Technical details and preliminary results of a full robotic type II endoleak treatment with the da Vinci Xi

Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives

Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.

Treatment of Aortoiliac Occlusive Lesions by Aortic Robotic Surgery: Learning Curve and Midterm Outcome

BACKGROUD

The learning curve and midterm results of aortoiliac occlusive disease (AIOD) revascularization by robot-assisted laparoscopic (RAL) surgery may be known.

METHODS

A prospective single-center study was conducted in the vascular surgery department of Georges Pompidou European Hospital (Paris, France). Patients with AIOD treated by RAL from February 2014 to February 2019 were included. Demographic characteristics, past medical history, Trans-Atlantic Inter-Society Consensus (TASC) lesions classifications, mortality, primary and secondary patency, as well as complication rates were collected. Safety was analyzed by the cumulative sum control chart method with a conversion rate of 10%, operative time by cumulative average-time model, and primary and secondary patency by the Kaplan-Meier method.

RESULTS

Seventy patients were included, 18 (25.7%) with TASC C lesions and 52 (74.3%) with TASC D lesions. Before discharge, 14 (24.3%) patients had surgical complications. Among them, 10 (14.3%) required at least one reintervention. One (1.4%) patient died during the hospitalization. The learning curve in terms of safety (conversion rate) was 13 cases with an operating time of 220 minutes after 35 patients. During follow-up (median 37 months [21; 49]), 63 patients (91.3%) improved their symptoms, 53 (76.8%) became asymptomatic, and 3 graft limb occlusions occurred. The primary patency at 12, 24, 36, and 48 months was 94%, 92%, 92%, and 92%, respectively, while the secondary patency for the same intervals was 100%, 98.1%, 98.1%, and 98.1%, respectively.

CONCLUSIONS

Robotic surgery in AIOD revascularization seems safe and effective; allowing to treat patients with few comorbidities and severe lesions, in a dedicated center experienced in RAL, with excellent patency. Prospective clinical trials should be performed to confirm safety.

Laparoscopic Ligation of the Inferior Mesenteric Artery: A Systematic Review of an Emerging Trend for Addressing Type II Endoleak Following Endovascular Aortic Aneurysm Repair

Background/Objectives: this systematic review aims to explore the efficacy and safety of the laparoscopic ligation of the inferior mesenteric artery (IMA) as an emerging trend for addressing a type II endoleak following endovascular aortic aneurysm repair (EVAR). Methods: A comprehensive literature search was conducted across several databases including Medline, Scopus, and the Cochrane Central Register of Controlled Trials, adhering to the PRISMA guidelines. The search focused on articles reporting on the laparoscopic ligation of the IMA for the treatment of a type II endoleak post-EVAR. Data were extracted regarding study characteristics, patient demographics, technical success rates, postoperative outcomes, and follow-up results. Results: Our analysis included ten case studies and two retrospective cohort studies, comprising a total of 26 patients who underwent a laparoscopic ligation of the IMA between 2000 and 2023. The mean age of the cohort was 72.3 years, with a male predominance (92.3%). The mean AAA diameter at the time of intervention was 69.7 mm. The technique demonstrated a high technical success rate of 92.3%, with a mean procedure time of 118.4 min and minimal blood loss. The average follow-up duration was 19.9 months, with 73% of patients experiencing regression of the aneurysmal sac, and no reports of an IMA-related type II endoleak during the follow-up period. Conclusions: The laparoscopic ligation of the IMA for a type II endoleak following EVAR presents a promising, minimally invasive alternative with high technical success rates and favorable postoperative outcomes. Despite its potential advantages, including reduced contrast agent use and radiation exposure, its application remains limited to specialized centers. The findings suggest the need for further research in larger prospective studies to validate the effectiveness of this procedure and potentially broaden its clinical adoption.

Indocyanine green colonic perfusion demonstration following robotic da Vinci X inferior mesenteric artery ligation for the treatment of type II endoleak

Background

We describe the technical operative details of the robotic repair of a type II endoleak (T2E) following endovascular abdominal aortic aneurysm repair (EVAR). We demonstrate that indocyanine green (ICG) can be used intra‐operatively to demonstrate perfusion of the colon following ligation of the inferior mesenteric artery (IMA) vessel feeding the aneurysm sac.

