate a regular diet on postoperative day 2, and was discharged on postoperative day 4 without complications. Return to normal activities occurred 2.5 weeks postoperatively. The da Vinci robotic system facilitated creation of the aortic anastomosis and shortened aortic clamp time over that achieved with laparoscopic techniques. Robot-assisted laparoscopic aortofemoral bypass should decrease the morbidity and mortality of aortic reconstruction, while providing a durable solution to aortoiliac occlusive disease.     

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.     

Robot-assisted laparoscopic aortobifemoral bypass: initial experience developing a new program

Despite improved technology for endovascular treatment of aorto iliac occlusive disease, aortobifemoral bypass (ABF) continues to offer superior long-term patency. In an effort to reduce the morbidity of surgical ABF, multiple minimally invasive techniques have been reported. The da Vinci robot may facilitate the construction of a minimally invasive aortic anastomosis using standard vascular suture techniques. Our initial experience in the development of a minimally invasive surgical aortic reconstruction program is reported. After extensive time in the laboratory developing our surgical technique in human cadavers and a pig model, our team initiated a robotic vascular surgery program in 2007. A retrospective review of our initial six robot-assisted laparoscopic ABF cases was conducted. The aorta was exposed laparoscopically using the Stadler technique and the aortic anastomosis performed with the da Vinci robot. These results are compared with currently published reports of robotic ABF and alternative methods of minimally invasive aortic reconstruction. From January 2007 to August 2007, six robot-assisted laparoscopic ABFs were performed. Two patients had prior abdominal surgical procedures. Four patients had prior endovascular or surgical aorto iliac reconstruction. Operative time varied from 5 h 26 min to 8 h 12 min. Total clamp time, for the aortic anastomosis, ranged from 70 to 100 min with a mean of 75 min. Estimated blood loss ranged from 300 to 2,000 ml with a mean of 850 ml. Conversion with a short upper midline incision was required in one patient (16%) with an associated abdominal aortic aneurysm. Post operative length of stay ranged from five to ten days with a median of seven days. There was no operative mortality. Results from robotically assisted laparoscopic ABF are equivalent to those from other minimally invasive options while enabling a much shorter learning curve. Using the technique described, minimally invasive ABF was accomplished in a safe and reliable manner despite prior vascular treatment.     

Robot-assisted laparoscopic surgery of the infrarenal aorta

Background Recently introduced robot-assisted laparoscopic surgery (RALS) facilitates endoscopic surgical manipulation and thereby reduces the learning curve for (advanced) laparoscopic surgery. We present our learning curve with RALS for aortobifemoral bypass grafting as a treatment for aortoiliac occlusive disease. Methods Between February 2002 and May 2005, 17 patients were treated in our institution with robot-assisted laparoscopic aorto-bifemoral bypasses. Dissection was performed laparoscopically and the robot was used to make the aortic anastomosis. Operative time, clamping time, and anastomosis time, as well as blood loss and hospital stay, were used as parameters to evaluate the results and to compare the first eight (group 1) and the last nine patients (group2). Results Total median operative, clamping, and anastomosis times were 365 min (range: 225–589 min), 86 min (range: 25–205 min), and 41 min (range: 22–110 min), respectively. Total median blood loss was 1,000 ml (range: 100–5,800 ml). Median hospital stay was 4 days (range: 3–57 days). In this series 16/18 anastomoses were completed with the use of the robotic system. Three patients were converted (two in group 1, one in group 2), and one patient died postoperatively (group 1). Median clamping and anastomosis times were significantly different between groups 1 and 2 (111 min [range: 85–205 min] versus 57.5 min [range: 25–130 min], p < 0.01 and 74 min [range: 40–110 min] versus 36 min [range: 22–69 min], p < 0.01, respectively) Total operative time, blood loss, and hospital stay showed no significant difference between groups 1 and 2. Conclusions Robot-assisted aortic anastomosis was shown to have a steep learning curve with considerable reduction of clamping and anastomosis times. However, due to a longer learning curve for laparoscopic dissection of the abdominal aorta, operation times were not significantly shortened. Even with robotic assistance, laparoscopic aortoiliac surgery remains a complex procedure. Presented at SAGES 2006, April 26–29 2006, Dallas, Texas, USA An erratum to this article can be found at     

