Current modifications to totally laparoscopic "apron technique"

Totally laparoscopic aortobifemoral bypass surgery in the treatment of aortoiliac occlusive disease or abdominal aortic aneurysms - a systematic review and critical appraisal of literature

PURPOSE

This systematic review aims to evaluate the published literature regarding totally laparoscopic aortobifemoral bypass (LABF) surgery in the treatment of aortoiliac occlusive disease (AIOD) or abdominal aortic aneurysms (AAA), compared with open aortobifemoral bypass surgery.

MATERIALS AND METHODS

A systematic review of the medical literature between 1990 and 2016 was performed, searching the medical databases Cochrane Library, OVID Medline, Embase and PubMed. Studies concerning totally LABF with or without control group and containing more than 10 patients were included in the analysis. Operative and aortic cross-clamping times, blood loss, rate of conversion to open surgery, mortality and morbidity within the first 30 postoperative days, hospital stay and primary and secondary patency of the graft were extracted and compared with open surgery when possible.

RESULTS

Sixty-six studies were deemed eligible for inclusion in this review, 16 of them matched the inclusion criteria for quantitative synthesis. The patient material consisted of 588 patients undergoing totally LABF, 22 due to AAA, and the remaining 566 for AIOD. Five comparative studies regarding AIOD compared 211 totally LABF procedures with 246 open procedures. Only one study concerning AAA was eligible for inclusion, and this study did not provide a comparison against an open group. The operating and aortic cross-clamping times were shorter in the open group. Conversion rates ranged from 0% to 27%. There was no statistically significant difference in mortality between the two groups (p=0.64). Hospital stays ranged from 4.0 to 12.1 and 5.0 to 12.8 days in the laparoscopic group and open group, respectively. Most of the studies provided low levels of evidence, mainly due to lack of blinding, randomization and correction of bias.

CONCLUSION

Totally laparoscopic aortoiliac surgery seems to be a feasible technique with unaffected mortality and trend toward benefits in hospital stay and possibly also in complication rates. The literature published this far is sparse and with inconsistent results. More randomized controlled trials are required before this method can be widely implemented.

Total Laparoscopic Aortofemoral Bypass as a Routine Procedure for the Treatment of Aortoiliac Occlusive Disease

The purpose of our study was to evaluate whether total laparoscopic aortofemoral bypass can be performed routinely in patients who require surgical intervention for aortoiliac occlusive disease. In a prospective study, 68 consecutive patients underwent total laparoscopic aortofemoral bypass between 2002 and 2004. Among these patients, there were 50 men and 18 women, with a mean age of 68.4 ± 9 years. The mean operating time was 199 minutes, with a mean aortic cross-clamp time of 85.8 minutes. There were five major complications (7.3%). The mean postoperative hospital stay was 6.3 days. Most of the younger patients could be discharged on the third or fourth postoperative day. Our results show that total laparoscopic aortic surgery can be offered as a routine procedure to the majority of patients with long-segment aortoiliac occlusive disease.

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.

Three trocars laparoscopic abdominal aortic aneurysm repair

Total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was performed in a 53-year-old woman diagnosed with an infrarenal abdominal aortic aneurysm. The operation was accomplished by a method using three trocars. The operation took 240 minutes. Blood loss was 600 mL. No complications occurred in 13 months of postoperative follow-up. These results show that total laparoscopic abdominal aortic aneurysm repair with three trocars is feasible and worthwhile.

Cirurgia aórtica totalmente laparoscópica para tratamento de isquemia crítica de membros: relato do primeiro caso no Brasil

A cirurgia videolaparoscópica (CVL) vem evoluindo como alternativa cirúrgica menos invasiva para o tratamento da doença aterosclerótica oclusiva aortoilíaca. O objetivo deste relato de caso foi demonstrar os resultados da primeira cirurgia aórtica totalmente laparoscópica relatada no Brasil para o tratamento da doença oclusiva aortoilíaca em paciente com isquemia crítica. Os tempos cirúrgicos totais de dissecção e exposição da aorta antes do clampeamento, exposição retroperitoneal da aorta, clampeamento total e da anastomose proximal com técnica totalmente laparoscópica foram de 220 minutos, 15 e 27 minutos, 42 minutos, 110 minutos e 78 minutos, respectivamente. A técnica videolaparoscópica é mais uma ferramenta minimamente invasiva, viável, segura e eficaz para o tratamento da doença oclusiva aortoilíaca extensa. Ela, que nada mais é do que a cirurgia convencional realizada sob visão laparoscópica, tem bons resultados a longo prazo, que se associam à elegância técnica.

