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

Sexual dysfunction after elective laparoscopic or endovascular abdominal aortic aneurysm repair in men

INTRODUCTION

Infrarenal abdominal aortic aneurysm (AAA) repair can lead to ejaculation and erection troubles in men. There are few studies on sexual dysfunction after endovascular repair (EVAR) but they suggest less retrograde ejaculation than after open repair. We assessed the sexual dysfunction and ejaculation troubles after elective laparoscopic repair or EVAR.

METHODS

We conducted a monocentric prospective study on 124 patients undergoing AAA repair between 2013 and 2015. Sexual function was evaluated using the IIEF-15 questionnaire and questions on ejaculation.

RESULTS

Only 45 patients (36.3%) accepted to complete the IIEF preoperatively with 20-37.8% having preoperative sexual dysfunction. Among them, 21 (46.7%) accepted to complete the questionnaire at 3, 6 and 12 months. Mean age at inclusion was 65±5.6 years in the laparoscopic group and 77±10.5 years in the EVAR group (P=0.003). Erectile and sexual function were slightly improved at 12 months in the laparoscopic group (+1.4 for erectile score and +4.6 for IIEF score) with no significant difference (P=0.83 and 0.74) whereas 8 patients (61.5%) had persistent ejaculation troubles at 3 months. In the EVAR group, patients had moderate sexual dysfunction at baseline without improvement at 12 months, but only one patient reported ejaculation troubles.

CONCLUSIONS

Most patients eligible for AAA repair present with baseline erectile and sexual dysfunction. Laparoscopic AAA repair provides no onset of erectile or sexual dysfunction but a global improvement after surgery. Ejaculation troubles are frequent and persistent at 1 year. However, EVAR treatment, doesn't allow recovering of sexual function at 1 year.

LEVEL OF EVIDENCE

4.

Hepatic artery reconstruction following iatrogenic injury during laparoscopic distal pancreatectomy: Minimal access surgery is new horizon

Although minimally invasive surgery has evolved in every field of surgery, its use in vascular surgery is limited to major vessel diseases only. A 23-year-old female presented with a cystic lesion in the distal body and the tail of the pancreas. Triphasic computed tomography (CT) abdomen revealed a 4.5 cm × 3.2 cm-sized mass with calcifications. A diagnosis of the mucinous cystic neoplasm in the distal body and the tail of the pancreas was made and the patient was planned for laparoscopic distal pancreatectomy. During the procedure, hepatic artery was accidentally injured due to its anomalous course. The artery was then reconstructed laparoscopically using left gastric artery as conduit. The time duration of the procedure was 45 min and blood loss was approximately 75 mL. The patient recovered well and the postoperative Doppler study revealed normal blood flow. Medium-vessel surgery through laparoscopic approach is feasible and safe in select cases, while availing benefits of laparoscopy.

“Fast-Track” Abdominal Aortic Aneurysm Repair

The “open” repair of abdominal aortic aneurysm (AAA) continues to evolve with incorporation of less invasive methods for surgical exposure and the use of patient care pathways for shorter hospital stays. In a consecutive series of 30 patients with infrarenal AAA, a “ fasttrack” hospital care pathway was implemented that included the following: AAA exposure via a limited (10–15 cm) retroperitoneal incision, use of self-retaining retractor and special vascular clamps/instruments, and prosthetic graft endoaneurysmorrhaphy. Excellent anatomic exposure for graft implantation was achieved with an average operative time of 175 minutes. Use of oral metoclopromide and patient-controlled epidural analgesia resulted in patient ambulation and oral diet on postoperative day 1. Average length of hospital stay was 3.6 days (range: 3–7 days), and no patient required readmission for AAA repair-related or gastrointestinal problems. One patient died (30-day mortality rate of 3.3%) caused by delayed recognition of a splenic injury, and 1 patient sustained an intraoperative ureter injury that was repaired and stented. Although stent-graft exclusion for AAA repair has become popular, the major advantages of endovascular therapy, such as shorter ICU and hospital stays, earlier dietary feeding, and reduction in postoperative morbidity, can also be achieved by using minimal incision exposure for AAA interposition grafting combined with traditional hand-sewn vascular anastomoses. “Fast-track” AAA repair is applicable to the majority of patients with infrarenal AAAs, and vascular surgeons can easily master the technique of “limited” incision retroperitoneal exposure. This approach avoids the concerns of endovascular stent-graft durability and the mandatory vascular imaging follow-up to identify endoleak development and AAA enlargement.