Robot-assisted laparoscopic intestinal anastomosis

Introduction: Robotic telemanipulation systems have been introduced recently to enhance the surgeon's dexterity and visualization in videoscopic surgery in order to facilitate refined dissection, suturing, and knot tying. The aim of this study was to demonstrate the technical feasibility of performing a safe and efficient robot-assisted handsewn laparoscopic intestinal anastomosis in a pig model. Methods: Thirty intestinal anastomoses were performed in pigs. Twenty anastomoses were performed laparoscopically with the da Vinci robotic system (robot-assisted group), the remaining 10 anastomoses by laparotomy (control group). OR time, anastomosis time and complications were recorded. Effectiveness of the laparoscopic anastomoses was evaluated by postoperative observation of 10/20 pigs of the robot-assisted group for 14 days and by testing mechanical integrity in all pigs by measuring passage, circumference, number of stitches, and bursting pressure. These parameters and anastomosis time were compared to the anastomoses performed in the control group. Results: In all cases of the robot-assisted group the procedure was completed laparoscopically. The only perioperative complication was an intestinal perforation, caused by an assisting instrument. The median procedure time was 77 min. Anastomosis time was longer in the laparoscopic cases than in the controls (25 vs 10 min; p <0.001). Postoperatively, one pig developed an ileus, based on a herniation of the spiral colon through a trocar-port. For this reason it was terminated on the sixth postoperative day. All anastomoses of the robot-assisted group were mechanically intact and all parameters were comparable to those of the control group. Conclusion: Technical feasibility of performing a safe and efficient robot-assisted laparoscopic intestinal anastomosis in a pig model was repeatedly demonstrated in this study, with a reasonable time required for the anastomosis.     

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.     

The efficacy of robot-assisted versus conventional laparoscopic vascular anastomoses in an experimental model.

BACKGROUND: Robot-assisted surgery is thought to facilitate complex laparoscopic movements, enhancing advanced laparoscopic procedures. OBJECTIVE: To evaluate the benefit of robotic assistance for laparoscopic vascular surgery. DESIGN: Experimental study using prosthetic conduits in a laparoscopic training box. METHODS: Two surgeons each performed 40 laparoscopic vascular anastomoses alternating with and without robotic assistance. A Zeus-Aesop surgical Robotic system trade mark with 3-D visualisation was used. Each surgeon made 40 anastomoses in total, using different prostheses (5 mm PTFE and 16 mm Dacron) and suture material (Prolene and PTFE). A time-action analysis was performed to evaluate surgical performance. Primary efficacy parameters were quality and leakage of the anastomosis, total time and total number of actions. RESULTS: Equal quality scores and anastomotic leakage were achieved with both techniques. Robotic assistance resulted in significant longer suture and knot tying time and significant more actions were needed compared to the manual laparoscopic procedures. Significant more failures occurred during the robot-assisted procedures. CONCLUSION: In this study, robotic (Zeus-Aesop) assistance did not improve the laparoscopic performance of the surgeon whilst making vascular anastomoses.     

Robot-assisted laparoscopic ileal ureter

BACKGROUND AND OBJECTIVES: A patient with a solitary kidney, cysteine stones, and recurrent ureteral strictures underwent robot-assisted laparoscopic ureterectomy with ileal ureter formation. METHODS: Using a transperitoneal, 4-port robotic approach, we removed the strictured ureter and created an ileal ureter. The ileal-pyelo and ileal-vesical anastomoses were performed using the robotic system. An extracorporeal bowel anastomosis was performed using stapling devices. Operative time was 9 hours with negligible blood loss, and the patient was discharged after 5 days. RESULTS: A cystogram at 10 days demonstrated patent anastomoses without extravasation. The patient continues to do well 48 months later. CONCLUSION: Robot-assisted laparoscopic ileal ureter replacement is feasible with excellent long-term outcome.     

