Total laparoscopic abdominal aortic aneurysm repair with reimplantation of the inferior mesenteric artery

Successful reimplantation of the hypertrophied inferior mesenteric artery during an open abdominal aortic aneurysm repair

Ischemic colitis is the most common form of an iatrogenic intestinal ischemia following an aortic surgery. It can be transient and self-limiting but, when severe, is associated with mortality even as high as 80%. Careful preoperative assessment can help to anticipate the need for the inferior mesenteric artery (IMA) reimplantation. Some patients lack the sufficient collateral blood supply to the colon and can benefit from the IMA reimplantation, which not only reduces the risk of postoperative colonic necrosis but also can be lifesaving. We report a case of a successful reimplantation of the IMA based on the careful preoperative planning. If unrecognized, this undoubtedly would lead to postoperative colonic ischemia. Therefore, we feel it is important to share our experience regarding the successful management of the presented case.

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.

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 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.