Total laparoscopic abdominal aortic aneurysms repair

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.     

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.     

Total laparoscopic versus conventional abdominal aortic aneurysm repair: a case-control study

PURPOSE: This study was designed to identify differences in the per- and postoperative outcomes between total laparoscopic and open surgical repair of abdominal aortic aneurysms (AAA). METHODS: We reviewed 30 patients who underwent total laparoscopic AAA repair between July 2003 and December 2004 (group I). This group was matched in a case-control fashion by AAA morphology and American Society of Anesthesiologists class with a group of 30 patients who underwent conventional AAA repair between April 1997 and May 2004 (group II). Proportions and categoric data were compared with a chi(2) test. Continuous data were compared with a Mann-Whitney test. RESULTS: The two groups had comparable characteristics of age and cardiovascular risk factors. The number of tube and bifurcated grafts was 13 for group I and 17 for group II. Median operative time was 255 minutes (range, 170 to 410 minutes) in group I and 200 minutes (range, 130 to 410) in group II (P <.001). Median aortic clamping time was 80 minutes (range, 35 to 110 minutes) in group I and 50 minutes (range, 24 to 150 minutes) in group II (P < .0001). Total blood loss was 1600 mL (range, 400 to 4000 mL) for group I vd 1000 mL (range, 100 to 2900) for group II (P < .01). The mortality rate was 3.3% for group I (1 patient) vs 6.6% (2 patients) for group II (NS). There were no significant differences between the two groups in terms of postoperative systemic complications (23.3% vs 30%, NS) and local and vascular complications (10% vs 3.3%). Duration of ileus (2 vs 3 days, P < .05), return to normal diet (4 vs 8 days, P < .0001), day of ambulation (3 vs 4 days, P < .05) and dose of narcotics (3.5 mg vs 28.5 mg, P < .05) were significantly lower in group I. Median length of intensive care unit stay was similar between the two groups (48 hours). Median hospital stay was lower in group I but without significant differences with group II (9 vs 11 days, NS). CONCLUSION: This case-control study provides preliminary results that short-term outcomes of total laparoscopic AAA repair are comparable with those of open surgery. Peroperative data demonstrate that laparoscopy is more technically demanding than open repair. However, the technical challenge of laparoscopy does not worsen the postoperative course.     

A comparison of 50 initial endoluminal endograft repairs for abdominal aortic aneurysm with 50 concurrent open repairs

PURPOSE: To review the results of our initial experience with endovascular repair of abdominal aortic aneurysm (AAA) with respect to morbidity and mortality and to compare these outcomes with those of transabdominal repair. METHODS: We reviewed the first 50 consecutive endovascular AAA repairs performed at our institution from November 1999 to January 2002. Pre-operative risk factors, intraoperative variables and post-operative outcomes were assessed. All endovascular patients were followed with periodic examination, contrast-enhanced computed tomography and/or duplex scanning. Comparison was made to 50 patients undergoing standard open repair over a similar time period. RESULTS: Fifty patients underwent endovascular AAA repair (mean age 72.5, AAA size 5.5 cm). Endovascular devices employed were manufactured by Ancure (Guidant Corp.), and AneuRx (Medtronic). Preoperative risk factors were similar to patients undergoing transabdominal repair. Mean operative time was 169 minutes and estimated blood loss was 450cc with average blood replacement of.18 units. Median ICU stay was 0 days and mean hospital stay was 2.3 nights. There were no conversions to open repair, however there was one aborted endovascular attempt. Morbidity included MI (2%), colon ischemia (1%), acute renal insufficiency (4%) and leg ischemia (4%). There was one death within 30 days. Seven endoleaks were identified (6 type II and 1 type I) and were managed angiographically. CONCLUSIONS: The short-term surgical morbidity and mortality rates for endovascular repair of AAA are acceptably low and are comparable to the transabdominal approach.     

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.     

A decade of experience with abdominal aortic aneurysm repair in octogenarians.

