A novel technique combining laparoscopic and endovascular approaches using image fusion guidance for anterior embolization of type II endoleak

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

Type II endoleak (T2E) represents a frequent and often challenging complication of endovascular aneurysm repair (EVAR). Endovascular treatment is the standard and most used strategy, but the recurrence after it remains high, especially due to lumbar arteries (LA) and inferior mesenteric artery (IMA) feeding. While conventional laparoscopy has been considered as an emerging method, robotic surgery is not reported yet for this indication. We herein describe our technique of minimally invasive T2E repair using a full robotic approach with the da Vinci Xi, reporting our preliminary experience with the first two patients who underwent this operation at our Institution. The procedure comprises two phases. The first phase consists of IMA ligation, left colon mobilization and infra-renal exposure of the anterior longitudinal ligament of the column and of the left side of the sac. The second phase entails the posterior aneurysm mobilization and the selective clipping of LA responsible of the T2E, as identified by the pre-operative CT scan. No intra-operative complications occurred and the average length of surgery was 183 min. The average length of hospitalization was 2.5 days. Robotic T2E repair can be considered a safe procedure and the da Vinci Xi, thanks to its increased dexterity and flexibility, allows to easily perform this multi-target operation (IMA and LA). The articulated instruments with motion scaling and tremor filtering facilitate a gently vascular dissection and an easy IMA and LA identification, dissection, and ligation. The TilePro function permits the operator to control from the console, with intra-operative color-Doppler ultrasound, the absence of residual endoleaks.