Laparoscopic-assisted abdominal aortic aneurysmectomy

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.

Systematic review of perioperative outcomes following laparoscopic abdominal aortic aneurysm repair

OBJECTIVE

To collate information available in the literature regarding perioperative outcomes following elective laparoscopic abdominal aortic aneurysm repair.

MATERIALS AND METHODS

Electronic databases were searched and a systematic review was performed. In total, 1256 abstracts were screened, from which 10 studies were included for analysis. Perioperative and technical outcomes were analysed.

RESULTS

In the totally laparoscopic repair of infra-renal aneurysms (n = 302), 30-day mortality ranged between 0% and 6% and in the laparoscopic-assisted cases (n = 547) ranged between 0% and 7%. Of the former group, 5-30% of cases were converted to open repair, with 6% reintervention rate, whereas there was a 5-10% conversion and 3% reintervention rate in the latter group.

CONCLUSIONS

The outcomes from selected patients in selected centres demonstrate that elective laparoscopic repair of aortic aneurysms is feasible and comparable in safety to open repair; it remains unclear, however, whether there are substantial advantages of this method compared with open and endovascular repair.

Minilaparotomy abdominal aortic aneurysm repair in the era of minimally invasive vascular surgery: preliminary results

BACKGROUND

This study aimed to evaluate the early post-operative clinical impact of minimal incision aortic surgery (MIAS) for infrarenal abdominal aortic aneurysm (AAA) repair in comparison with the standard open repair.

METHODS

A case-control study was conducted. Patients of groups A (19 patients) and B (18 patients) were treated with the MIAS technique and the standard open method, respectively.

RESULTS

There were significant differences between the two groups in fluid resuscitation during the operation. Post-operatively, there were significant differences between groups A and B in the time until starting liquid diet (2 +/- 0.74 versus 3.55 +/- 0.85 post-operative days (PD), respectively; P < 0.05), the time until starting the solid diet (3.05 +/- 0.77 versus 5.11 +/- 0.75 PD, respectively; P < 0.05), the time of ambulation (2 +/- 0.74 versus 3.4 +/- 0.98 PD, respectively; P < 0.05) and in the hospital length of stay (4 +/- 0.81 versus 9.7 +/- 2.66 days, respectively; P < 0.05).

CONCLUSIONS

The MIAS technique, for repair of infrarenal aortic aneurysms, is a safe and feasible procedure that combines the early advantages of endovascular repair with the long-term advantages of the traditional open repair.

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.

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.

A Modified Technique of Transperitoneal Direct Approach for Totally Laparoscopic Aortoiliac Surgery

OBJECTIVE

To present our modification of the transperitoneal direct approach (TDA) for totally laparoscopic aortoiliac surgery.

METHODS AND RESULTS

From September 2003 to August 2005 a total of 52 patients underwent laparoscopic operations for aortoiliac disease (50 aortoiliac occlusive disease; two abdominal aortic aneurysm). The modified TDA was used in 20 patients.

CONCLUSION

The main advantage of TDA is reduced dissection of the aorta and pelvic arteries resulting in lowered blood loss and lymphatic injury.

A Laparoscopic Access Technique for Endovascular Procedures:Surgeon Training in an Animal Model

PURPOSE

To present a laparoscopic technique for placing a transperitoneal conduit in the common iliac artery (CIA) or distal aorta to circumvent stenosed or occluded iliac systems and to assess the success of this laparoscopic access in a live animal model.