BACKGROUND: Should abdominal aortic aneurysms (AAA) be electively repaired in octogenarians? METHODS: This was a retrospective review of patients' charts over a ten-year period starting in January 1995. This study was conducted at St. Francis Hospital, Roslyn, New York, which is a tertiary referral center. All octogenarians who underwent AAA repair (elective and emergent) were included in this study (mean age 82.9 years). A total of 71 such patients were identified. Sixty-two patients had elective surgery and nine patients had emergent repair of the ruptured AAA. It was hypothesized before the study was conducted that AAA could be repaired in octogenarians with acceptable morbidity and mortality in an institution with vast experience in dealing with this disease. RESULTS: The mean aneurysm diameter was 6.73 cm. Twenty patients (28%) received bifurcated grafts, while 51 patients (72%) received tubular grafts. Four patients had coronary artery bypass graft before aneurysm surgery. Forty-four patients (62%) were male and 27 (38%) were female. The thirty day mortality rate after elective AAA repair was 1.4%, whereas after the repair of ruptured aneurysms was 44.4%. CONCLUSIONS: We concluded that the elective repair of abdominal aneurysms in most octogenarians is a safe and life-prolonging procedure if performed in an experienced tertiary center.     

The role of aortic stent grafting in the treatment of atheromatous embolization syndrome: results after a mean of 15 months follow-up

BACKGROUND: Endovascular stent-graft (ESG) repair of abdominal aortic aneurysm (AAA) has emerged as an alternative to open surgery. The role of ESG in patients with challenging medical and anatomic problems remains an area of general debate. This study reviews an experience with stent grafts to treat patients with AAA and atheromatous embolization syndrome (AES) presenting with chronic distal embolization (CDE). METHODS: Over a 5-year period 660 patients with AAA were treated with aortic stent grafts. Patients with AAA and ischemic ulcerations or toe gangrene due to CDE despite palpable foot pulses were investigated for successful aneurysm exclusion, resolution of ischemic symptoms, complications and survival. Follow-up averaged 15.3 +/- 14.9 months (range, 1 to 60 months). RESULTS: Nineteen patients had AAA and manifestations of CDE. The population (16 males/3 females) had a mean age of 79 +/- 7 years and mean aneurysm diameter of 5.5 cm. Renal insufficiency was present in 5/19 (26 %). Ischemia presented as ischemic ulcers (16/19 [84.2%]) or toe gangrene (3/19 [15.8%]). Stent grafts included 6 aortouniiliac and 13 bifurcated devices. Exclusion was achieved in all but 2 patients who had type II lumbar endoleaks. At 30-day postoperative follow-up, mortality was 0 % and resolution of CDE/ischemia was noted in 2 of 19 (10.5%) patients. Eight of 9 patients with follow-up of 1 year had complete resolution of their ischemic symptoms, with no recurrent manifestations of AES. Complications included progression of renal insufficiency over an 18-month period in 1 patient and an unstable expanding pararenal aortic neck in 1 patient. Foot ischemia persisted at 1 year in a patient with severe coexisting thoracic aortic disease despite successful AAA exclusion. Six (31.6%) patients died during a mean follow-up of 15.3 months from causes unrelated to their AAA. CONCLUSION: On the basis of this experience, stent-graft repair of AAA and CDE may be an effective strategy to prevent future embolization. Recognition of coexisting thoracic aortic disease is essential. ESG does not address the extremely high morbidity and mortality from cardiovascular causes in this population.     

Endovascular Treatment of Failed Prior Abdominal Aortic Aneurysm Repair

Failure of endovascular or conventional abdominal aortic aneurysm (AAA) repair may occur as a result of attachment site endoleak (type I) or paraanastomotic aneurysm and pseudoaneurysm formation. This study examined the results of the use of secondary endovascular grafts for the treatment of failed prior infrarenal AAA repair procedures. Forty-seven patients were treated with endovascular grafts. These included 14 patients with type I endoleaks (5 proximal, 8 distal, 1 proximal and distal) and 33 patients with paraanastomotic aneurysms after standard open surgical AAA repair (3 proximal aorta, 5 distal aorta, 21 iliac, 4 proximal and distal). The interval between the primary aortic procedure and the endovascular repair was significantly shorter for failed endovascular procedures (mean, 18.2 months; range, 1-42 months) than for failed conventional procedures (mean, 108.9 months; range, 12-216 months) (p <0.01). The endovascular devices used for correction of the failed AAA repairs were Talent (23), physician-made (19), AneuRx (2), Vanguard (2), and Excluder (1). Transrenal fixation was used for repair of all proximal anastomotic failures. Mean follow-up after reintervention was 12.2 months in patients with failed endovascular grafts and 10.6 months in patients with failed conventional grafts. Patient demographics were as follows: average age, 78 years; 36 male and 11 female; and 4.1 comorbid medical conditions per patient. The endovascular graft was successfully deployed in all 47 cases; 1 patient experienced a persistent proximal attachment site endoleak after endograft deployment. Endovascular grafts may be used to treat previously failed endovascular and conventional AAA repair procedures with good short- and intermediate-term results. Endovascular treatments in these cases may avoid the difficulties of aortic reoperation or AAA repair in the setting of prior endovascular aortic grafting.     

