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

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.

Robot-assisted techniques in vascular and endovascular surgery

For thousands of years, robots have inspired the imagination of humans, but it was only about 35 years ago that a robot was used for the first time in medicine. Since then, robot-assisted procedures have become increasingly popular in urology, general surgical specialties, and gynecology. Robot-assisted vascular surgery was first introduced in 2002 and was thought to overcome the limitations of laparoscopy. However, it did not gain widespread popularity, and its usage is still limited to a few centers worldwide. Robot-assisted endovascular procedures, on the other hand, while still in its infancy, have become a promising alternative to existing techniques. The improvements of the robotic systems promote better surgical performance and reduce occupational hazards for vascular and endovascular surgeons. A comprehensive review of literature was performed using the search terms “robotic,” “robot assisted,” “vascular surgery,” and “aortic” for surgical procedures or “robotic,” “robot assisted,” and “endovascular” for endovascular procedures. Full text articles that were published between January 1990 and March 2021 were included. This review summarizes the development of the techniques for robot-assisted vascular and endovascular surgery in recent years, its outcomes, advantages, disadvantages, and perspectives.

[Robot-assisted operations in vascular surgery]

The article contains a systematic review of the literature dedicated to vascular robot-assisted operations, also discussing the use of robotic technologies in vascular surgery, their advantages and disadvantages. In so doing, we studied the experience of Russian and leading international surgical centres, comparing the reported outcomes by such parameters as the average duration of the operation, mean time of aortic cross-clamping, time spent for anastomosis formation, frequency of postoperative complications, etc. Benefits of robot-assisted operations allowed the latter to occupy the leading positions in various fields of surgery, although the use of robots in vascular surgery has only begun to gain popularity. A robotically assisted system eliminates the main shortcomings of laparoscopy and opens opportunities for expanding robot-assisted surgery in this field.

Robotic Treatment of Complex Splenic Artery Aneurysms with Deep Hilar Location: Technical Insights and Midterm Results

BACKGROUND

Splenic artery aneurysms are rare, but their occurrence is burdened by considerable mortality and morbidity rates. Although the indications to treatment are quite clear-cut, there is still debate on the first-choice technique of treatment (endovascular, open, or laparoscopic surgery). Recently, robotic surgery has been proposed as an alternative option in patients at high surgical risk. The present case series aims to assess the value of robotic treatment of splenic artery aneurysms in patients unfit for surgery.

METHODS

All cases of splenic artery aneurysms treated by robotic surgery at our center between 2014 and 2018 were retrospectively reviewed. Primary endpoints were clinical and technical success and disease-free survival.

RESULTS

Robotic surgery was used to treat four patients affected by splenic artery aneurysms, with the guidance of 3D printed patient-specific models. All patients, after aneurysm excision, received reconstruction of the splenic artery by direct anastomosis. All cases were treated successfully without mortality. Reintervention-free survival at 24-month mean follow-up is 100%, and no systemic complication of clinical relevance was reported. The mean time of organ ischemia was 45 min.

CONCLUSIONS

Robotic surgery is a safe and effective option in treating visceral aneurysms, providing the possibility to reconstruct the splenic artery after aneurysm excision.

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.

A minimally invasive approach for open surgical thoracoabdominal aortic replacement: experimental concept for a novel surgical procedure

Objectives

We aimed to develop a simple, reliable, and timesaving technique for the therapy of thoracoabdominal aortic (TAA) aneurysms that are not suitable for endovascular repair.

Methods

In this pilot study, we sought to combine the advantages of classic open vascular procedure with the use of endoscopic surgical tools and small skin incisions to develop a minimally invasive approach for TAA replacement. The following procedures were used: endoscopic exposure and closure of the lower intercostal arteries; small posterolateral thoracotomy and left retroperitoneal incisions to expose the anastomotic regions of the aorta; partial anticoagulation; passive bypass and sequential aortic clamping; tunnelling of the graft through the native aortic lumen (endoaneurysmorrhaphy) and open performance of vascular anastomosis.