TECHNIQUE

A porcine model was used owing to similarities in anatomy and size of the pig aorta to the human common iliac artery (CIA). Ethical approval was obtained, and the technique was developed in 8 animals under general anesthesia. A curved hollow needle, a partially stented Dacron conduit, an airtight laparoscopic port and a sealing sheath and valve were developed specifically for percutaneous access through the abdominal wall. A transperitoneal approach was used to the distal aorta. Cannulation by the curved hollow needle via the new port was under direct vision. The conduit was inserted over a guidewire after needle removal and deployed under fluoroscopy. The distal end of the conduit was secured by the sealing sheath and valve, enabling wire and catheter exchange thereafter. A 2-day educational workshop was held for 12 vascular surgeons with a range of laparoscopic experience. After learning the technique on a simulator model, they worked in pairs, alternating surgeon/assistant roles to insert conduits into 12 animals under general anesthesia. Laparoscopic cannulation in all 12 animals was successful. There was no bleeding around the conduit at the aortic arteriotomy. All animals were euthanized after confirmation of conduit patency by back-bleeding.

CONCLUSION

This novel technique bridges the gap between laparoscopic and endovascular techniques in striving for minimally invasive solutions to the treatment of vascular disease. Adaptation to human beings is currently underway and will mean increasing the applicability of endovascular solutions to those patients in whom it would otherwise be denied. The technique would appear not to require specialist laparoscopic skills.

Laparoscopy-assisted abdominal aortic aneurysm repair: Early and middle-term results of a consecutive series of 122 cases

BACKGROUND

Endoaneurysmorrhaphy with intraluminal graft placement, described by Creech, is the gold standard for abdominal aortic aneurysm (AAA) repair. Endovascular aneurysm repair has gained popularity for its minimal invasiveness and satisfying short-term results, but there are still many concerns about the long-term success of the procedure. Since 1998, laparoscopic surgery has been proposed for AAA treatment. The potential benefits of a minimally invasive procedure reproducing the endoaneurysmorrhaphy results over time have been advocated. In our experience, hand-assisted laparoscopic surgery (HALS) has been routinely used for the open-surgery transperitoneal/retroperitoneal approach and for endovascular aneurysm repair. After 4 years, we are able to define the early and middle-term results of such laparoscopic-assisted treatment.

METHODS

From October 2000 to March 2004, 604 consecutive nonurgent AAAs were treated at our institution. Of these, 122 (20.2%) were treated by HALS. Exclusion criteria for HALS were hostile abdomen (previous major abdominal or aortic surgery), bilateral diffuse common iliac and/or hypogastric aneurysms, massive aortoiliac calcifications, and severe cardiac (ejection fraction <35%) and respiratory (P(O2) <60 mm Hg or carbon dioxide >50 mm Hg) insufficiency. Juxtarenal and proximal iliac aneurysms were not a contraindication, nor was obesity. In all patients, we performed a minilaparotomy (7-8 cm) both for laparoscopic hand-assisted dissection and for endoaneurysmorrhaphy. All perioperative data were prospectively recorded. Follow-up consisted of ultrasonography and clinical evaluation after 6 and 12 months and then every year after surgery.

RESULTS

The mean laparoscopic and total operative times were respectively 64 +/- 32 minutes and 257 +/- 70 minutes, the mean aortic cross-clamping time was 76 +/- 26 minutes, and the mean autotransfused blood volume was 1136 +/- 711 mL. The overall mortality and morbidity were respectively 0% and 12.2%. Morbidity was surgery related in only two cases (bleeding from an ipogastric artery lesion and a leg graft thrombosis). The mean intensive care unit stay was 14.3 +/- 13 hours. Oral food intake was resumed after 27.4 +/- 15 hours, and patients were discharged after a mean of 4.4 +/- 1.7 days. Operative times were not affected by obesity, suprarenal aortic cross-clamping, or aneurysm size. Both concomitant iliac aneurysms and bifurcated graft implantation (related to longer vascular reconstruction) involved significantly longer operative times. The learning curve of the procedure (comparing the first 30 patients with the last 92 patients) led to significantly shorter endoscopic, cross-clamping, and total operative times (P = .000). The mean follow-up was 28.6 +/- 16 months. Three incisional hernias and one case of bowel occlusion were detected. All these cases (3.4%) required laparoscopic treatment.