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.

An update on the 'fast-track' abdominal aortic aneurysm repair

Patients who have unfavourable anatomy for endovascular repair of an abdominal aortic aneurysm require open repair. This is particularly the case for juxtarenal aortic aneurysms, or those patients with small or occluded iliac access vessels.An experience of 'fast-track' abdominal aortic aneurysm repair that was previously reported is updated in the present case. A retroperitoneal approach to the aorta is taken, using a small incision, and is followed by a patient care pathway protocol that demonstrated excellent results and a shortened length of stay. The present update on 56 patients is approximately double the previously reported experience.

Sexual dysfunction after elective endovascular or hand-assisted laparoscopic abdominal aneurysm repair

OBJECTIVE

To evaluate the incidence of sexual dysfunction and retrograde ejaculation after elective endovascular aneurysm repair (EVAR) and hand-assisted laparoscopic surgery (HALS) for abdominal aortic aneurysm (AAA).

METHODS

A total of 100 patients eligible for elective repair of infrarenal AAAs were randomised in two groups: EVAR and HALS. The quality of sexual function was evaluated using the International Index of Erectile Function (IIEF), a 15-item questionnaire. Patients completed the IIEF preoperatively and at 12 months. The incidence of retrograde ejaculation was also evaluated.

RESULTS

One- and 12-month mortality rates were zero. Three patients in the EVAR group (6%) and two patients in the HALS group (4%) reported an erectile dysfunction (p = NS). The quality of sexual function at 1 year was similar in both groups: total score of 66 in the EVAR group versus 68 in the HALS group (p = 0.66). Retrograde ejaculation was detected in three cases in the HALS group versus no case in the EVAR group.

CONCLUSIONS

The HALS technique could be a minimally invasive alternative for sexually active males unsuitable for EVAR 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.

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.

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 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.

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.

Laparoscopic surgery: current status, issues and future developments

Laparoscopic surgery has come a long way since its introduction two decades ago. In essence it represents a new era of technology-dependent surgical interventions, and to some extent its future progress depends on the growth of interventional technologies and devices (facilitative, enabling and additive). Laparoscopic surgery has had a significant impact on all surgical disciplines and is now firmly embedded in routine surgical practice. There remain, however, several outstanding issues that need to be addressed. These concern mainly quality assurance, training, resource allocation, assessment of competence and tiers of laparoscopic surgical practice in line with the changing situation facing the next generation of surgeons.

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.

Totally laparoscopic aortic repair: A new device for direct transperitoneal approach

On the basis of our experience with more than 71 cases of totally laparoscopic aortic surgery by the retrocolic approach, we have developed a new technique by a simple transperitoneal approach. The purpose of this report is to describe that technique and the novel laparoscopic bowel retractor used to ensure stable exposure of the aorta.

Early and Mid-term Results of Totally Laparoscopic Surgery for Aortoiliac Disease

The present article is the first in the literature reporting short- and medium-term results using a totally laparoscopic technique for aortoiliac disease.Forty-nine patients, 6 having an associated small aneurysm, were scheduled for totally laparoscopic surgery (TLS) for aortoiliac occlusive disease and 2 for treatment of aortic aneurysmal disease (AAA). Patients' characteristics, intraoperative, postoperative data and mid-term data were recorded.TLS was successfully completed in 45 patients. Of those patients, 41 received an aortobifemoral bypass; three, an iliofemoral bypass; and one, an aortoaortic bypass. Five patients were converted from TLS to video-assisted laparoscopic surgery using incisions varying in size from 7 cm to 11 cm. One patient underwent conversion to standard open surgery. One death occurred unrelated to the technique. Major perioperative complications related to the technique were few and presented in the early phase of the study: One intraoperative embolization to the lower limbs that needed embolectomy, and one acute aortic false aneurysm. Midterm results were favorable, demonstrating two limb graft thromboses. Hernias at trocar sites occurred in only 3.9%. The patients benefited from this procedure, which is considered definitive like its standard open counterpart. The conversion rate is lower than that reported for acute cholecystitis. Selection of patients has been less stringent during the second half of the study in term of inclusion of patients with AAA and of more TASC IV patients. Surgeons willing to learn this technique should attend dedicated courses. In the future, as this surgical innovation matures, controlled randomized studies should be initiated.