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.     

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.     

Robot-assisted laparoscopic choledochojejunostomy

Background: Endoscopic stenting is the treatment of choice for palliative relief of biliary obstruction by a periampullary tumor. If treated surgically, a choledochojejunostomy and Roux-en-Y diversion is still performed by laparotomy in a large number of cases due to technical challenges of the biliodigestive anastomosis in the laparoscopic approach. Robotic systems may enhance dexterity and vision and might therefore support surgeons in delicate laparoscopic interventions. The purpose of this study is to assess the efficacy and safety of performing a laparoscopic choledochojejunostomy and Roux-en-Y reconstruction with the aid of a robotic system. Methods: Ten laparoscopic procedures were performed in pigs with the da Vinci robotic system and compared to 10 procedures performed by laparotomy (controls). Operation room time, anastomoses time, blood loss, and complications were recorded. The effectiveness of the anastomoses was evaluated by postoperative observation for 14 days and by measuring passage, circumference, and number of stitches. Results: Operating room time was significantly longer for the robot-assisted group than for controls (140 vs 82 min, p < 0.05). The anastomoses times were longer in the robot-assisted cases but not statistically significant (biliodigestive anastomosis, 29 vs 20 min; intestinal anastomosis, 30 vs 15 min), Blood loss was less than 10 cc in all robot-assisted cases and 30 cc (10–50 cc) in the controls. In both groups, there were no intraoperative complications. In the control group, one pig died of gastroparesis on postoperative day 6. In the robot-assisted group, one pig died on postoperative day 7 due to a volvulus of the jejunum. At autopsy, a bilioma was found in one pig in the robot-assisted group. In all pigs, the biliodigestive and intestinal anastomoses were macroscopically patent with an adequate passage. Circumference and number of stitches were similar. Conclusion: The safety and efficacy of robot-assisted laparoscopic choledochojejunostomy was proven in this study. The procedure can be performed within an acceptable time frame.     

Initial Experience with Robot-Assisted Nephrectomy for Living-Donor Kidney Transplantation: Feasibility and Technical Notes

Background

Robot-assisted surgery provide endowrist instruments and 3-dimensional visualization of the operative field that are improvements over traditional laparoscopy. The few research studies published so far have demonstrated that living-donor nephrectomy using the robot-assisted technique is safe and feasible, providing advantages for patients.

Methods

Since November 2009, we performed 20 robot-assisted living-donor nephrectomies. Eight patients underwent hand-assisted robotic nephrectomy, whereas 20, totally robotic nephrectomy.

Results

Median intraoperative bleeding was 174 mL (range, 10–750) but no patient needed intraoperative transfusion with blood cells. The median warm ischemia time was 3.16 minutes (range, 0.30–6.5). there was no case of conversion to an open procedure. The median operative time was 311 minutes (range, 85–530); the median console time was 160 minutes (range, 135–220).

Conclusion

Robot-assisted living-donor kidney recovery was a safe and effective procedure. The totally robotic recovery is an evolving technique. The prospect of robotic staplers, endowrist ligature, and robotic single port may further increase these advantages.     

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.     

Robot-assisted radical cystectomy and urinary diversion in female patients: technique with preservation of the uterus and vagina

