Totally laparoscopic aortobifemoral bypass: A review of 22 cases

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.

Evaluation of Three-Dimensional Versus Conventional Laparoscopy for Kidney Transplant Procedures in a Human Cadaveric Model

OBJECTIVES

There are increased reports that kidney transplant can be performed by laparoscopic surgery. The further development of this technique could revolutionize human kidney transplant surgery. However, laparoscopic kidney transplant demands a high level of skill for vascular anastomoses. The emerging technology of the three-dimensional, high-definition laparoscopic system may facilitate the application of this technique. Therefore, in this study, we evaluated this system in performing kidney transplant surgery versus the two-dimensional laparoscopic system.

MATERIALS AND METHODS

Four fresh-frozen human cadavers were used in this study, with 2 for the 3-dimensional and 2 for the 2-dimensional system. Kidneys were retrieved by using the retroperitoneoscopic technique for living donor nephrectomy from the same cadaver. The kidney graft was transplanted at the right iliac fossa using a laparoscopic technique by extraperitoneal approach. The procedure was recorded, and the vessel anastomotic time was analyzed.

RESULTS

Kidney transplant procedures were conducted successfully in the 3-dimensional, high-definition and the 2-dimensional groups. We recorded no significant differences in terms of vessel anastomotic time between the 2 groups. The total surgery time was shorter in the 3-dimensional, high-definition group than in the 2-dimensional group (P = .02).

CONCLUSIONS

This pilot study reinforces that kidney transplant with either the 3-dimensional, high-definition or 2-dimensional laparoscopy is feasible in a human cadaveric model. The operation was the same as open kidney transplant, but the procedure was performed by a laparoscopic approach with a smaller incision.

Long-term Results of Totally Laparoscopic Aortobifemoral Bypass

OBJECTIVES

The aim was to estimate the long-term results and patency rates of totally laparoscopic aortobifemoral bypass in aorto-iliac occlusive disease (AIOD).

METHODS

All 87 patients who received a laparoscopic aortobifemoral bypass for AIOD on an intention to treat basis between October 2003 and October 2013 were identified. All operations were performed by the same surgical team using a totally laparoscopic technique. Demographic, pre-operative, peri-operative, and follow up variables were collected and analyzed. Patients were followed up at 1 month post-operatively and annually thereafter. Patency rates were calculated in accordance with published patency reporting standards.

RESULTS

The median age was 57 years (range 40-78 years). The conversion rate was 20.6% overall. The thirty-day post-operative mortality was 1.1%. Six patients required early re-intervention. There were no graft infections. The median length hospital stay was 6 days (range 4-39 days). The mean follow up was 58.0 months (range 1-133 months). Graft limb based primary, primary assisted, and secondary patency rates were respectively 96.1%, 98.1% and 99.4% at 1 year, and 83.0%, 92.0% and 97.0% at 5 years.

CONCLUSION

Totally laparoscopic aortobifemoral bypass is a safe alternative to open surgery in selected patients, with excellent long-term patency rates, albeit at the cost of a steep learning curve.

Preliminary results from a prospective study of laparoscopic aortobifemoral bypass using a clampless and sutureless aortic anastomotic technique

OBJECTIVE

This prospective study describes the feasibility and safety of a new clampless and sutureless aortic anastomotic technique used during retroperitoneal laparoscopic aortobifemoral bypass in extensive aortoiliac occlusive lesions. This is a case series of a previously published technique, demonstrating wider applicability of the technique.

MATERIALS AND METHODS

Twelve patients underwent a clampless and sutureless laparoscopic bypass for TASC D aortoiliac occlusive lesions using the EndoVascular REtroperitoneoScopic Technique (EVREST). Dissection of the retroperitoneal space and the infrarenal aorta was performed laparoscopically. A bifurcated graft was inserted into the retroperitoneal space. The main body of the graft was connected on the left side of the aorta by an intra- and extra-aortic covered stent-graft. An aortic clamp was used temporarily on four patients because of excessive bleeding when the connector was deployed. The femoral anastomoses were performed by classic open surgery. Initial technical success, complications, and bypass patency were assessed.

RESULTS

Median follow-up was 9.3 months. Median operative time was 265 minutes. Median duration of aorto-prosthetic connection was 60 seconds. Thirty-day postoperative mortality was 0%. No major postoperative complications were observed. All grafts were patent at the end of follow-up and there was no early or late disruption of the proximal assembly.

CONCLUSIONS

EVREST greatly facilitates laparoscopic aortic surgery in occlusive disease with no need for suture or clamping of the aorta. This technique performed in a single center on 12 patients, seems to be feasible and safe. It offers the advantages of laparoscopy and those of endovascular surgery, especially in the challenging conditions encountered during aortic laparoscopic surgery. Early experience supports procedural and initial postprocedural safety and demonstrates proof-of-concept for EVREST.

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.