Results

Five mixed-breed dogs (25-35 kg) underwent minimally invasive TAA replacement. All animals survived the operation without blood transfusion (lowest Hb = 5.5 mg/dl). Total operation time was 364 ± 46.3 min. Clamping times were 17.6 ± 3.2 min for proximal anastomosis, 33.2 ± 2.48 min for visceral patch and 11 ± 2.3 min for distal anastomosis. The pull-through procedure of graft through the native aorta was performed during the visceral clamp time.

Conclusions

Surgical replacement of the TAA through small transverse incisions of the thoracic and abdominal wall is feasible and allows open performance of all vascular anastomosis with no leakage at any anastomotic site. Further experimental studies and clinical implementation are needed to establish the safety and long-term outcome of minimally invasive TAA replacement as a possible primary therapeutic tool for complex aneurysms that are not suitable for endovascular treatment and require open surgical repair.

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.

Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years

Background

Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures.

Methods

MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov were searched from 1990 up to October 2013 with no language restriction. Relevant review articles were hand-searched for remaining studies. Randomised controlled trials (RCTs) and prospective comparative studies (PROs) on perioperative outcomes, regardless of patient age and sex, were included. Primary outcomes were blood loss, blood transfusion rate, operative time, length of hospital stay, and 30-day overall complication rate.

Results

We identified 99 relevant articles (108 studies, 14,448 patients). For robotic versus OS, 50 studies (11 RCTs, 39 PROs) demonstrated reduction in blood loss [ratio of means (RoM) 0.505, 95 % confidence interval (CI) 0.408–0.602], transfusion rate [risk ratio (RR) 0.272, 95 % CI 0.165–0.449], length of hospital stay (RoM 0.695, 0.615–0.774), and 30-day overall complication rate (RR 0.637, 0.483–0.838) in favour of robotic surgery. For robotic versus MIS, 58 studies (21 RCTs, 37 PROs) demonstrated reduced blood loss (RoM 0.853, 0.736–0.969) and transfusion rate (RR 0.621, 0.390–0.988) in favour of robotic surgery but similar length of hospital stay (RoM 0.982, 0.936–1.027) and 30-day overall complication rate (RR 0.988, 0.822–1.188). In both comparisons, robotic surgery prolonged operative time (OS: RoM 1.073, 1.022–1.124; MIS: RoM 1.135, 1.096–1.173). The benefits of robotic surgery lacked robustness on RCT-sensitivity analyses. However, many studies, including the relatively few available RCTs, suffered from high risk of bias and inadequate statistical power.

Conclusions

Our results showed that robotic surgery contributed positively to some perioperative outcomes but longer operative times remained a shortcoming. Better quality evidence is needed to guide surgical decision making regarding the precise clinical targets of this innovation in the next generation of its use.

A proof-of-principle robot with potential for the development of a hand-held tactile instrument for minimally-invasive artery cross-clamping

One of the most common diseases of the vascular system is abdominal aortic aneurysm (AAA), for which the most definitive treatment is surgery. Minimally invasive aorta surgery is a novel method of surgery performed through small incisions and offers significant advantages including less pain, shorter hospital stay, faster patient recovery, less possibility of infection, etc. However, lack of sense of touch is the main drawback of this type of aorta surgery that would incapacitate the surgeon to exactly distinguish the aorta from its surrounding tissues which could cause various problems during the aorta cross-clamping process. One of the most important drawbacks is that it makes the aorta cross-clamping process the most time-consuming process of aortic repair surgery. The artificial tactile sensing approach is a novel method that can be used in various fields of medicine and, more specifically, in minimally invasive surgeries, where using the 'tactile sense' is not possible. In this paper, considering the present problems during aortic-repair-laparoscopy and imitating the movement of surgeons' fingers during aorta cross-clamping, a novel tactile-based artery cross-clamping robot is introduced and its function is evaluated experimentally. It is illustrated that this new tactile-based artery cross-clamping robot is well capable of dissecting an artery from its adjacent tissues in a short time with an acceptable accuracy.

How does the surgeon's experience of abdominal operations influence the learning curves for robot-assisted vascular anastomosis?

OBJECTIVE

Endoscopic vascular anastomosis of abdominal aortic aneurysms is rarely performed and requires standardization. Here, we examined the impact of the surgeon's experience of abdominal aortic aneurysm surgery on the learning curve for robot-assisted endoscopic vascular anastomosis.