BACKGROUND: After performing more than 500 robotic radical prostatectomy and robotic radical cystoprostatectomy in men, we attempted to develop the technique of robot-assisted radical cystectomy in women. This article describes two techniques of robot-assisted radical cystectomy for women, conventional and with preservation of the uterus and vagina. To the best of our knowledge, this is the first case series of robot-assisted radical cystectomy and urinary diversion in women. STUDY DESIGN: Robot-assisted radical cystectomy was undertaken in three female patients with transitional cell carcinoma of the urinary bladder. The operation was performed with the conventional anterior approach in one patient and with a new technique in two patients, which allows preservation of urethra, uterus, vagina, and both ovaries. As planned, the radical cystectomy was done robotically, using the da Vinci Surgical System (Intuitive Surgical). The bladder was entrapped in an Endocatch bag and removed through a small subumbilical incision. Urinary reconstruction was performed extracorporeally after exteriorizing the bowel through the incision used for retrieving the specimen. In two patients, the reconstructed pouch was placed in the pelvis and the abdominal incision was closed. Urethroneovesical anastomosis was done robotically, using a technique described previously for men. RESULTS: The average operating time for the robotic radical cystectomy was 160 minutes and the mean operating times for ileal conduit and orthotopic neobladder were 130 minutes and 180 minutes, respectively. The mean blood loss was less than 100 mL. The mean number of lymph nodes removed was 12 (range 3 to 21). Surgical margins were free of tumor in all three patients. CONCLUSIONS: This approach incorporates advantages of minimally invasive and open surgery. Performing the radical cystectomy with the robot allows precise and rapid removal of the bladder with minimal blood loss. Extracorporeal reconstruction of the urinary tract reduces operative time at this stage of evolution of laparoscopic and robotic instrumentation. In the future, with the development of technology, instrumentation, and with additional refinement of our technique, the entire procedure may be done completely intracorporeally with equal efficiency.     

Laparoscopic aortofemoral bypass. Initial experience in an animal model.

OBJECTIVE: The study objective was to evaluate the feasibility of laparoscopic aortofemoral bypass in a porcine model. SUMMARY BACKGROUND DATA: Laparoscopic techniques have been applied to numerous general and thoracic surgical procedures. Their application to vascular surgery has been virtually nonexistent. Open surgery for aortoiliac occlusive disease is accompanied by significant morbidity rates, and minimally invasive procedures have the disadvantage of reduced patency rates. Laparoscopic aortofemoral replacement has the theoretical advantage of long-term patency with reduced postoperative complications. METHODS: Between January and September 1993, laparoscopic surgery was performed on 16 pigs: 6 underwent transperitoneal laparoscopic aortic dissection and vessel control alone; 7 underwent complete transperitoneal laparoscopic aortofemoral bypass; and 3 underwent a retroperitoneal approach. The aortic anastomosis was performed using a combination of sutures and titanium clips in an end-to-side fashion in five pigs, and a custom-made nonsutured graft was secured with use of an end-to-end method in five pigs. Femoral anastomoses were performed with the standard open technique. RESULTS: Technical success was achieved in all 10 animals and with no major complications. Mean blood loss was 20 ml (range, 5-50 ml), and mean operative time was 2.45 hours (range, 2-4 hrs). On aortic-clamp release, 2 of the end-to-side anastomoses required additional sutures to stop bleeding between oversized staples, and 2 of the end-to-end anastomoses required additional ties to reinforce loose ties. All 10 grafts and anastomoses were patent and free of leaks after completion of the procedure. CONCLUSIONS: Laparoscopic aortofemoral bypass is technically feasible in a porcine model. Further experimental work with new instrumentation and technical refinement will make laparoscopic surgery feasible for the treatment of vascular disease in humans.     

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。     

Operative results and outcome of twenty-four totally laparoscopic vascular procedures for aortoiliac occlusive disease