Cirurgia aorto-ilíaca videolaparoscópica para tratamento de isquemia crítica de membros: relato do primeiro caso no Brasil

A cirurgia videolaparoscópica vem evoluindo como alternativa cirúrgica menos invasiva para o tratamento da doença aterosclerótica oclusiva aorto-ilíaca. O objetivo deste relato é demonstrar os resultados da primeira cirurgia videolaparoscópica realizada no Brasil para o tratamento da doença oclusiva aorto-ilíaca, associada a procedimentos híbridos distais para lesões ateroscleróticas multissegmentares em paciente com isquemia crítica. A técnica videolaparoscópica é mais uma ferramenta minimamente invasiva, viável, segura e eficaz para o tratamento da doença oclusiva aorto-ilíaca extensa. A referida técnica, que nada mais é do que a cirurgia convencional realizada sob visão laparoscópica, tem bons resultados a longo prazo, associados à elegância técnica.

Laparoscopic surgery in the management of complex aortic disease: techniques and lessons learned

Laparoscopic vascular surgery must be assessed in the context of both open and endovascular interventions. The development of improved laparoscopic equipment and endoscopic techniques makes performance of laparoscopy easier, but endovascular interventions still hold wide appeal because they are minimally invasive and are easier to master by vascular surgeons. Despite decreased morbidity and recovery time, endovascular interventions have inferior durability and higher reintervention rates when compared with open aortoiliac interventions. In particular, after endovascular aneurysm repair, patients need lifelong surveillance because there is potential for delayed endoleaks, aortic neck dilatation, graft migration, and ongoing risk of aneurysmal rupture. These limitations of endovascular therapy are the impetus behind the pursuit of other minimally invasive techniques, such as laparoscopy, in vascular surgery. Currently, two evolving laparoscopic approaches are available for abdominal vascular surgery: total laparoscopic aortic surgery and hybrid techniques that combine laparoscopy with endovascular techniques to treat failing endografts.

Curva de aprendizado em cirurgia aórtica videolaparoscópica: estudo experimental em porcos

CONTEXTO: A cirurgia videolaparoscópica (CVL) vem evoluindo como alternativa cirúrgica menos invasiva para o tratamento da doença aterosclerótica oclusiva aorto-ilíaca e do aneurisma da aorta abdominal. Poucos estudos avaliaram objetivamente a curva de aprendizado com essa técnica em cirurgia vascular. OBJETIVO: Avaliar objetivamente os tempos e a evolução de cada passo cirúrgico e demonstrar a exeqüibilidade dessa técnica. MÉTODOS: Entre outubro 2007 e janeiro de 2008, dois cirurgiões vasculares iniciantes na CVL operaram, após cursos e treinamentos, seis porcos consecutivos, com dissecção aórtica e interposição de um enxerto de dácron em um segmento da aorta infra-renal abdominal, com técnica totalmente laparoscópica. RESULTADOS: Todos os tempos cirúrgicos foram decrescentes ao longo do estudo, apresentando redução de 45,9% no tempo total de cirurgia, 85,8% no tempo de dissecção da aorta, 81,2% na exposição da aorta, 55,1% no clampeamento total, 71% na confecção da anastomose proximal e 64,9% na anastomose distal. CONCLUSÃO: O presente estudo mostrou que os resultados técnicos satisfatórios da CVL vascular ocorreram somente após longa curva de aprendizado, que foi decrescente ao longo do tempo, à medida que aumentou a experiência e vivência com os materiais e com a visão não-estereoscópica. Essa técnica pode ser realizada com perfeição por cirurgiões vasculares desde que façam cursos especializados, com treinamento em simuladores e animais, e desde que busquem constante aprimoramento a fim de conseguir resultados similares aos obtidos com a cirurgia convencional.