METHODS

Three vascular surgeons with more than 10 years' experience (group A), three vascular surgeons with less than 10 years' experience (group B), and three medical students with no experience (group C) of performing vascular surgery used the da Vinci surgical system to anastomose 8-mm-diameter vascular prostheses in an end-to-end manner with continuous 5-0 Prolene sutures. The procedure was performed five times by each participant. Outcomes were anastomosis time, number of actions, visual score, and pressure test. Snapping of the prolene thread was recorded as a procedural failure.

RESULTS

Procedural failure occurred only in group C (3/15 trials, 20%; P < 0.0001). Learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions. Between trials 1 and 5, learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions but were not apparent for leakage or visual score in any group. Visual score and leakage were not significantly different among the three groups in each trial (P = 0.10 and P = 0.45, respectively).

CONCLUSIONS

By using the da Vinci surgical system, experienced vascular surgeons and surgically naive students showed marked improvements in vascular anastomosis techniques with a short period of training.

Artificial tactile sensing approach in aortic-repair-laparoscopy: aorta cross clamping during surgery

Abdominal aortic aneurysm is one of the most common diseases of the vascular system for which the most definitive treatment is surgery. Laparoscopy is a primary method of minimally invasive surgery that could be useful in aortic repair surgeries. Although this method of surgery has significant advantages, the difficulty of exactly distinguishing the aorta from its surrounding tissues is its main drawback; this can cause many problems during the aorta cross clamping process. One of the most important limitations is that it is a time-consuming process; aorta cross clamping leads to increases in surgery duration. Artificial tactile sensing is an innovative technology aiming to make tactile data more available for surgeons, especially in situations where developments in technology make the surgeons less efficient. In this paper, considering the present problems during aortic repair laparoscopy, applicability of a novel tactile robotic system capable of cross clamping an artery during laparoscopy was evaluated. Having considered a small, 5-degree-of-planar-freedom robot and imitated surgeon's palpation using software, the path followed by the tip of the new tactile robotic system was extracted. It is shown that this new tactile robotic system is well capable of dissecting an artery from its adjacent tissues in a short time with an acceptable accuracy. The functional principles of the tactile robotic system capable of cross clamping the aorta during laparoscopy will also be presented.

Endoscopic type 2 endoleak repair following endovascular aortic aneurysm repair: acute results and follow-up experience

The purpose of this study was to evaluate immediate and long-term results of endoscopic type 2 endoleak repair (EER) following endovascular abdominal aortic aneurysm repair. The basic methods include a retrospective review of electronic and paper medical records of patients admitted or referred to our institution for EER. Between July 1999 and October 2007, eight consecutive patients underwent EER. Mean operative time was 190 (104–355) min. One patient died preoperatively, due to profuse venous bleeding . One procedure was redone due to a missed pair of lumbar arteries. Mean hospital stay was five days (2–10). During mean follow-up, 50 months (29–91), one patient required additional coil embolization for a persistent type 2 endoleak. Four patients were diagnosed with a type 1 and one with a type 3 endoleak; three of these patients required an additional procedure. In conclusion, in this small series EER proved not to be beneficial.

Clinical applications of robotic technology in vascular and endovascular surgery

BACKGROUND

Emerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery.

METHODS

A systematic literature search was performed in order to identify all published clinical studies related to robotic implementation in vascular intervention. Web-based search engines were searched using the keywords "surgical robotics," "robotic surgery," "robotics," "computer assisted surgery," and "vascular surgery" or "endovascular" for articles published between January 1990 and November 2009. An evaluation and critical overview of these studies is reported. In addition, an analysis and discussion of supporting evidence for robotic computer-enhanced telemanipulation systems in relation to their applications in laparoscopic vascular and endovascular surgery was undertaken.

RESULTS

Seventeen articles reporting on clinical applications of robotics in laparoscopic vascular and endovascular surgery were detected. They were either case reports or retrospective patient series and prospective studies reporting laparoscopic vascular and endovascular treatments for patients using robotic technology. Minimal comparative clinical evidence to evaluate the advantages of robot-assisted vascular procedures was identified. Robot-assisted laparoscopic aortic procedures have been reported by several studies with satisfactory results. Furthermore, the use of robotic technology as a sole modality for abdominal aortic aneurysm repair and expansion of its applications to splenic and renal artery aneurysm reconstruction have been described. Robotically steerable endovascular catheter systems have potential advantages over conventional catheterization systems. Promising results from applications in cardiac interventions and preclinical studies have urged their use in vascular surgery. Although successful applications in endovascular repair of abdominal aortic aneurysm and lower extremity arterial disease have been reported, published clinical experience with the endovascular robot is limited.