CONCLUSIONS

The HALS technique is a safe and minimally invasive treatment for AAA; it is useful for limiting the need for conventional open surgery and reducing the length of hospital stay. Despite the lack of randomized studies, HALS seems to be associated with a better postoperative course than standard open surgery. HALS can also be considered as an equivalent of a well-established procedure and as a bridge between open and total laparoscopic surgery.

Total laparoscopic versus conventional abdominal aortic aneurysm repair: A case-control study

PURPOSE

This study was designed to identify differences in the per- and postoperative outcomes between total laparoscopic and open surgical repair of abdominal aortic aneurysms (AAA).

METHODS

We reviewed 30 patients who underwent total laparoscopic AAA repair between July 2003 and December 2004 (group I). This group was matched in a case-control fashion by AAA morphology and American Society of Anesthesiologists class with a group of 30 patients who underwent conventional AAA repair between April 1997 and May 2004 (group II). Proportions and categoric data were compared with a chi(2) test. Continuous data were compared with a Mann-Whitney test.

RESULTS

The two groups had comparable characteristics of age and cardiovascular risk factors. The number of tube and bifurcated grafts was 13 for group I and 17 for group II. Median operative time was 255 minutes (range, 170 to 410 minutes) in group I and 200 minutes (range, 130 to 410) in group II (P <.001). Median aortic clamping time was 80 minutes (range, 35 to 110 minutes) in group I and 50 minutes (range, 24 to 150 minutes) in group II (P < .0001). Total blood loss was 1600 mL (range, 400 to 4000 mL) for group I vd 1000 mL (range, 100 to 2900) for group II (P < .01). The mortality rate was 3.3% for group I (1 patient) vs 6.6% (2 patients) for group II (NS). There were no significant differences between the two groups in terms of postoperative systemic complications (23.3% vs 30%, NS) and local and vascular complications (10% vs 3.3%). Duration of ileus (2 vs 3 days, P < .05), return to normal diet (4 vs 8 days, P < .0001), day of ambulation (3 vs 4 days, P < .05) and dose of narcotics (3.5 mg vs 28.5 mg, P < .05) were significantly lower in group I. Median length of intensive care unit stay was similar between the two groups (48 hours). Median hospital stay was lower in group I but without significant differences with group II (9 vs 11 days, NS).

CONCLUSION

This case-control study provides preliminary results that short-term outcomes of total laparoscopic AAA repair are comparable with those of open surgery. Peroperative data demonstrate that laparoscopy is more technically demanding than open repair. However, the technical challenge of laparoscopy does not worsen the postoperative course.

[Prevention of venous thromboembolism following cardiac, vascular or thoracic surgery]

In the absence of thromboprophylaxis, coronary artery bypass graft surgery (CABG), intrathoracic surgery (thoracotomy or video-assisted thoracoscopy), abdominal aortic surgery and infrainguinal vascular surgery are high-risk surgeries for the development of venous thromboembolic events (VTE). The incidence of VTE following surgery of the intrathoracic aorta, carotid endarterectomy or mediastinoscopy is unknown. Data from the litterature are lacking to draw evidence-based recommandations for venous thromboprophylaxis after these three types of surgeries, and the following guidelines are but experts'opinions (Grade D recommendations). Thromboprophylaxis is recommended after CABG (Grade D), with either subcutaneous (SC) low molecular weight heparin (LMWH) or SC or intravenous (i.v.) unfractioned heparin (UH) (PTT target = 1.1-1.5 time control value) (both grade D). This may be combined with the use of intermittent pneumatic compression device (Grade B). After valve surgery. The anticoagulation recommended to prevent valve thrombosis is sufficient in order to prevent VTE. We recommend thromboprophylaxis with either LMWH or low dose UH to prevent VTE after aortic or lower limbs infrainguinal vascular surgery (both grade B and D). Vitamine K antagonists (VKA) are not recommended in this indication (Grade D). We recommend thromprophylaxis following intrathoracic surgery via thoracotomy or videoassisted thoracoscopy (grade C). Either subcutaneous LMWH or subcutaneous or i.v. low dose UH may be used (Grade C). Efficacy of intermittent pneumatic compression device has been demonstrated in a study (grade C). VKA are not recommended (grade D). No further recommendation regarding the duration of thromboprophylaxis after these three types of surgeries can be made.