Totally Laparoscopic Aortohepatic Bypass for Aortic Debranching During Endovascular Thoracoabdominal Aneurysm Repair

INTRODUCTION

Endovascular grafting of the aorta is gaining widespread acceptance for treating aortic aneurysms. Para-renal aneurysms or thoraco-abdominal aneurysms may be a relative contra-indication for endovascular aneurysm repair (EVAR) unless visceral vessels can be debranched.

REPORT

We describe a case of thoraco-abdominal aneurysm extending from the descending thoracic aorta to the level of coeliac artery. A totally laparoscopic retrograde aorto-hepatic bypass was performed in conjunction with endograft exclusion of the aneurysm and coverage of the coeliac artery ostium.

DISCUSSION

Laparoscopic debranching of visceral vessels extends the indications of EVAR.

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.

Laparoscopic Vascular Surgery: A Systematic Review

OBJECTIVE

The objective of this systematic review is to evaluate the results of clinical studies on laparoscopic surgery for aorto-iliac disease.

METHODS

A systematic review of the literature from 1966 to September 2006 on laparoscopic and robotic vascular surgery was performed. Only patient series containing more than 5 cases were included. Operative, clamping and anastomosis times, conversion, mortality and morbidity and hospital stay were evaluated.

RESULTS

Thirty studies were identified. These were all descriptive and included 9 comparative studies. Operative times varied widely, the shortest being for hand-assisted procedures (2.5-4 hours) and the longest for totally laparoscopic procedures (4-6.5 hours). Clamping times were all<1 hour in hand-assisted procedures while in other techniques clamping times from 1-2.5 hours were seen. The conversion rate varied from <5% up to 16% in smaller series. The mortality rate was approximately 5% and frequently caused by cardiac ischemia. A variety of problems ranging from minor local wound problems to cardiopulmonary- and renal insufficiency, bleeding, ureter lesions and graft thrombosis were described. Mean hospital stay for nearly all procedures was <1 week.

CONCLUSIONS

Experience of laparoscopic surgery for aorto-iliac disease is still limited. Most study results are biased by patient selection. Only a few surgeons have mastered the required surgical technique and more data are needed to asses the clinical potential of this type of surgery, in comparison with the endovascular alternative. For wider implementation simplification of the surgical procedure seems necessary.

Total Laparoscopic Iliac Artery Aneurysm Repair Using Endoscopic Techniques and Endovascular Balloon Occlusion

We present a novel total laparoscopic technique to treat patients with iliac and aorto iliac aneurysms. The laparoscopic procedure does not require clamping of the iliac arteries because of a hybrid approach.

REPORT

Laparoscopic exposure of the aorta is performed using transperitoneal left retrorenal access. A transfemorally placed balloon catheter blocks the external iliac artery. Two haemostatic sheaths are inserted directly through the skin into the abdominal cavity. Balloons are passed through these sheaths to block the common iliac artery and the hypogastric artery, allowing bypass grafting to be performed with appropriate haemostatic control.

DISCUSSION

The technique described preserves inflow into the hypogastric arteries . This is accomplished by a combination of laparoscopic and endovascular techniques reducing the problems that can be caused by clamping diseased arteries.

Hand assisted laparoscopic surgery of aortoiliac occlusive disease: initial results

OBJECTIVES

Open aortobifemoral bypass grafting has been the procedure of choice for many years in patients with symptomatic aortoiliac occlusive disease (AIOD). Hand assisted laparoscopic surgery (HALS) for AIOD could have advantages like faster recovery, faster oral intake and shorter hospital stay compared to the conventional technique. We documented the results of patients who underwent HALS for AIOD in our hospitals.

MATERIALS AND METHODS

from January 1999 to December 2002, 33 consecutive patients underwent HALS for AIOD. Peri- and postoperative results were prospectively registered. Three different laparoscopic approaches were applied: transperitoneal, retroperitoneal and apron approach.