Purpose: The study objective was to apply laparoscopic techniques to conventional bypass procedures for aortoiliac occlusive disease. Methods: From October 1995 to August 1997, we performed seven iliofemoral (IFB), five unilateral aortofemoral (UAFB), and 11 aortobifemoral (AFB) bypass procedures and one aortic endarterectomy (TEA) totally laparoscopic. A transabdominal approach with pneumoperitoneum was preferred, and only laparoscopic vascular instruments were used. Endoscopic intervention followed principles of vascular surgery. As in open surgery, we used Dacron grafts and polypropylene sutures. Results: Twenty procedures were carried out totally laparoscopic; four conversions to open surgery were necessary. Severe complications included one postoperative respiratory failure requiring ventilatory support for four days, and one iliac vein lesion with subsequent open surgery. Mean operating time was 258 ± 49 minutes for IFB, 218 ± 54 minutes for UAFB, 279 ± 69 minutes for AFB, and 290 minutes for aortic TEA. Mean blood loss was 92 ± 49 ml for IFB, 390 ± 316 ml for UAFB, 563 ± 516 ml for AFB, and 100 ml for aortic TEA. Mean postoperative stay was 7.4 days for IFB, 7.8 days for UAFB, and 10.1 days for AFB. After the aortic TEA, the patient was discharged on day 6. At control examination all grafts were patent; two patients had mild claudication because of one progressive disease and one distal suture stenosis. Conclusion: Laparoscopic vascular surgery for aortoiliac occlusive disease is feasible, safe, and effective. At the beginning, a cooperation between experienced laparoscopists and vascular surgeons is needed to overcome procedural challenge, because operating time and conversion rate decrease with growing experience. The advantages observed in the majority of our patients were minimal tissue trauma, decreased blood loss, and faster postoperative recovery when compared with patients who had open aortic surgery at our institution. Further evidence has to be gained by clinical trials to define the role of laparoscopic vascular surgery for aortoiliac occlusive disease. (J Vasc Surg 1998;28:136-42.)     

Randomized clinical trial of robot-assisted versus laparoscopic Nissen fundoplication

BACKGROUND: Several studies have shown the safety and feasibility of robot-assisted antireflux surgery but comparative data are lacking. METHODS: Fifty consecutive patients scheduled for laparoscopic antireflux surgery were randomized into two groups. Twenty-five patients underwent robot-assisted surgery and 25 standard laparoscopic fundoplication. All robot-assisted procedures were performed with the da Vinci Surgical System. RESULTS: There were no significant differences in age, sex, body mass or preoperative reflux pattern between the groups. Operating times were significantly longer for robot-assisted than standard laparoscopic operations (mean total operating time 131.3 versus 91.1 min, P < 0.001; skin-to-skin time 78.0 versus 63.5 min, P = 0.001). There was no conversion to open surgery. Conversion to standard laparoscopy was necessary in one of 25 robot-assisted procedures. The length of hospital stay was similar in both groups. Robot-assisted surgery was associated with significantly higher mean total costs (euro 3157 versus euro 1527; P < 0.001). There were no significant differences in clinical, endoscopic and functional outcomes between groups. There was no procedure-related mortality. CONCLUSION: Robot-assisted laparoscopic fundoplication is comparable to the standard laparoscopic procedure in terms of feasibility and outcome, but costs are higher owing to longer operating times and the use of more expensive instruments.     

Robot-assisted laparoscopic dismembered pyeloplasty.

OBJECTIVE: Advanced laparoscopic skills limit the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the da Vinci Robotic Surgical System at 3 New York City medical centers. METHODS: A review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 38 patients (21 females, 17 males) between April 2001 and January 2004 was performed. All patients had symptoms or radiographic evidence of ureteropelvic junction obstruction. Robotic assistance with the da Vinci Robotic Surgical System was used after preparation of the ureteropelvic junction with a standard laparoscopic approach. RESULTS: The average patient age was 39.3 years (range, 15 to 69). The mean operative time and suturing time were 225.6+/-59.3 minutes and 64.2+/-14.6 minutes. The average estimated blood loss was minimal at 77.3+/-55.3 mL. The mean length of hospitalization was 69.6 hours (range, 28 to 310). The average use of intravenous morphine was 26.5 mg (range, 0 to 162). No intraoperative complications occurred, and open conversions were not necessary. A mean follow-up of 12.2 months revealed a success rate of 94.7% with 2/38 patients requiring further treatments. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the da Vinci Surgical System is safe and reproducible. These intermediate results appear comparable to results with open and laparoscopic pyeloplasty repairs.