Laparoscopic vascular anastomoses: does robotic (Zeus–Aesop) assistance help to overcome the learning curve?

BACKGROUND

Considerable training is necessary to master laparoscopic suturing and knot-tying. Robotic systems are assumed to facilitate these skills and shorten the learning curve. The effect of laparoscopic experience and robotic assistance on the learning curve of vascular anastomoses was studied.

METHODS

A laparoscopically experienced surgeon and a laparoscopically inexperienced surgeon made alternating laparoscopic vascular anastomoses and robot-assisted laparoscopic vascular anastomoses using a Zeus-Aesop surgical robotic system with various prosthetic conduits and suture materials in a laparoscopic training box.

RESULTS

Neither laparoscopic method influenced the quality score or leakage rate, but with laparoscopic experience, significantly fewer failures were made. Suturing and knot-tying were faster with laparoscopic experience both with and without the robotic system, and fewer stitch actions and knot actions were performed. The learning curves of both surgeons were not improved by the robotic system.

CONCLUSIONS

Experience is the most important factor in the performance of laparoscopic vascular anastomoses. The robotic system was not helpful in shortening the learning curve.

Treatment of infrarenal aortic aneurysm by minimally invasive retroperitoneal approach: use of a video-assisted technique

We propose a technique for treating abdominal aortic aneurysm in which first a minilaparotomy (retroperitoneal) is performed to make a conventional arterial dissection; then, video assistance is used to control the left lumbar arteries and to make the aortic anastomosis. This technique can be performed with no significant laparoscopic capability.The patient was installed in a 20-degree right lateral decubitus. A transverse left 8- to 10-cm abdominal incision was made, followed by separation of the muscular structures. Retroperitoneal control of the proximal aortic neck and of both common iliac arteries was obtained by digital and instrumental dissection. A 30-degree laparoscope was then introduced through a 8- to 12-mm trocar and provided the light and magnification that facilitated the dissection of the posterior wall of the aortic neck and of the left flank of the aneurysm, looking for the lumbar arteries to be clipped. A suspended running suture to make the aorto-prosthetic anastomosis was facilitated by the magnification of the camera, especially during the passage of needles. Between March and September 2001, 32 patients fulfilled the anatomic conditions: an infrarenal aortic neck length of 2 cm or more, absence of hypogastric artery aneurysm, and no need for inferior mesenteric artery reimplantation. In 30 patients, the surgery was performed by using the planned minimally invasive approach, and extension of the incision was necessary in two patients.

Total laparoscopic infrarenal aortic aneurysm repair: Preliminary results

OBJECTIVES

We describe our initial experience of total laparoscopic abdominal aortic aneurysm (AAA) repair.

MATERIAL AND METHODS

Between February 2002 and September 2003, we performed 30 total laparoscopic AAA repairs in 27 men and 3 women. Median age was 71.5 years (range, 46-85 years). Median aneurysm size was 51.5 mm (range, 30-79 mm). American Society of Anesthesiologists class of patients was II, III and IV in 10, 19, and 1 cases, respectively. We performed total laparoscopic endoaneurysmorrhaphy and aneurysm exclusion in 27 and 3 patients, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 27 patients. We operated on 2 patients via a tranperitoneal left retrorenal approach and 1 patient via a retroperitoneoscopic approach.