RESULTS

There were 23 males and 10 females, with a mean age of 59 years (range 39-85). The surgical technique applied was: transperitoneal: 22 patients, retroperitoneal: 7 patients, apron: 4 patients. Per-operative results (median) of the transperitoneal, retroperitoneal and apron approach are: operating time 240, 420 and 263 minutes, cross clamp time 32.5, 40 and 33.5 minutes, blood loss 1150, 2100 and 950 ml, respectively. Postoperatively oral intake was fully resumed in 3, 4.5 and 2 days after performing the transperitoneal, retroperitoneal and apron technique. During the ICU stay patients received artificial respiration for 0, 1 and 0 days, admission to the ICU was 0.5, 1 and 0.75 days for the transperitoneal, retroperitoneal and apron approach. Finally, hospital stay was 8, 12.5 and 7 days after the transperitoneal, retroperitoneal and apron approach. Four patients (12%) had a minor complication, 4 patients (12%) had a major complication; pneumonia with ARDS, sepsis, bypass occlusion and chylo-abdomen. No patients died.

CONCLUSIONS

HALS for AIOD is a technically demanding operation with a long learning curve. All three approaches are feasible. In this series of patients, we feel the transperitoneal and apron approach have the most advantages because of the larger working space. Finally, randomized trials will determine if laparoscopic assisted or total laparoscopic aortoiliac surgery has the potential to reduce morbidity for the patient compared to the conventional technique.

Laparoscopic aortic reconstruction: early experience

BACKGROUND

Laparoscopic reconstruction of the abdominal aorta has been described as early as 1993. The techniques used have varied but all have been labor intensive. With advances in laparoscopic technique and the available tools, the role in aortic reconstruction is expanding. The high cost of endovascular techniques as well as the morbidity of traditional open surgery has resulted in an increased focus on the laparoscopic approach. Our goal was to determine the feasibility of this technique.

METHODS

Retrospective review of the charts of patients undergoing laparoscopic aortobifemoral bypass grafting for chronic lower-limb occlusive disease.

RESULTS

Thirteen patients were selected for the procedure. Ten were completed successfully and form the basis of the report. The average length of stay was 6.7 days compared with a historic cohort of 12 days. The average operative time was 6.5 hours, more than twice as long as the open technique. There was a tendency to lower blood replacement and less abdominal pain. One patient suffered a stroke postoperatively; no deaths occurred.

CONCLUSION

This procedure is technically challenging but can be performed safely and successfully with adherence to several key anatomic principles. More widespread adoption of this technique may lead to improvements in the instruments and other technologies. Our very early experience is encouraging. There appear to be benefits of reduced length of stay, but improved operative times will be required to make this technique truly valuable.

Videoendoscopically assisted combined retroperitoneal and pelvic extraperitoneal approach for aortoiliac occlusive disease

BACKGROUND

Laparoendoscopic surgery has emerged as a new method for the management of iliac and aortoiliac occlusive disease. This article describes a combined retroperitoneal and pelvic extraperitoneal approach to aorta and iliac arteries.

METHODS

A review was performed for 15 patients who underwent videoendoscopically assisted vascular bypass procedures between January 1999 and June 2003. A minimal access approach was used for access to the proximal anastomotic site (proximal common iliac or distal aorta) and creation of a tunnel for the prosthetic graft placement up to the distal anastomotic site. Altogether, 11 iliofemoral bypasses, 2 iliobifemoral bypasses and 2 aortobifemoral bypasses were performed. Patients with diffuse stenosis/long-segment occlusion and multiple lesions for whom percutaneous transluminal angioplasty with stenting proved to be unsuitable were included. The outcome parameters measured were intraoperative time, intraoperative blood loss, skin incision length, length of hospital stay, postoperative pain and analgesia requirement, and patency of graft.

