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.