RESULTS

We implanted tube grafts and bifurcated grafts in 11 and 19 patients, respectively. Two minilaparotomies were performed. In 1 case, exposure via a retroperitoneal approach was difficult and, in another case, distal aorta was extremely calcified. Median operative time was 290 minutes (range, 160-420 minutes). Median aortic clamping time was 78 minutes (range, 35-230 minutes). Median blood loss was 1680 cc (range, 300-6900 cc). In our early experience, 2 patients died of myocardial infarction. Ten major nonlethal postoperative complications were observed in 8 patients: 4 transcient renal insufficiencies, 2 cases of lung atelectasis, 1 bowel obstruction, 1 spleen rupture, 1 external iliac artery dissection, and 1 iliac hematoma. Others patients had an excellent recovery with rapid return to general diet and ambulation. Median hospital stay was 9 days (range, 8-37 days). With a median follow-up of 12 months (range, 0.5-20 months), patients had a complete recovery and all grafts were patent.

CONCLUSION

These preliminary results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. However, prior training and experience in laparoscopic aortic surgery are needed to perform total laparoscopic AAA repair. Despite these encouraging results, a greater experience and further evaluation are required to ensure the real benefit of this technique compared with open AAA repair.

Minimally invasive retroperitoneal approach for the treatment of infrarenal aortic disease

PURPOSE

In order to decrease complications and improve postoperative recovery, we have developed a minimally invasive retroperitoneal approach (MIRPA) for the treatment of infrarenal aortic disease. This study was carried out to define the limitations and applicability of this technique in the treatment of aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysms (AAAs).

METHODS

From November 2000 to February 2004, 150 patients with AAA (n = 130) or AIOD (n = 20) were prospectively included in the study. The procedure consisted in a standard aneurysmorrhaphy or bypass procedure performed through a video assisted left minilombotomy.The main outcomes measured were mortality, complications, operative time, aortic cross-clamp time, time to solid diet, and length of intensive care unit and hospital stay.

RESULTS

Operative mortality was 0.7 %. Nonfatal postoperative complications occurred in 12 patients (8%). Conversion to a standard procedure was necessary in 3 patients. Mean operative time was 207 +/- 57 minutes (AAA) and 224 +/- 55 minutes (AIOD). Mean aortic cross-clamp time was 76 +/- 26 minutes (AAA) and 48 +/- 21 minutes (AIOD). Median resumption of regular diet was 2 days. Median length of stay in the intensive care unit was 1 day and in the hospital 8 days.

CONCLUSION

Our results suggest that MIRPA is a safe and effective minimally invasive procedure in the treatment of infrarenal aortic disease.

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

BACKGROUND

Laparoscopically assisted aortic aneurysm resection requiring a minilaparotomy can be performed as a routine procedure. It was the purpose of our study to evaluate whether a total laparoscopic operation can be offered to aneurysm patients as a minimally invasive alternative. We also wanted to test whether a master-slave robot could facilitate the total laparoscopic procedure.

METHODS

A prospective, consecutive number of 50 patients was evaluated. A transperitoneal left retrocolic access was used to expose the aorta. If possible, a tube graft repair was performed. The aortic anastomosis was sutured totally laparoscopically, with the surgeon standing on the right side of the operating table. In 10 consecutive patients, the anastomosis was sutured with the help of the Zeus robot.

RESULTS

After excluding 3 cases that required suprarenal cross-clamping, 47 patients were operated using a total laparoscopic approach. A totally laparoscopic operation could be performed successfully in 39 patients with aneurysms. In 8 patients (17%), conversion to a laparoscopic hand-assisted operation with a 7-cm minilaparotomy was required. The robot was used to perform the aortic anastomosis in 10 patients. In 8 patients, a tube graft repair could successfully be performed totally laparoscopically. In the remaining patients, a bifurcated graft was implanted laparoscopically. The mean operating time was 227 minutes in the laparoscopy group and was 242 minutes in those patients in whom the anastomosis was sutured with the help of the Zeus Robot. Mean cross-clamping time, +/- SD, was 81.4 + 31 minutes. None of the patients died perioperatively. Major complications occurred in three patients (6.3%). The overall morbidity was 14.8%, including one patient who required temporary hemodialysis postoperatively. The time to suture the aortic anastomosis was significantly shorter in the robotic-assistance group (40.8 +/- 4 minutes), yet total operating time was longer in this group because of the technical complexity of the robotic device. Patients with a total laparoscopic procedure asked for significantly fewer analgesics and could regain full mobility earlier compared with those patients for whom a minilaparotomy after conversion to the laparoscopic hand-assist procedure was required.