Total laparoscopic repair of abdominal aortic aneurysm with short proximal necks

With the development of endovascular aneurysm repair, abdominal aortic aneurysms with short infrarenal necks (< or =10 mm, AAASN) are considered juxtarenal aneurysms. Minimally invasive treatment consists of hybrid procedures or fenestrated endografts. We present our experience with direct aortic repair for AAASN performed via a total laparoscopic approach. Data are expressed as median values with extremes. From February 2002 to December 2007, 32 patients had total laparoscopic AAASN repair. Length of the infrarenal aortic neck was 5 mm (0-10). Median age of the 29 men and three women was 70 years (range 50-84). Nine patients presented with preoperative grade 1 renal insufficiency (28.1%). The procedure was totally laparoscopic in 30 patients (93.7%). Aortic approaches included left retrorenal (n = 24) and transperitoneal left retrocolic (n = 8) exposures. Median operative and clamping times were 270 (range 215-410) and 83 (range 36-147) min, respectively. Aortic clamping was suprarenal in 14 cases (43.7%), with suprarenal clamping time of 24 min (range 9-37). Median blood loss was 850 mL (range 215-2,400). Thirty-day mortality was 3.1% (one patient died from myocardial infarction). Two patients presented with severe systemic complications (6.4%, postoperative coagulopathy with hemorrhagic syndrome, pneumopathy). Seventeen patients developed mild or moderate systemic nonlethal complications (53.1%): transient renal insufficiencies (n = 12), grade 1 ischemic colitis (n = 1), surrenal insufficiency (n = 1), myocardial ischemia (n = 1), and cardiac arythmia (n = 2). One patient was reoperated for an intestinal obstruction. Liquid diet was reintroduced after 1 day (range 1-13). Most patients were ambulatory by day 3 (range 2-17). Median lengths of stay were 48 hr (range 12-552) in the intensive care unit and 10 days (range 4-37) in the hospital. With a median follow-up of 27 months (range 1-50), 28 patients are alive, with complete recovery without graft anomalies. Three patients died, from pneumopathy (n = 1) and carcinoma (n = 2), respectively, at 29, 19, and 44 months' follow-up. Two patients presented stable juxta-renal aortic dilation <35 mm. Total laparoscopic juxtarenal AAA repair is feasible and worthwhile for patients with AAASN. Short- and midterm results match well with those of open surgery. Total laparoscopic repair in AAASN reduces the trauma of extensive surgical approaches. Based on these encouraging early results, we elected to perform laparoscopy whenever possible in good surgical risk patients with AASN.

Early Experiences of Laparoscopic Aortofemoral Bypass in Korea-report from a Single Center

Although endovascular approach can be widely applied to occlusive aortoiliac segment, aortofemoral bypass (AFB) continues to offer superior long term patency. In an effort to reduce the morbidity of AFB, LAFB (laparoscopic AFB) has been developed. We report our initial experiences to determine the feasibility and safety. From September 2005 to May 2008, LAFB was performed in 12 patients. A transabdominal retrocolic approach with pneumoperitoneum or direct approach was preferred. LAFB consisted of aortic dissection, vascular control with or without intracorporeal anastomosis. Last two cases were performed using da Vinci system for secure proximal anastomosis as an end to side fashion. Laparoscopic procedures were successfully performed in 11 patients. One patient underwent open conversion due to small bowel injury and bleeding. Mean operating time and aortic clamping time was 446 minutes and 87.5 minutes. The time to return of bowel function was about 2.1 days (2.1 ± 1.2). Compartment syndrome was developed in one patient at immediate postoperatively. During this study period, operating time was shown in decreasing tendency. Although LAFB is challenging procedure with steep learning curve, it is feasible technique and appears to ease patient's postoperative course.

Laparoscopic Diagnosis and Treatment of Aortic Vascular Prosthetic Graft Infections in a Porcine Model

OBJECTIVES

To study the feasibility and efficacy of experimental laparoscopy in the diagnosis of aortic graft infection in pigs.

MATERIAL AND METHODS

Eight pigs had an aortic tube graft implanted and inoculated with either 5 x 10(4) or 10(6) CFU of Staphylococcus aureus ATCC 29213. Laparoscopy was performed after a median of 20 days with debridement and sampling for bacterial culture. Thereafter, the grafts were locally soaked in rifampicin and postoperatively, the pigs received rifampicin and ciprofloxacin orally for two weeks and were then sacrificed.

RESULTS

All pigs developed graft infection. One pig died from severe clostridial septicaemia before laparoscopy could be performed. The remaining pigs had all samples for bacterial culture taken by laparoscopy from the inflamed tissue. The temperature dropped significantly after laparoscopy, and no macroscopic signs of infection presented at autopsy. However, only culture from one pig was without S. aureus at autopsy.

CONCLUSIONS

Laparoscopy is a potential diagnostic tool for aortic graft infection and also affords the opportunity to carry out bacteriological sampling and local antibiotic treatment. The efficacy of laparoscopic treatment needs further evaluation.

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.

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.

Hand assisted laparoscopic surgery of aortoiliac occlusive disease: initial results

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic aortic reconstruction: early experience

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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