RESULTS

Videoendoscopy was used to complete 14 procedures. The mean operating time was 258 +/- 49 min (range, 180-300 min) and the mean blood loss was 124 +/- 28.23 ml (range, 80-150 ml). The mean hospital stay was 6.7 +/- 4.46 days (range, 4-9 days). After a mean follow-up period of 14.4 +/- 3.55 months (range, 6-20 months), all grafts were patent.

CONCLUSION

Videoendoscopically assisted vascular surgery for iliac and aortoiliac occlusive disease by a combined retroperitoneal and pelvic extraperitoneal approach is feasible and appears to confer many advantages of minimal access surgery. However, prospective randomized trials are needed to define clearly any advantages of this approach over conventional surgery.

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.

Totally laparoscopic aortic repair: A new device for direct transperitoneal approach

On the basis of our experience with more than 71 cases of totally laparoscopic aortic surgery by the retrocolic approach, we have developed a new technique by a simple transperitoneal approach. The purpose of this report is to describe that technique and the novel laparoscopic bowel retractor used to ensure stable exposure of the aorta.

Comparison of a Plasma-based Composite Biologic Sealant With Fibrin Glue (Tisseel??) for Vascular Anastomoses

Biologic sealants are needed in numerous, more and more demanding, procedures--especially with developments occurring in endovascular and laparoscopic vascular techniques. An initial pilot study in dogs showed that a 4-cm aortotomy closed with a polyester patch sutured in place by a 4-mm-spaced running suture consistently led to massive hemorrhage. We then designed a study using five dogs where two aortotomies were done to compare the effect of Tisseel to that of an autologous sealant prepared in our laboratory. Arterial pressures and heparinization were maintained throughout the surgical procedure. Both biologic sealants prevented hemorrhage from the arteriotomy at unclamping. Macroscopic and histologic assessments were performed. At killing, one week later, the autologous sealant exhibited less blood saturation of the collagen sponge compared with Tisseel. The use of autologous plasma combined with other adhesive components could be an efficient alternative to allogenic fibrin glue. Further studies are needed to confirm these observations.

Early and Mid-term Results of Totally Laparoscopic Surgery for Aortoiliac Disease

The present article is the first in the literature reporting short- and medium-term results using a totally laparoscopic technique for aortoiliac disease.Forty-nine patients, 6 having an associated small aneurysm, were scheduled for totally laparoscopic surgery (TLS) for aortoiliac occlusive disease and 2 for treatment of aortic aneurysmal disease (AAA). Patients' characteristics, intraoperative, postoperative data and mid-term data were recorded.TLS was successfully completed in 45 patients. Of those patients, 41 received an aortobifemoral bypass; three, an iliofemoral bypass; and one, an aortoaortic bypass. Five patients were converted from TLS to video-assisted laparoscopic surgery using incisions varying in size from 7 cm to 11 cm. One patient underwent conversion to standard open surgery. One death occurred unrelated to the technique. Major perioperative complications related to the technique were few and presented in the early phase of the study: One intraoperative embolization to the lower limbs that needed embolectomy, and one acute aortic false aneurysm. Midterm results were favorable, demonstrating two limb graft thromboses. Hernias at trocar sites occurred in only 3.9%. The patients benefited from this procedure, which is considered definitive like its standard open counterpart. The conversion rate is lower than that reported for acute cholecystitis. Selection of patients has been less stringent during the second half of the study in term of inclusion of patients with AAA and of more TASC IV patients. Surgeons willing to learn this technique should attend dedicated courses. In the future, as this surgical innovation matures, controlled randomized studies should be initiated.

Total laparoscopic repeat aortic surgery

We report our initial experience with total laparoscopic repeat aortic surgery between June 2002 and October 2003. There were 4 patients, 3 men and 1 woman, ages 83, 67, 49, and 61 years, respectively. First operations were performed to treat aortoiliac occlusive disease. Repeat aortic surgery was indicated to treat para-anastomotic aneurysms (n = 2) and graft occlusion (n = 2). All patients underwent total laparoscopic surgery. There were no postoperative deaths. Only 1 patient had postoperative complications that required complementary surgical treatment. All patients were alive with patent revascularization after a mean follow-up of 14, 17, 20, and 12 months, respectively.

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.