Influence of sex on expansion rate of abdominal aortic aneurysms

BACKGROUND: The UK Small Aneurysm Trial suggested that female sex is an independent risk factor for rupture of abdominal aortic aneurysm (AAA). This study assessed the effect of sex on the growth rate of AAA. METHODS: Between January 1985 and August 2005 all patients who were referred to the Royal Infirmary of Edinburgh with an AAA who were not considered for early aneurysm repair were assessed by serial abdominal ultrasonography. Maximum anteroposterior and transverse diameters of the AAAs were measured. RESULTS: A total of 1255 patients (824 men and 431 women) were followed up for a median of 30 (range 6-185) months. A median of six examinations (range 2-37) was performed for each patient. Median diameter on initial examination was 41 (range 25-83) mm. Median growth rate overall was 2.79 (range - 4.80-37.02) mm per year. Median growth rate of AAA was significantly greater in women than men (3.67 (range - 1.2-37.02) versus 2.03 (range - 4.80-21.00) mm per year; P < 0.01). Weighted linear regression analysis revealed that large initial anteroposterior AAA diameter and female sex were significant predictors of faster aneurysm growth rate (P < 0.001 and P = 0.006 respectively). CONCLUSION: The growth rate of AAA was significantly greater in women than in men. This may have implications for the frequency of follow-up and timing of repair of AAA in women.     

Impact of endovascular repair on open aortic aneurysm surgical training.

PURPOSE: The purpose of this study was to determine the impact of an endovascular stent-graft program on vascular training in open aortic aneurysm surgery. METHODS: The institutional and vascular surgery fellow experience in aortic aneurysm repair during a 6-year period was reviewed. The 3-year period before introduction of endovascular repair was compared with the 3-year period after introduction of endovascular repair. All patients undergoing abdominal aortic aneurysm (AAA) or thoracoabdominal aortic aneurysm repairs were entered prospectively into a vascular registry and retrospectively analyzed to evaluate the changing patterns in aortic aneurysm treatment and surgical training. RESULTS: Between July 1994 and June 2000, a total of 588 patients with AAA or thoracoabdominal aneurysms were treated at Stanford University Medical Center. There were 296 (50%) open infrarenal AAA repairs, 87 (15%) suprarenal AAA repairs, 47 (8%) thoracoabdominal aneurysm repairs, and 153 (26%) endovascular stent-grafts. The total number of aneurysms repaired per year by vascular fellows before the endovascular program was 71.3 +/- 4.9 (range, 68-77) and increased to 124.7 +/- 35.6 (range, 91-162) after introduction of endovascular repair (P <.05). This increase was primarily caused by the addition of endovascular stent-graft repairs by vascular fellows (51.0 +/- 29.0/year [range, 23-81]). There was no change in the number of open infrarenal aortic aneurysm repairs per year, 53.0 +/- 6.6 (range, 48-56) before endovascular repair versus 47.0 +/- 1.7 (range, 46-49) after (P = not significant). There was a significant increase in the number of suprarenal AAA repairs per year by vascular fellows, 10.0 +/- 1.0 (range, 9-11) before endovascular repair compared with 19.0 +/- 6.5 (range, 13-26) after (P <.05). There was no change in the number of thoracoabdominal aneurysm repairs per year between the two groups, 8.0 +/- 3.0 (range, 4-11) before endovascular repair compared with 7.6 +/- 2.3 (range, 5-9) after. CONCLUSIONS: Introduction of an endovascular aneurysm stent-graft program significantly increased the total number of aneurysms treated. Although the number of open aneurysm repairs has remained the same, the complexity of the open aneurysm experience has increased significantly for vascular fellows in training.     

A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm - results of a pilot study and lessons learned for future studies.

INTRODUCTION: EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations. METHODS: An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited. RESULTS: Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group. CONCLUSIONS: Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment.     

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.     

Fenestrated and branched stent-grafting after previous surgery provides a good alternative to open redo surgery.

