Total Laparoscopic Aortic Surgery Versus Minimal Access Techniques: Review Of More Than 600 Patients

Review and current update of robotic-assisted laparoscopic vascular surgery

The field of vascular surgery is constantly evolving and is unsurpassed in its innovation and adoption of new technologies. Endovascular therapy has fundamentally changed the treatment paradigms for aneurysm and occlusive disease. As we continue to make advances in not only endovascular therapy, but also robotic surgery, artificial intelligence, and minimally invasive surgery, it is important that the vascular community stay at the forefront. Topics include the advantages of laparoscopic and robotic surgery over open surgery for aortic procedures, robotic versus laparoscopic aortic surgery, patient candidacy for robotic-assisted aortic surgery, and how to increase training and adoption of robotic-assisted laparoscopic aortic surgery. Future growth includes the development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics in vascular surgery.

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.

Endovascular Electrodes for Electrical Stimulation of Blood Vessels for Vasoconstriction - a Finite Element Simulation Study

Hemorrhagic shock accounts for 30-40 percent of trauma mortality, as bleeding may sometimes be hard to control. Application of short electrical pulses on blood vessels was recently shown to elicit robust vasoconstriction and reduction of blood loss following vascular injury. In this study we present a novel approach for vasoconstriction based on endovascular application of electrical pulses for situations where access to the vessel is limited. In addition to ease of access, we hypothesize that this novel approach will result in a localized and efficient vasoconstriction. Using computer modeling (COMSOL Multiphysics, Electric Currents Module), we studied the effect of endovascular pulsed electrical treatment on abdominal aorta of pigs, and compared the efficiency of different electrodes configurations on the electric field amplitude, homogeneity and locality when applied on a blood vessel wall. Results reveal that the optimal configuration is the endovascular approach where four electrodes are used, spaced 13 mm apart. Furthermore, computer based temperature investigations (bio-heat model, COMSOL Multiphysics) show that the maximum expected temperature rise is of 1.2 degrees; highlighting the safety of the four endovascular electrodes configuration. These results can aid in planning the application of endovascular pulsed electrical treatment as an efficient and safe vasoconstriction approach.

Learning Curve of Robotic-Assisted Anastomosis: Shorter than the Laparoscopic Technique? An Educational Study

BACKGROUND

Achieving aortic anastomosis in laparoscopic surgery remains a technical challenge. The Da Vinci robot could theoretically counteract this issue by minimizing the technical challenge. The aim of this study was to compare the learning curves of performing vascular anastomoses by trainees without any experience using purely laparoscopic versus robotic-assisted techniques.

METHODS

Surgery residents were randomly included in the laparoscopic group (group A, n = 3) and the robotic group (group B, n = 3). They performed 10 end-to-end anastomoses on 18-mm-diameter tubular expanded polytetrafluoroethylene grafts. The parameters recorded were duration to complete the anastomosis and an indirect sealing quality evaluation (ISQE) defined as the following ratio: number of stitches with a distance of less than 4 mm/total number of stitches.

RESULTS

The mean duration to perform the anastomosis decreased from 2340 s (±64) for the first anastomosis to 651 s (±248) for the last in group A (P < 0.05) and from 1989 s (±556) to 801 s (±120) in group B (P < 0.05). The mean ISQE increased from 74% (±18) for the first anastomosis to 98% (±3) for the last in group A (P < 0.05) and decreased from 100% to 98% (±2) in group B (nonsignificant). The mean duration to perform the first anastomosis was lower in group B than in group A (P < 0.05). The mean duration to perform the last anastomosis was not significantly different between the groups. Sealing tended to be better in group B for the first anastomosis compared with group A.

CONCLUSIONS

Minimally invasive laparoscopic technique training demonstrates a learning curve to perform vascular anastomoses. The robotic-assisted technique tended to improve suturing skills and should be considered as a valuable tool to reduce the technical learning curve.

A comparative cohort study of totally laparoscopic and open aortobifemoral bypass for the treatment of advanced atherosclerosis

Background

Totally laparoscopic aortobifemoral bypass (LABF) procedure has been shown to be feasible for the treatment of advanced aortoiliac occlusive disease (AIOD). This study compares the LABF with the open aortobifemoral bypass (OABF) operation.

Methods

In this prospective comparative cohort study, 50 consecutive patients with type D atherosclerotic lesions in the aortoiliac segment were treated with an LABF operation. The group was compared with 30 patients who were operated on with the OABF procedure for the same disease and time period. We had an explanatory strategy, and our research hypothesis was to compare the two surgical procedures based on a composite event (all-cause mortality, graft occlusion, and systemic morbidity). Stratification analysis was performed by using the Mantel–Haenszel method with the patient–time model. Cox multivariate regression method was used to adjust for confounding effect after considering the proportional hazard assumption. Cox proportional cause-specific hazard regression model was used for competing risk endpoint.

Results

There was a higher frequency of comorbidity in the OABF group. A significant reduction of composite event, 82% (hazard ratio 0.18; 95% CI 0.08–0.42, P=0.0001) was found in the LABF group when compared with OABF group, during a median follow-up time period of 4.12 years (range from 1 day to 9.32 years). In addition, less operative bleeding and shorter length of hospital stay were observed in the LABF group when compared with the OABF group. All components of the composite event showed the same positive effect in favor of LABF procedure.

Conclusion

LABF for the treatment of AIOD, Trans-Atlantic Inter-Society Consensus II type D lesions, seems to result in a less composite event when compared with the OABF procedure. To conclude, our results need to be replicated by a randomized clinical trial.

Introduction of laparoscopic abdominal aortic aneurysm repair

BACKGROUND

The aim was to review a consecutive series of patients treated with laparoscopic abdominal aortic aneurysm (AAA) repair. These patients were compared with patients having elective open AAA repair.

METHODS

Demographic and operative details were collected prospectively and outcomes recorded for all patients undergoing laparoscopic or open AAA repair.

RESULTS

A total of 316 patients underwent laparoscopic (51), open (53) or endovascular (EVAR; 212) AAA repair between 2007 and 2013. The median age of patients who had laparoscopic or open repair was 72 (i.q.r. 66-75) years, and 92·3 per cent were men. There was no significant difference in sex distribution, age or V-POSSUM physiology score between laparoscopic and open repair. Of the 51 laparoscopic procedures, six were totally laparoscopic, 43 were laparoscopically assisted and two were converted to open repair. Pain scores were similar on days 1 and 3 after laparoscopic and open repair, even though epidurals were used in the open group, and were lower on days 5 and 7 after laparoscopic procedures. Patients who had laparoscopic repair had significantly fewer postoperative cardiorespiratory and renal complications (P = 0·017), and were discharged from hospital sooner (median 5 (i.q.r. 3-7) versus 8 (6-11) days; P = 0 ·001).

CONCLUSION

Laparoscopic AAA repair was performed safely, and with at least equivalent outcomes to open repair, in patients unfavourable for EVAR.

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.

Endoscopic-assisted robotic aortic thrombectomy and aortobiiliac bypass: a case report

In this report, not only our experience with laparoscopy-assisted robotic aortic thrombectomy and aortobiiliac bypass procedure was presented but also current status of vascular interventions via endoscopically was discussed.

Successful total robotic-assisted aortobifemoral bypass for treatment of complicated aortoiliac occlusive disease

Laparoscopic aortobifemoral bypass (AFB) for aortoiliac occlusive disease (AIOD) is a durable, minimally invasive procedure with comparable long-term outcomes to conventional open AFB. However, laparoscopic AFB requires advance training in laparoscopy with prolong learning curve to accomplish infrarenal aortic dissection and vascular reconstruction to minimize aortic clamp time and leg ischemia time. We describe another minimally invasive technique of total robotic-assisted AFB for extensive, complicated AIOD in 3 patients who are not endovascular candidate or have failed endoluminal approach previously.

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.

Total laparoscopic repair for abdominal aortic aneurysm

Surgical resection and grafting have long been the standard treatment for abdominal aortic aneurysm and provide an excellent long-term outcome. However, there is tremendous impact on patients due to the surgical invasiveness. Endovascular aortic repair using stent graft was introduced in 1991. After refinement of the techniques and technology, endovascular aortic repair was approved by most health authorities and is associated with less periprocedural morbidities. In between these two extremes, some surgeons endeavored to create an alternative and perform less invasive surgeries. Hand-assisted laparoscopic aortic surgery and laparoscopic-assisted aortic surgery were introduced in 1996. In 2001, total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was first performed in Canada. Till now, only a few vascular units in North America and Europe perform these delicate techniques. We report our first case of total laparoscopic abdominal aortic aneurysm repair. Laparoscopic aortic surgery provides better visualization of the aneurysm neck, less bowel manipulation and avoidance of hypothermia. The minimal invasiveness could translate to better perioperative outcome. To our knowledge, this is also the first case report in Asia. The detailed techniques are described.