CONCLUSIONS

Total laparoscopic aneurysm resection can be offered to the majority of patients in our institution. The robot still requires further refinements to reduce operating times and the aortic cross-clamping period. We now have the technique and the instrumentation to offer laparoscopic aneurysm surgery as a minimally invasive alternative for patients whose conditions are unsuitable for endovascular aneurysm repair.

Comparison of minimal incision aortic surgery with endovascular aortic repair

BACKGROUND

Enthusiasm for endovascular aortic repair (EVAR) has been tempered by midterm outcomes that raise valid concern about long-term durability.

METHODS

This article compares outcome data from a prospective nonrandomized comparison of a less-invasive open surgical repair technique-minimal incision aortic surgery (MIAS)-and EVAR.

RESULTS

MIAS and EVAR had comparable intensive care unit stays (1 day or less), quick return to general dietary feeding (2 days), and comparable hospital length of stay (4.8 days [3.4 days for uncomplicated cases MIAS] and 2.0 days for EVAR). Overall morbidity and mortality for MIAS and EVAR were comparable (18% versus 27%). MIAS was more cost effective than EVAR (net revenue MIAS = +8,445 US dollars, EVAR -7,263 US dollars).

CONCLUSIONS

MIAS is a safe, cost-effective alternative to endovascular aortic repair.

Laparoscopy-assisted abdominal aortic aneurysm endoaneurysmorraphy: early and mid-term results

OBJECTIVES

This study was undertaken to evaluate the consequences on patient selection and on early and mid-term results during the learning curve of a surgical team performing laparoscopy-assisted surgery to treat abdominal aortic aneurysm (AAA).

PATIENTS AND METHODS

Between December 1998 and January 2002, 24 patients (22 men, 2 women; mean age, 68.2 years [range, 57-82 years]) were included in a prospective study and underwent laparoscopic transperitoneal AAA dissection followed by graft implantation through a 6 to 9 cm minilaparotomy. Perioperative data for the first 10 patients, obtained during the first 25 months of the study (group 1), were compared with data for the last 14 patients, obtained during the last 13 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomographic scanning before discharge and yearly thereafter.

RESULTS

One patient (4.3%) died in the immediate postoperative period. In this patient and two others (12.5%), the minilaparotomy was extended intraoperatively, from 12 cm to 16 cm. With experience, initial contraindications such as obesity and short proximal or calcified aortic neck were eliminated, enabling increase in rate of patients included, from 27.7% during the first 25 first months to 56% during the last 13 months (P =.063). Mean duration of operative clamping decreased from 275 minutes in group 1 to 195 minutes in group 2 (P <.0001), and mean duration of aortic clamping decreased from 101 minutes in group 1 to 52 minutes in group 2 (P <.0001). The number of early repeat interventions was reduced from 3 (30%) in group 1 to 2 (14.3%) in group 2 (P =.61), and clinical recovery period decreased from 6.8 days to 4.3 days (P <.005). During mean follow-up of 17.1 months (range, 3-38 months), no late aortoiliac procedures were necessary and no prosthetic abnormality was detected.

CONCLUSION

This minimally invasive video-assisted technique provides good postoperative comfort and excellent mid-term results. Developments in experience and instrumentation have enabled us to include a growing number of patients and to reduce the duration of the procedure.

Can minilaparotomy abdominal aortic aneurysm repair be performed safely and effectively without special skills?