Methods

A 74‐year old male underwent EVAR for a 5.8 cm infra‐renal abdominal aortic aneurysm using an E‐Tegra, Jotec Device (JOTEC Gmb, Lotzenäcker 23,D‐72379 Hechingen). Surveillance contrast CT (CTA) over the ensuing 30 months confirmed progressive sac expansion.

Results

ICG confirmed colonic perfusion via the marginals after IMA ligation. Total operative time 56 min < 50 mls blood loss and 1‐day hospital stay. 3‐month follow‐up: CTA and ultrasound demonstrated complete resolution of T2E and adequately perfused colon.

Conclusion

A total robotic approach can be performed safely with intra‐operative ICG used to demonstrate colonic perfusion as an added safety measure.

Robotic-assisted abdominal aortic surgery: evidence and techniques

In various disciplines, robotic-assisted surgery is a well-proven routine procedure, but have never been established in vascular surgery so far. This review summarizes the results to date of robotic-assisted abdominal aortic surgery (RAAS) in the treatment of aorto-iliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). Web-based literature search of robotic-assisted surgical procedures on the abdominal aorta and iliac arteries between 1990 and 2020 including the Cochrane Library, OVID Medline, Embase, and PubMed medical databases. All studies conducting Robotic-assisted surgery were included in the quantitative analysis regarding operative and cross-clamping times, conversion rates, mortality and morbidity within the first 30 days, and in-hospital stay. Case reports and case studies (< 5 patients) were not included. Twenty-four studies were deemed thematically eligible for inclusion; after exclusion of duplicate publications, nine met the inclusion criteria for further analysis. A total of 850 patients who had either abdominal aortic aneurysm or aorto-iliac occlusive disease underwent RAAS. One study of abdominal aortic aneurysm, three of aorto-iliac occlusive disease, and five studies of both disease entities were analyzed quantitatively. For AAA, conversion rates ranged from 13.1 to 20% and perioperative mortality ranged from 0 to 1.6% with in-hospital stay of 7 days. For aorto-iliac occlusive disease, conversion rates ranged from 0 to 20%, and perioperative mortality ranged from 0 to 3.6% with in-hospital stay of 5–8 days. RAAS has been shown to be technically feasible with acceptable short-term outcomes and questionable benefits in terms of in-hospital stay and complication rates. RAAS is currently considered only an outsider procedure. Randomized-controlled trials are indispensable for regular use in vascular surgery as well as a clear approval situation for the vascular sector.

Review and current update of robotic-assisted laparoscopic vascular surgery

The field of vascular surgery is constantly evolving and is unsurpassed in its innovation and adoption of new technologies. Endovascular therapy has fundamentally changed the treatment paradigms for aneurysm and occlusive disease. As we continue to make advances in not only endovascular therapy, but also robotic surgery, artificial intelligence, and minimally invasive surgery, it is important that the vascular community stay at the forefront. Topics include the advantages of laparoscopic and robotic surgery over open surgery for aortic procedures, robotic versus laparoscopic aortic surgery, patient candidacy for robotic-assisted aortic surgery, and how to increase training and adoption of robotic-assisted laparoscopic aortic surgery. Future growth includes the development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics in vascular surgery.

Challenges and experience of setting up an aortic service

Aortic surgery is a complex procedure posing high risks in comparison to other adult cardiac surgeries. Novel surgical approaches including minimally invasive procedures, sutureless aortic valve replacement, and transcatheter aortic valve implantation have been found to be acceptable alternatives to conventional surgeries. In addition, novel endovascular repair techniques and hybrid procedures have been introduced for the management of patients with thoracoabdominal aortic pathologies. However, these modalities are not readily available in every center, and such novel procedures impose a learning curve for surgeons and high costs for affected patients. In this review, we discuss the challenges of setting up an aortic service, having regard to the Iranian experience.

Recent Update of Endovascular Type 2 Endoleak Management

EVAR has been used clinically for almost three decades, and it has been widely applied in clinical practice and has been applied to difficult cases as devices and techniques have evolved. Although the major advantage of EVAR is its lower perioperative mortality, compared with open surgery, late-onset complications such as endoleaks have become major issues, requiring lifelong follow-up after EVAR. The clinical guidelines have been updated, and many systematic reviews/meta-analyses and multi-center registries have been published; surgeons must keep up-to-date regarding these changes. In this review, the author reviews evidence on the recent update of the type 2 endoleak management.