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

PRELIMINARY EXPERIENCE OF THE AORTO-FEMORAL SHUNTING USING THE DA VINCI SURGICAL SYSTEM

Introduction. Robot surgery is one of the most high-demand and dynamic developing realms of medicine. It is widely used in urology, proctology, thoracic, cardiovascular surgery and gynecology. In February 2018 a robot surgery centre opened in Volga Federal District of the Russian Federation based on the clinic of the Bashkir State Medical University (city of Ufa).

Materials and methods. The present paper demonstrates the first successful robot-assisted vascular operations within a master-class called "Aorto-Femoral Shunting with the use of robot-assisted surgical system Da Vinci".

Results. Exemplified with three operations: two linear aorto-femoral shunting and lumbar sympathectomy demonstrate technical peculiarities and advantages of robot-assisted vascular surgery. The findings show positive short-term results of the performed surgical interference that combine minimal injury and blood loss which help to reduce hospital stay in an intensive therapy department and intestinal distention duration. These clinical effects enabled to provide early activization of patients and possibility to adequately correct nutritional status with enteral feeding. The above-mentioned advantages eventually resulted in reduction of post-operation stay of patients in in-patient department and of cost of treatment.

Conclusion. Robot-assisted surgical system Da Vinci being the most cutting-edge in the realm of endoscopic surgery, enables to carry out operational interference with minimal blood loss and injury of tissues which helps to reduce postoperation and recovery periods. 

Robot-Assisted Laparoscopic Aortic Reconstruction for Occlusive Disease

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.

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.

Aortic aneurysm surgery: problems and innovations

A long way was traveled since the first surgery was performed for the treatment of abdominal aortic aneurysm. Throughout this time, several innovations have been created in order to reduce the invasiveness of the surgical procedures and to improve their safety and durability. This review discusses the major and recent advances on aortic aneurysm interventions, including, the endovascular aortic repair, the laparoscopic aortic surgery, the conventional hybrid and endovascular techniques, combined laparoscopic and endovascular techniques, as well as future prospects for both thoracic and abdominal aorta. Faced with so many changes and developments, modern vascular surgeons must keep their minds open to innovations and should develop comprehensive training with different techniques, to provide the best therapeutic option for their patients.

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.

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.

A Modified Technique of Transperitoneal Direct Approach for Totally Laparoscopic Aortoiliac Surgery

OBJECTIVE

To present our modification of the transperitoneal direct approach (TDA) for totally laparoscopic aortoiliac surgery.

METHODS AND RESULTS

From September 2003 to August 2005 a total of 52 patients underwent laparoscopic operations for aortoiliac disease (50 aortoiliac occlusive disease; two abdominal aortic aneurysm). The modified TDA was used in 20 patients.

CONCLUSION

The main advantage of TDA is reduced dissection of the aorta and pelvic arteries resulting in lowered blood loss and lymphatic injury.

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.

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.

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.

Minilaparotomy for Aortoiliac Aneurysmal Disease

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

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.

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.

Current modifications to totally laparoscopic "apron technique"

Since our original description in 1997 of a totally laparoscopic technique for treatment of aortoiliac disease, this type of minimally invasive procedure has been used both in the United States and abroad. We describe improvements that should make this technique more easily reproducible. This modified procedure was offered to six patients, one of whom received a tube graft for treatment of aneurysm disease.

[Laparoscopic aortoiliac surgery for occlusive disease and or aneurysms]

The techniques of video-assisted surgery have been recently applied to aortoiliac surgery. The choices between first the retroperitoneal approach or the transperitoneal approach and the place of video-assisted surgery in relation to totally laparoscopic surgery are at the centre of debates. The aim of this clarification is to relate the evolution of laparoscopic aortoiliac surgery for occlusive disease and aneurysms through a review of the literature on this subject.