BACKGROUND

The purpose of this study was to determine whether a surgeon without special skills can perform minimal incision abdominal aortic aneurysm repair as safely and effectively as traditional retroperitoneal aneurysmectomy.

METHODS

After informed consent, eligible patients were randomized into minilaparotomy and retroperitoneal groups. The minilaparotomy repair consisted of a short transabdominal midline incision, intraabdominal retraction of the bowel, control of back bleeding with balloon catheters, and hand-sewn anastomoses. The retroperitoneal approach was performed through a left vertical-lateral abdominal incision.

RESULTS

Twenty-six patients were randomly treated by minilaparotomy approach (n = 14) or retroperitoneal approach (n = 12) from December, 1999, to May 2001. Parameters for speed of recovery were indistinguishable and of no clinical significance. In the long-term follow-up (mean period, 27 months), no patients in the minilaparatomy group complained of discomfort from the incision, whereas 4 patients in the retroperitoneal group complained of discomfort (P < 0.05).

CONCLUSIONS

Minilaparotomy approach can be performed safely and effectively without specialized skill. With regard to wound discomfort, the minilaparotomy technique is excellent. The minilaparotomy approach is therefore a useful alternative to traditional repair.

Totally laparoscopic juxtarenal aortic anastomosis: an experimental study

The surgical management of juxtarenal aneurysms necessitates suprarenal aortic clamping and control of the renal arteries. We attempted to reproduce this procedure laparoscopically. Five female piglets were submitted to a totally laparoscopic approach of the aortoiliac segment. After laparoscopic control of the renal arteries and suprarenal clamping, a 6-mm Dacron tube graft was anastomosed to the juxtarenal aorta. After the procedure, a midline laparotomy allowed verification of the patency of the renal arteries and the quality of the anastomosis. Mean operative time was 198 minutes (range, 170-240 minutes). The dissection took an average of 92 minutes (range, 75-110 minutes). The mean suprarenal aortic cross-clamp time was 46.3 minutes (range, 29.1-81.5 minutes), and the mean anastomotic time was 28.9 minutes (range, 16.5-68.1 minutes). This study demonstrates in this animal model the feasibility of juxtarenal aortic anastomosis using a laparoscopic technique. Newly designed instruments should allow a shorter clamping time in the future.

Minimal incision aortic surgery (MIAS)

This study evaluates the clinical and economic impact of using less extensive minimal invasive aortic surgery (MIAS) for elective treatment of infrarenal aortic aneurysms (AAA) and aortoiliac occlusive disease (AIOD) in two independent surgical departments. Surgeons from two institutions conducted a prospective consecutive, nonrandomized analysis of MIAS electively performed in 80 patients. MIAS outcomes were compared with 80 consecutive elective standard open aortic procedures (40 from each institution), which were performed during the same time period. Cost analyses for MIAS and standard open repair were performed at each institution. Our results indicated that MIAS is as safe as standard open repair, is more cost-effective, and has significantly shorter hospital stays than with standard open repair.

[Laparoscopic aortoiliac surgery for occlusive disease and or aneurysms]

The techniques of video-assisted surgery have been recently applied to aortoiliac surgery. The choices between first the retroperitoneal approach or the transperitoneal approach and the place of video-assisted surgery in relation to totally laparoscopic surgery are at the centre of debates. The aim of this clarification is to relate the evolution of laparoscopic aortoiliac surgery for occlusive disease and aneurysms through a review of the literature on this subject.

Less-invasive thoracic aortic aneurysm repair

To minimize surgical trauma, we performed graft replacement of a descending aortic aneurysm through a minithoracotomy (12 cm) with the use of thoracoscopy and special vascular clamps. Contrast magnetic resonance angiography can be useful for preventing postoperative paraplegia by revealing the Adamkiewicz artery. The patient was satisfied with the postoperative comfort and good cosmetic result. Further refinement of the technique and instrumentation would make this technique a valuable adjunct to conventional thoracic aortic surgery.