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.

Are Laparoscopic Staplers Effective for Ligation of Large Intraabdominal Arteries?

OBJECTIVES

To evaluate ligation of aortoiliac arteries with laparoscopic staplers in order to develop specifically designed staplers.

METHODS

Cadaveric study. Seven human cadaver aortas were stapled using EndoGIA60 staplers. Efficiency was evaluated macroscopically and on a hydrodynamic bench. Clinical study. Twelve patients had ligation of 14 large abdominal arteries (aorta: nine, iliac artery: four, hepatic artery: one) using a laparoscopic stapler. Stapling efficiency was judged on peroperative clinical and postoperative CT scan criteria.

RESULTS

Cadaveric study. Stapling was performed perfectly on four moderately calcified aortas, without leakage with a pulsatile pressure of >250 mmHg. For three aortas with severe calcification, stapling was not efficient and major leakage occurred. Clinical study. Stapling appeared clinically efficient on all arteries but one aorta: this severely calcified aorta was ligated conventionally. The staplers are not easy to use due to their shape and their lack of articulation. After a mean follow-up of 31.3 months, all the other stapled arteries were effectively ligated.

CONCLUSION

The commercially available staplers can be used securely on moderately calcified arteries but stapling of severely calcified arteries should be avoided. These devices should be redesigned to facilitate their use in vascular surgery.

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.

Laparoscopy-assisted reconstruction to treat severe aortoiliac occlusive disease: early and midterm results

OBJECTIVES

The purpose of this study was to evaluate the consequences on patient selection and on early and midterm results of the learning curve of a surgical team performing laparoscopy-assisted surgery in the treatment of severe aortoiliac occlusive disease (AIOD).

PATIENTS AND METHOD

Between January 1998 and June 2003, 58 patients (53 men, 5 women; mean age, 59.5 years [range, 37-76 years]) were included in a prospective study and underwent a laparoscopy-assisted aortofemoral reconstruction with graft implantation through a 5-cm to 8-cm minilaparotomy. Fifty-one patients (88%) had claudication (category 2 or 3, Rutherford classification), and seven patients (12%) had tissue loss; at presentation they had TransAtlantic Inter-Society Consensus C (n=24, 41.4 %) or D (n=32, 55.2%) iliac lesions, and the last 2 patients (3.4%) had severe aortic lesions. Perioperative data for the first 29 patients, obtained during the first 34 months of the study (group 1), were compared with data for the last 29 patients, obtained during the last 32 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 tomography before discharge and then every 2 years.

RESULTS

One intraoperative surgical conversion (1.7%) was necessary, and two other patients (3.4%) died in the immediate postoperative period. With experience, initial contraindications such as obesity or suprarenal artery aortic clamping were eliminated, making it possible to increase the percentage of patients included, from 53.7% during the first 34 months to 90.6% during the last 32 months (P=.003). The mean duration of the operative procedure decreased from 285 minutes in group 1 to 192 minutes in group 2 (P<.001), and the mean duration of aortic clamping decreased from 76.4 minutes in group 1 to 31.8 minutes in group 2 (P<.001). The number of early repeat interventions was reduced from three (10.3%) in group 1 to 2 (6.9%) in group 2 (P=NS), and the clinical recovery period decreased from 7 days to 4.5 days (P=.05). During a mean follow-up of 26.7 months (range, 1-66 months) there were 5 repeat surgeries (9%) to treat late graft occlusion, establishing midterm primary and secondary patency rates of 89.3% and 91%, respectively. No aortic false aneurysms were detected, and no major amputations were performed.

CONCLUSION

These preliminary results assess the feasability and the safety of this minimally invasive video-assisted technique. A short period of postoperative recovery and good midterm patency rate are the two main benefits of this new surgical option.