CONCLUSIONS

Robotic technology may enhance vascular surgical techniques given preclinical evidence and early clinical reports. Further clinical studies are required to quantify its advantages over conventional treatments and define its role in vascular and endovascular surgery.

Mid-term results of robot-assisted laparoscopic surgery for aortoiliac occlusive disease

The aim of this study was to evaluate middle-term clinical results of robot-assisted laparoscopic surgery (RALS) to treat aortoiliac occlusive disease (AIOD). Between 2002 and 2007, 28 consecutive patients received robot-assisted laparoscopic aortobifemoral bypass grafting ( n = 24) or aortoiliac endarterectomy ( n = 4). Patients were followed prospectively. RALS could be completed successfully in 24 patients; conversion to open surgery was necessary in four patients (14%). Median operative time was 350 min. Median aortic clamping time was 70 min. Median hospital stay was five days. One patient died within 30 days. Non-lethal complications occurred in four patients (14%). Clinical symptoms improved in all patients. Primary and secondary limb-based patencies at 36 months were 89% and 91%, respectively. In conclusion, RALS is a feasible and durable technique for patients with AIOD. Although operative times are long, RALS allows rapid postoperative recovery.

Accuracy and speed trade-off in robot-assisted surgery

BACKGROUND

Controlling surgical task speed and maintaining accuracy are vital components of robotic surgical skills. This study was designed to investigate the relationship between accuracy and speed for robot-assisted surgical skills.

METHODS

Ten participants were asked to alternately touch two circular targets with various dimensions and distances between two targets, using the da Vinci Surgical System. The design of this study was based on Fitt's law. Statistical correlations between the index of difficulty (ID) and the movement time (MT), as well as the ID and the smoothness of the movement, were analysed.

RESULTS

A significant linear correlation between MT and ID was shown. Speed was reduced to maintain accuracy as the level of task difficulty increased. There was no significant correlation between the smoothness of the movement and ID.

CONCLUSIONS

The trade-off between speed and accuracy plays an important role in robot-assisted surgical proficiency.

Gasless laparoscopic aorto-bifemoral bypass grafting using self-designed abdominal lifting system

Severe aorto-iliac occlusive disease can cause disabling symptoms. The treatment of aorto-iliac occlusive disease has dramatically changed with the introduction of endoluminal techniques. However, according to the Trans-Atlantic Inter-Society Consensus for severe aorto-iliac disease, aorto-bifemoral bypass remains the therapy of choice. A recent addition to the open repair is laparoscopic-assisted aorto-bifemoral bypass, especially in occlusive arterial disease. In this article, we describe a new technique of performing gasless laparoscopic-assisted aorto-bifemoral bypass grafting with a self-designed abdominal wall-lifting system. We dealt with a patient who had a history of coronary artery disease and poor cardiopulmonary functional reserve. He had disabling symptoms of claudication and rest pain on bilateral lower extremities. Aorto-biliac-femoral occlusive disease was diagnosed in him, and he underwent the gasless laparoscopic-assisted aorto-bifemoral bypass. The total procedure time was 260 minutes. The patient was extubated 5 hours postoperatively. He was discharged home without complications 5 days after the surgery. This procedure is attractive not only to minimize the length of the wound and the time to extubation but also to avoid the possible lethal complications associated with the traditional laparascopic pneumoperitoneum. This device and technique can also provide a bridge for young or less-experienced surgeons to be familiar with total laparoscopic aortic surgery from traditional open repair.

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.

Reduced access aortic exposure (RAAE) technique for infrarenal abdominal aortic aneurysm (AAA) repair

OBJECTIVE

A reduced access aortic exposure (RAAE) technique for repair of infrarenal AAA repair has been evaluated and the short-term surgical outcomes are compared with conventional open repair (OPEN).