OBJECTIVE: To present our experience using fenestrated and branched endoluminal grafts for Para-anastomotic aneurysms (PAA) following prior open aneurysm surgery, and after previous endovascular aneurysm repair (EVAR) complicated by proximal type I endoleak. METHODS: Fenestrated and/or branched EVAR was performed on eleven patients. Indications included proximal type I endoleak after EVAR and short infrarenal neck (n=4), suprarenal aneurysm after open AAA (n=4), distal type I endoleak after endovascular TAA (n=1), proximal anastomotic aneurysm after open AAA (n=1), and an aborted open AAA repair due to bleeding around a short infrarenal neck. RESULTS: The operative target vessel success rate was 100% (28/28) with aneurysm exclusion in all patients. Mean hospital stay was 6.0 days (range 2-12 days, SD 3.5 days). Thirty day mortality was 0%. All cause mortality during 18 months mean follow-up (range 5-44 months, SD 16.7 months) was 18% (2/11) with no deaths from aneurysm rupture. Cumulative visceral branch patency was 96% (27/28) at 42 months. Average renal function remained unchanged during the follow-up period. CONCLUSIONS: Our report highlights the potential of fenestrated and branched technology to improve re-operative aortic surgical outcomes. The unique difficulties of increased graft on graft friction hindering placement, short working distance, and increased patient co-morbidities should be recognized.     

Total laparoscopic aortic repair for occlusive and aneurysmal disease: first 95 cases.

OBJECTIVES: To analyze the outcome of our preliminary experience with total laparoscopic aortic repair in patients with occlusive or aneurysmal disease. MATERIAL AND METHODS: From September 2002 to April 2005, we performed 95 consecutive total laparoscopic aortic repair procedures including 72 for aortic occlusive disease (group A) and 23 for abdominal aortic aneurysm (group B). RESULTS: In group A, mean operating time was 216+/-50 min with a mean clamp time of 57+/-21 min and surgical conversion was required in two cases (2.7%). No postoperative death occurred but there were three postoperative complications necessitating re-intervention (retroperitoneal hematoma, embolic ischemia, and early prosthetic infection). Mean duration of hospitalization was 8 days (range, 5-42 days). All grafts were patent at 2 months. In group B, mean operating time was 251+/-57 min with a mean clamp time of 101+/-15 min and surgical conversion was required in seven cases (30%). There was one postoperative death (4.3%) due to pulmonary embolism and one non-fatal complication (retroperitoneal hematoma). Mean duration of hospitalization was 6.4 days (range, 4-12 days). All grafts were patent at 2 months. CONCLUSION: Total laparoscopic repair is feasible and safe for occlusive and aneurysmal aortic disease. Operators must acquire technical skills using simulators.     

Ruptured inflammatory abdominal aortic aneurysm: insights in clinical management and outcome

BACKGROUND: Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment. METHODS: Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay. RESULTS: Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy. CONCLUSIONS: Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.     

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.     

Total laparoscopically and robotically assisted aortic aneurysm surgery: a critical evaluation

BACKGROUND: Laparoscopically assisted aortic aneurysm resection requiring a minilaparotomy can be performed as a routine procedure. It was the purpose of our study to evaluate whether a total laparoscopic operation can be offered to aneurysm patients as a minimally invasive alternative. We also wanted to test whether a master-slave robot could facilitate the total laparoscopic procedure. METHODS: A prospective, consecutive number of 50 patients was evaluated. A transperitoneal left retrocolic access was used to expose the aorta. If possible, a tube graft repair was performed. The aortic anastomosis was sutured totally laparoscopically, with the surgeon standing on the right side of the operating table. In 10 consecutive patients, the anastomosis was sutured with the help of the Zeus robot. RESULTS: After excluding 3 cases that required suprarenal cross-clamping, 47 patients were operated using a total laparoscopic approach. A totally laparoscopic operation could be performed successfully in 39 patients with aneurysms. In 8 patients (17%), conversion to a laparoscopic hand-assisted operation with a 7-cm minilaparotomy was required. The robot was used to perform the aortic anastomosis in 10 patients. In 8 patients, a tube graft repair could successfully be performed totally laparoscopically. In the remaining patients, a bifurcated graft was implanted laparoscopically. The mean operating time was 227 minutes in the laparoscopy group and was 242 minutes in those patients in whom the anastomosis was sutured with the help of the Zeus Robot. Mean cross-clamping time, +/- SD, was 81.4 + 31 minutes. None of the patients died perioperatively. Major complications occurred in three patients (6.3%). The overall morbidity was 14.8%, including one patient who required temporary hemodialysis postoperatively. The time to suture the aortic anastomosis was significantly shorter in the robotic-assistance group (40.8 +/- 4 minutes), yet total operating time was longer in this group because of the technical complexity of the robotic device. Patients with a total laparoscopic procedure asked for significantly fewer analgesics and could regain full mobility earlier compared with those patients for whom a minilaparotomy after conversion to the laparoscopic hand-assist procedure was required. CONCLUSIONS: Total laparoscopic aneurysm resection can be offered to the majority of patients in our institution. The robot still requires further refinements to reduce operating times and the aortic cross-clamping period. We now have the technique and the instrumentation to offer laparoscopic aneurysm surgery as a minimally invasive alternative for patients whose conditions are unsuitable for endovascular aneurysm repair.     

