Minilaparotomy for aortoiliac aneurysmal disease: experience and review of the literature.

Vascular surgery is evolving, as other specialities, toward minimally invasive techniques. Presently, 3 approaches to aortoiliac disease are suggested as minimally invasive. Besides the endovascular procedures, laparoscopic techniques and minilaparotomy are being advocated. Although for aneurysmal disease, we favor a totally laparoscopic approach, criticisms raised over laparoscopy-assisted techniques by those advocating minilaparotomy led us to investigate the benefits of the latter technique. We first evaluated the procedure in 7 patients with infrarenal abdominal aortic aneurysm (AAA). We found the procedure impossible to perform with an 8- to 10-cm incision in 6 of the 7 patients. This led us to evaluate causes of failure of the technique. It appeared to us that most of our complications were related to inadequate exposure. Fifty consecutive computed tomography scans from patients with AAA of surgical size were then reviewed to evaluate the aneurysm lengths and compare them to the reported lengths of skin incision for minilaparotomy. Results were expressed adding a total of 2 cm for proximal and distal clamping. Only 2% of patients would present with aneurysms suitable for treatment through an 8-cm midline incision and 30% through a 10-cm incision. We then reviewed the literature on minilaparotomy. We believe that minilaparotomy should be reserved for those patients with purely aortic disease and the appropriate body habitus.

Comparison of a plasma-based composite biologic sealant with fibrin glue (Tisseel) for vascular anastomoses.

Biologic sealants are needed in numerous, more and more demanding, procedures--especially with developments occurring in endovascular and laparoscopic vascular techniques. An initial pilot study in dogs showed that a 4-cm aortotomy closed with a polyester patch sutured in place by a 4-mm-spaced running suture consistently led to massive hemorrhage. We then designed a study using five dogs where two aortotomies were done to compare the effect of Tisseel to that of an autologous sealant prepared in our laboratory. Arterial pressures and heparinization were maintained throughout the surgical procedure. Both biologic sealants prevented hemorrhage from the arteriotomy at unclamping. Macroscopic and histologic assessments were performed. At killing, one week later, the autologous sealant exhibited less blood saturation of the collagen sponge compared with Tisseel. The use of autologous plasma combined with other adhesive components could be an efficient alternative to allogenic fibrin glue. Further studies are needed to confirm these observations.

Early and mid-term results of totally laparoscopic surgery for aortoiliac disease: lessons learned.

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.

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.

Endovascular procedures under near-real-time MRI guidance: present status and future perspectives.

Indications for endoluminal treatment of occlusive aorto-iliac disease are well known. Endovascular grafting is a technique currently being evaluated for its efficacy for treatment of aneurysmal disease. The success of those techniques is due to their favorable results and non-invasive characteristics. X-ray contrast angiography (CA) is the most currently used imaging modality for endovascular procedures; however, the iodinated contrast agent is directly responsible for systemic and renal adverse effects in 3% to 12% of patients.

Thoracoscopic transpleural azygos vein cannulation as vascular access for hemodialysis: experimental study in a porcine model.

Temporary hemodialysis is conventionally performed by accessing either the jugular, the femoral, or the subclavian veins. Repetitive or chronic use of these venous sites may lead to complications such as thrombosis of the superior vena cava. Alternative venous accesses have been described. The purpose of this acute experiment is to evaluate in 8 female pigs the feasibility and immediate complications associated with the transpleural cannulation of the azygos vein performed under thoracoscopy. All animals survived the experiment. There were 5 successful cannulations. There was one termination of the procedure and 2 conversions to thoracotomy because of bleeding which, even if minor, hindered the view of the operation field. There was one lung injury caused by a retractor. In conclusion, the thoracoscopic technique was found to be feasible and could become an alternative access in patients with unsuitable conventional central venous access. Further investigation could validate our findings.

Minimally invasive interventions in aorto-iliac occlusive disease.

INTRODUCTION: Aorto-iliac occlusive disease can cause disabling symptoms and Trans-Atlantic Inter-Society Consensus (TASC II) has recommended the treatment options for varying severity of the disease. In the TASC II article, an increasing interest for laparoscopic aorto-ilio-femoral surgery was noted. AIM: To review the literature on the minimally invasive interventions currently used in aorto-iliac occlusive disease with a focus on laparoscopic aortic surgery. METHODS: Medline search and hand search of references from relevant articles to describe the current management options for aorto-iliac occlusive disease. CONCLUSION: Laparoscopic aorto-femoral surgery is a therapeutic option for most TASC C and D lesions.

Current modifications to totally laparoscopic "apron technique".

Since our original description in 1997 of a totally laparoscopic technique for treatment of aortoiliac disease, this type of minimally invasive procedure has been used both in the United States and abroad. We describe improvements that should make this technique more easily reproducible. This modified procedure was offered to six patients, one of whom received a tube graft for treatment of aneurysm disease.

Early transient hydronephrosis after laparoscopic aortobifemoral bypass grafting.

Hydronephrosis early after aorto-bifemoral bypass grafting is probably an underestimated complication. We describe early and transient hydronephrosis that developed in two patients after totally laparoscopic aorto-bifemoral bypass surgery to treat aortoiliac occlusive disease. A conservative approach to treatment was adopted, and both patients recovered. We review the literature and discuss the pathophysiology, diagnosis, and treatment of this unusual form of hydronephrosis.

Laparoscopic remodeling of abdominal aortic aneurysms after endovascular exclusion: a technical description.

We report our experience with a novel combined laparoscopic-endovascular procedure to treat endoleaks and graft migration. The operative procedure consisted of the following steps: laparoscopic exposure of the aorta, clipping of lumbar arteries and of the inferior mesenteric artery, incision of the sac of the aneurysm without clamping the aorta, and removal of thrombus material. Laparoscopic sutures were placed externally to attach the endograft to the aortic neck. Laparoscopy was performed a mean interval of 20.2 months after endovascular abdominal aortic aneurysm repair in four cases and immediately after endovascular abdominal aortic aneurysm exclusion in eight consecutive patients. We have yet to prove whether this combined approach is superior to a purely endovascular technique.