METHODS

All consecutive patients having repair of infrarenal AAA over a period of 3 years were included in this study. A group of these patients had AAA repair using the RAAE technique with a small midline incision (<8 cm). Patient characteristics and peri-operative outcomes were compared with the other group treated with the traditional full-length midline incision (OPEN).

RESULTS

Sixty patients underwent AAA repair in this study (38 in the RAAE group and 22 in the OPEN group). The age, sex distribution and co-morbidities were similar across the two groups (median age 76 and 75 years respectively). The RAAE group had a significantly shorter Intensive care stay (2 vs. 4 days, p=0.041) and a shorter total hospital stay (9 vs. 14 days, p=0.004). Significant postoperative chest infection was recorded in 13% (5/38) in the RAAE group as compared to 41% (9/21) in the OPEN group (p=0.025).

CONCLUSIONS

The RAAE technique for infra renal AAA repair is feasible and safe, and allows quicker postoperative recovery with comparable morbidity and mortality to the conventional technique.

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.

Total laparoscopic repair for abdominal aortic aneurysm

Surgical resection and grafting have long been the standard treatment for abdominal aortic aneurysm and provide an excellent long-term outcome. However, there is tremendous impact on patients due to the surgical invasiveness. Endovascular aortic repair using stent graft was introduced in 1991. After refinement of the techniques and technology, endovascular aortic repair was approved by most health authorities and is associated with less periprocedural morbidities. In between these two extremes, some surgeons endeavored to create an alternative and perform less invasive surgeries. Hand-assisted laparoscopic aortic surgery and laparoscopic-assisted aortic surgery were introduced in 1996. In 2001, total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was first performed in Canada. Till now, only a few vascular units in North America and Europe perform these delicate techniques. We report our first case of total laparoscopic abdominal aortic aneurysm repair. Laparoscopic aortic surgery provides better visualization of the aneurysm neck, less bowel manipulation and avoidance of hypothermia. The minimal invasiveness could translate to better perioperative outcome. To our knowledge, this is also the first case report in Asia. The detailed techniques are described.

Suture damage during robot-assisted vascular surgery: is it an issue?

BACKGROUND

Manipulation of sutures during endoscopic surgery could lead to damage of suture structure, supposedly resulting in loss of strength. Lack of tactile feedback in robotic surgical systems might increase this problem. The objective of this study is to evaluate suture strength after robotic manipulation and to determine which suture material is least susceptible to damage from robotic manipulation.

METHODS

The da Vinci surgical system was used to manipulate sutures. Three different suture materials (Prolene, ePTFE, Ethibond) of 3 different sizes (3-0, 4-0, and 5-0) were tested. A total of 270 sutures were pulled on a Servohydraulic Universal Testing Machine. The frequency of breaks at a manipulation-point and the maximum applied force (N) before the suture broke were used for statistic analysis.

RESULTS

No loss in strength was shown in the ePTFE sutures after manipulation, whereas both Prolene and Ethibond sutures showed a significant loss of strength.

CONCLUSIONS

ePTFE sutures are least susceptible to robotic manipulations and are, therefore, to be considered as a material of first choice.

Sobrevida tardia de pacientes submetidos à correção aberta eletiva de aneurisma de aorta abdominal

CONTEXTO: Os autores fazem uma revisão dos pacientes operados em hospital privado para determinar a causa da mortalidade tardia, a evolução dos demais segmentos da aorta e as complicações relacionadas à prótese. OBJETIVOS: Relatar o seguimento tardio de uma série de 76 casos operados eletivamente para a correção de aneurisma de aorta abdominal, no período de março de 1995 a janeiro de 2007. MÉTODOS: Convocação dos pacientes para uma consulta de retorno e daqueles que não puderam comparecer pessoalmente através de contato telefônico. RESULTADOS: A mortalidade operatória em 30 dias foi de 5,3%. A sobrevida tardia obtida por curva atuarial foi de 95% em 1 ano, 88% em 3 anos e 72% em 8 anos. As doenças cardiovasculares foram a principal causa de mortalidade tardia, seguidas das neoplasias malignas. A dilatação de segmento de aorta proximal à correção cirúrgica ocorreu em 9,7% dos pacientes operados, e as complicações relacionadas à prótese ocorreram em quatro casos (5,3%), sendo uma infecção de prótese, um pseudo-aneurisma proximal, um pseudo-aneurisma em ilíaca e uma oclusão de ramo. CONCLUSÃO: A cirurgia aberta para correção do aneurisma de aorta abdominal apresenta bom resultado em longo prazo, semelhante ao da literatura nacional e internacional, sendo uma boa opção para o paciente que tenha um baixo risco cirúrgico.