Feasibility of preoperative computer tomography in patients with ruptured abdominal aortic aneurysm: a time-to-death study in patients without operation

INTRODUCTION: Despite advances in surgery, anaesthesia, and critical care, mortality from ruptured abdominal aortic aneurysms (AAAs) has not decreased over the last 20 years. Endovascular aneurysm repair (EVAR) of ruptured AAAs is an alternative to open repair, which may improve outcome. However, a computed tomography (CT) scan is usually required to assess the anatomic suitability of the aneurysm for EVAR. This may result in delay in transferring patients to the operating room. We evaluated all patients admitted to hospital with a ruptured AAA who died without undergoing surgery, to determine time to death after AAA rupture and thus the potential time available for obtaining a CT scan. METHODS: A retrospective case note review was conducted of 56 patients admitted to a single center with ruptured AAAs who did not undergo surgery because of advanced age or associated comorbidity over 8 years from 1995 to 2003. Statistical analysis was performed with the Fisher exact test. RESULTS: The 56 patients (33 men, 59%; 23 women, 41%) had a median age of 85 years (range, 71-98 years). Reasons for no operation being performed were shock (9%), cardiac arrest (11%), quality of life (29%), malignancy (7%), cardiac disease (15%), respiratory disease (16%) and age (14%). Median systolic blood pressure at admission was 110 mm Hg, heart rate was 88 beats per minute, and hemoglobin concentration was 10.5 g/dL. Patients were not aggressively resuscitated once a decision was made to not perform surgery. Death within 2 hours of hospital admission occurred in 7 (12.5%) patients, and 49 (87.5%) patients died more than 2 hours after admission. Median interval between onset of symptoms and admission to hospital was 2 hours 30 minutes (range, 44 minutes-36 hours), and the median interval between admission and death was 10 hours 45 minutes (range, 1 hour 1 minute-143 hours 55 minutes). The median total time to death from onset of symptoms was 16 hours 38 minutes (range, 2 hours 6 minutes-146 hours 50 minutes). CONCLUSION: Most (87.5%) patients admitted to hospital with a ruptured AAA died after more than 2 hours. These data show that most patients with a ruptured AAA who reach the hospital alive are sufficiently stable to undergo CT and consideration of EVAR.     

Laparoscopic Hand-Assisted Abdominal Aortic Surgery for Aneurysmal and Occlusive Disease: a One-Year Clinical Experience

Purpose : To describe our technique and one year clinical experience with laparoscopic hand-assisted abdominal aortic surgery for aneurysmal and occlusive disease.

Patients and Methods : Between June 2001 and May 2002, 13 patients underwent a laparoscopic hand-assisted abdominal aortic operation.

Results : The median operating time and aortic cross-clamp time were 230 and 29 minutes respectively. The median intra-operative blood loss was 625cc. There were no peri-operative (30 day) deaths. The conversion to open surgery ratio was 1/13. One major arterial and one systemic complication occurred. Median hospital stay was 6 days (range 442 days).

Conclusion : Laparoscopic hand-assisted abdominal aortic surgery for aneurysmal and occlusive disease is technically feasible and safe. The use of this laparoscopic technique combines the advantage of minimally invasive surgery and the reliability of an established open procedure without the risk of endoleaks in aneurysm surgery.     

Large diameter expanded polytetrafluoroethylene grafts for infrarenal aortic aneurysm surgery

The performance of an expanded polytetrafluoroethylene (ePTFE) graft used for aortic aneurysm replacement was evaluated. ePTFE grafts were implanted in 241 patients undergoing infrarenal abdominal aortic aneurysm (AAA) repair. Sixty patients were operated as emergencies for aneurysm rupture and 181 electively. One hundred and fourteen bifurcated and 127 tube grafts were inserted. The transperitoneal approach was used in 64 cases and the remainder were placed using a retroperitoneal approach. There was a one-month mortality of 2.8% in elective and 20% in emergency cases. Median follow-up was 26 months. Specific graft complications included one infected graft resulting in a graft-enteric fistula. No graft rupture, degeneration, dilatation, pseudoaneurysm or late graft limb thromboses were observed in up to 7 years of follow-up. The aortic ePTFE prosthesis demonstrated satisfactory performance over the period studied.