A laparoscopic approach to the abdominal aorta for thoracic stent-graft deployment: evaluation in a porcine model

PURPOSE

To develop laparoscopic techniques for aortic stent-graft placement as an alternative to the femoral approach.

METHODS

Endovascular stent-grafts were placed in 8 pigs via a totally laparoscopic retroperitoneal approach. After needle puncture, a guidewire was inserted into the abdominal aorta, followed by an 18-F sheath through which a Talent stent-graft was deployed in the descending thoracic aorta without aortic clamping. All the endovascular tools were inserted into the retroperitoneal area via the ports. After the sheath was withdrawn, hemostasis was achieved by suturing the aortic puncture under aortic cross-clamping. After sacrificing the animals, the thoracic aorta was removed to verify the position and deployment of the stent-grafts.

RESULTS

Seven (87.5%) of 8 procedures were successfully completed; the first animal died from hemorrhage due to inadvertent injury to the posterior infrarenal aortic wall. The accurate deployment and position of the stent-grafts were verified visually after sacrifice. Mean (+/- SD) procedural, implantation, and aortic cross-clamping times were 205 +/- 56, 22 +/- 9, and 30 +/- 19 minutes, respectively. Mean blood loss was 120 +/- 56 mL.

CONCLUSIONS

Thoracic aortic stent-grafting using a laparoscopic approach to the infrarenal aorta is feasible. More studies will be required to define the place of combined endovascular and laparoscopic procedures as an alternative to the femoral surgical approach for stent-graft placement.

Minimally invasive vascular surgery for repair of infrarenal abdominal aortic aneurysm with iliac involvement

PURPOSE

A minimally invasive vascular surgery (MIVS) technique for repair of infrarenal abdominal aortic aneurysm (AAA) with iliac involvement was evaluated, and its outcome was compared with conventional open repair.

METHODS

Twenty patients with AAA with iliac involvement underwent treatment with bifurcated graft replacement with the MIVS technique. The procedure was performed via minilaparotomy, with the incision length determined according to the extent of the AAA obtained with ultrasound scanning and with the small intestine confined completely within the abdominal cavity. The proximal and distal operating fields were obtained with changing the patient position and arranging for the abdominal incision to be retracted cephalad and caudad. Perioperative courses in these 20 patients (the MIVS group) were analyzed in comparison with 14 patients who underwent conventional open repair, which was performed through the full midline laparotomy with the intestine simply covered with moistened towels (the conventional group).

RESULTS

The MIVS technique for AAA repair was performed with a mean abdominal incision length of 8.4 cm and a range from 6.5 to 11.2 cm. The patients in the MIVS group showed earlier resumption of oral intake and ambulation in comparison with those patients in the conventional group (liquid diet: 1.1 +/- 0.3 days versus 2.9 +/- 1.4 days; P <.01; solid diet: 2.0 +/- 0.2 days versus 3.9 +/- 1.4 days; P <.01; ambulation: 2.1 +/- 0.8 days versus 4.3 +/- 2.3 days; P <.01), with comparable mortality and morbidity rates. Accordingly, the patients in the MIVS group were discharged earlier (20.7 +/- 6.3 days versus 33.9 +/- 12.6 days; P <.01), and total hospitalization charges were significantly decreased (2,232,791 +/- 200,747 Japanese yen versus 2,640,441 +/- 243,889 Japanese yen; P <.01).

CONCLUSION

The MIVS technique allowed earlier postoperative recovery with comparable morbidity and mortality rates with the conventional technique and, therefore, saved hospital stay length and total hospitalization charges. Thus, the MIVS technique is considered as a new and effective minimally invasive technique for open AAA repair.

Minimal incision aortic surgery

PURPOSE

In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD).

METHOD

Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques.

RESULTS

Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs. 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs. 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (< or = 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs.

CONCLUSIONS

MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair.