Robot-assisted laparoscopic aortic reconstruction for occlusive disease-a case report.

Aortobifemoral bypass is the standard method for revascularization of aortoiliac occlusive disease but is associated with significant morbidity and mortality. Laparoscopic aortic reconstruction eliminates the large incision but is limited by the cumbersome nature of laparoscopic instrumentation. A robotic system (da Vinci Computer-Enhanced Robotic Surgical System, Intuitive Surgical, Mountain View, CA) has been developed that allows the surgeon to suture in the same manner as in open procedures. The authors report the first case of an aortic reconstruction for occlusive disease performed using the da Vinci system. A 53-year-old woman presented with gangrene of the left great toe. Angiography revealed distal aortic occlusive disease and occlusion of the common iliac arteries bilaterally. Dissection of the aorta was performed by a transabdominal-retroperitoneal approach modified from Dion (J Vasc Surg 26:128-132, 1997). With use of laparoscopic techniques, the abdominal contents were retracted to the patient's right side while the kidney and ureter remained in the retroperitoneum. The aorta was isolated from the bifurcation proximally to the left renal vein. The patient was anticoagulated, and the aorta was clamped below the left renal artery and proximal to the bifurcation. The da Vinci robotic system was placed on the patient's right side, and an extruded polytetrafluoroethylene (ePTFE) graft was passed into the retroperitoneum. While seated at a computer console viewing the operative field on a screen, the surgeon used robotic instruments to fashion an arteriotomy and complete an end-to-side aortic anastomosis using ePTFE suture. The left groin was opened and the aortic graft passed down to the groin. The reconstruction was completed by performing a left-to-right femoro-femoral bypass in standard, open fashion. The procedure was completed in 8 hours with an aortic clamp time of 65 minutes and a 500 cc blood loss. The patient was extubated in the operating room, ate a regular diet on postoperative day 2, and was discharged on postoperative day 4 without complications. Return to normal activities occurred 2.5 weeks postoperatively. The da Vinci robotic system facilitated creation of the aortic anastomosis and shortened aortic clamp time over that achieved with laparoscopic techniques. Robot-assisted laparoscopic aortofemoral bypass should decrease the morbidity and mortality of aortic reconstruction, while providing a durable solution to aortoiliac occlusive disease.

External pneumatic compression does not increase urokinase plasminogen activator after abdominal surgery.

External pneumatic compression (EPC) devices prevent lower extremity deep venous thrombosis (DVT) by reducing stasis. There is a widely held belief that they also enhance endogenous fibrinolysis; however, recent studies of tissue plasminogen activator (the primary activator of fibrinolysis) and plasminogen activator inhibitor-1 (the primary inhibitor of fibrinolysis) failed to confirm this. The hypothesis of this study was that EPC devices increase the level of urokinase plasminogen activator (uPA), a second activator of fibrinolysis. This was a prospective trial in which 44 subjects who underwent major abdominal surgery were randomized to receive unfractionated heparin injections, thigh-length sequential EPC devices, or both for DVT prophylaxis. Prophylaxis was begun immediately before surgical incision and continued until postoperative day 5 or discharge. Venous blood samples were collected from an antecubital vein for measurement of systemic uPA levels and from the common femoral vein for measurement of regional uPA levels. Samples were collected the day before surgery, after induction of anesthesia but before surgical incision, and on postoperative days 1, 3, and 5. uPA levels (ng/mL) were measured with an enzyme-linked immunoassay. Baseline uPA levels (0.41 to 0.56 ng/mL; P >.05, analysis of variance with repeated measures) were similar among the three groups. uPA levels did not change after surgery in systemic or regional blood samples in any group. There were no significant differences in systemic or regional uPA levels in the groups treated with EPC devices relative to those treated with heparin at any time point (P >.05, analysis of variance with repeated measures). Enhancement of fibrinolysis with EPC devices remains unproven; the findings reported here suggest that effective DVT prophylaxis can only be assured when the devices are used in a manner that reduces venous stasis.

Deep venous thrombosis prophylaxis in trauma: improved compliance with a novel miniaturized pneumatic compression device.

OBJECTIVE: Intermittent pneumatic compression (IPC) devices prevent lower-extremity deep venous thrombosis (LEDVT) when used properly, but compliance remains an issue. Devices are frequently discontinued when patients are out of bed, and they are rarely used in emergency departments. Trauma patients are at high risk for LEDVT; however, IPCs are underused in this population because of compliance limitations. The hypothesis of this study was that a new miniaturized, portable, battery-powered pneumatic compression device improves compliance in trauma patients over that provided by a standard device. METHODS: This was a prospective trial in which trauma patients (mean age, 46 years; revised trauma score, 11.7) were randomized to DVT prophylaxis with a standard calf-length sequential IPC device (SCD group) or a miniaturized sequential device (continuous enhanced-circulation therapy [CECT] group). The CECT device can be battery-operated for up to 6 hours and worn during ambulation. Timers attached to the devices, which recorded the time each device was applied to the legs and functioning, were used to quantify compliance. For each subject in each location during hospitalization, compliance rates were determined by dividing the number of minutes the device was functioning by the total minutes in that location. Compliance rates for all subjects were averaged in each location: emergency department, operating room, intensive care unit, and nursing ward. RESULTS: Total compliance rate in the CECT group was significantly higher than in the SCD group (77.7% vs. 58.9%, P =.004). Compliance in the emergency department and nursing ward were also significantly greater with the CECT device (P =.002 and P =.008 respectively). CONCLUSIONS: Previous studies have demonstrated that reduced compliance with IPC devices results in a higher incidence of LEDVT. Given its ability to improve compliance, the CECT may provide superior DVT prevention compared with that provided by standard devices.