Laparoscopic aortorenal bypass in an acute porcine model under warm ischemia: feasibility study and resident training module

BACKGROUND AND PURPOSE

Laparoscopic aortorenal bypass (LARB) in a human being has never been reported. Both the skills required and the concern over preserving renal parenchyma by minimizing ischemia time has limited laparoscopic renal revascularization. The limit of safe renal warm ischemia is 30 minutes, which, it may be argued, is too short to permit laparoscopic anastomosis by those who have never performed the procedure. We sought to demonstrate the feasibility of LARB by determining whether it can be performed under warm ischemia and entirely by a resident after sufficient training. We describe our training program and experience with LARB.

MATERIALS AND METHODS

An LARB was performed in four pigs. There were no practice pigs, as data were collected on the first pig, which was intentionally euthanized postoperatively, while the remaining three were allowed to survive for 24 hours. All procedures were performed by a resident with limited previous training after a regimented program in a "dry laboratory," beginning with basic skills and progressing to LARB modeling using cadaver pig kidneys.

RESULTS

The mean time needed for the graft-to-aorta anastomosis was 30.5 minutes (range 21-47 inutes). The renal arterial anastomosis was completed within 30 minutes in three of the four animals, including the first animal attempted (24, 32, 19, and 15 minutes, respectively). The mean total operative time was 3.1 hours.

CONCLUSIONS

With continuing refinements in technique, LARB under warm ischemia is feasible and not only for an elite few surgeons with advanced skills. We believe any surgeon can become capable of performing this procedure. In addition, LARB provides a porcine model for training that includes both advanced skill and time endpoints.

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.

Direct videoscopic approach to the descending thoracic aorta for aortic arch endograft delivery: evaluation in a porcine model

PURPOSE

To examine the feasibility of a direct videoscopic approach to the descending thoracic aorta for endograft delivery to the aortic arch.

METHODS

A double purse-string suture was placed on the aorta of 3 pigs via a thoracoscopic approach. Subsequently, the aorta was cannulated in the center of the purse-string. A 22-F delivery catheter was advanced under fluoroscopic control over a guidewire via a trocar into the proximal aorta. After deployment of a tubular endograft, the catheter was withdrawn from the aorta while simultaneously tightening the purse-string suture, without aortic cross clamping. The outcome was evaluated by post implant angiography and autopsy results.

RESULTS

The procedure was successfully completed in all animals, with a mean total procedure time of 126 minutes (range 118-137). Mean endograft implantation time from needle puncture to catheter extraction was 27 minutes (range 21-37). Hemostasis was obtained in all animals after withdrawal of the delivery catheter and tightening the purse-string suture. The mean blood loss was 143 mL (range 80-220). Autopsy proved all purse-string sutures to be adequately placed and all endografts deployed in the correct position.

CONCLUSION

A direct videoscopic approach to the descending thoracic aorta proved a feasible technique for endograft delivery to the aortic arch in a porcine model.

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.

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.

Robotic Replacement of the Descending Aorta in Human Cadaver

Robot-assisted replacement of the thoracic aorta was performed in a human cadaver. Temporary shunt bypass was established by inserting a left axillary artery catheter and directing it through the aortic arch toward the right femoral artery through the abdominal aorta. The technique utilized the da Vinci surgical system inserted through the 4-cm supramammary working port and two additional thoracoscopic ports. The working port allowed the introduction of an endoscope, endoscopic instruments, and artificial graft and suture materials. The aorta was dissected using the robotic instruments and was clamped with two transthoracic clamps. After transaction of the aorta, a 20-mm polytetrafluoroethylene graft was cut and an end-to-end anastomosis was then performed with running 3-0 Prolene sutures with robotic instruments. The robotic system provides superior optics and allows for enhanced dexterity. Minimally invasive robotic replacement of the descending aorta is an effective procedure and may add benefits for both surgeon and patients.

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.