Total Laparoscopic Aortofemoral Bypass as a Routine Procedure for the Treatment of Aortoiliac Occlusive Disease

Judith C. Lin, MD, Ralf Kolvenbach, MD, PhD; Elisabeth Schwierz MD; Sergej Wassiljew MD

Disclosures

Vascular. 2005;13(2):80-83. 

In This Article

Patients and Methods

The patient was placed on the operating table on a vacuum bag. When tilting the table to the right, the patient could be positioned almost 70° on the right lateral decubitus position. Seven or eight ports are used for access. In all patients, a transperitoneal, left retrocolic access was used for exposure of the aorta. The left hemicolon and splenic flexure were mobilized medially (fig 1). The apron technique, originally described by Dion and Gracia,[5] was used to separate the abdominal contents from the retroperitoneal space. Laparoscopic exposure of the aorta was initiated at the level of the left renal vein (fig 2). The laparoscopic camera was positioned in the left upper abdomen during exposure of the aorta. Only the area for the anastomosis proximal to the origin of the inferior mesenteric artery was dissected to avoid injury of the lumbosacral nerves adjacent to the aortic bifurcation.

Medial mobilization of the left hemicolon and the splenic flexure to expose the aorta.

Intraoperative photograph showing the left renal vein ( solid arrow ) and the aortic Dacron graft ( interrupted arrow ).

In patients for whom an end-to-end anastomosis was planned, the infrarenal aorta was stapled with a linear, noncutting stapler. If calcification was too severe, thromboendarterectomy of the aortic stump was performed. A deployable aortic clamp (Karl Storz, Tuttlingen, Germany) was used to occlude the distal aorta. Using this novel device, only the port for the proximal aortic clamp was obstructed with an instrument.

Laparoscopic dissection and suturing were performed with the surgeon standing on the right side of the patient during the operation.[6] In patients with an end-to-end anastomosis, the aorta was completely transected to facilitate the suturing process. In patients with an end-to-side anastomosis, an aortotomy was performed, and the anastomosis was started at the heel and posteriorly with a 3-0 polypropylene suture, 10 cm in length. A second suture was taken anteriorly, and both were tied intracorporally. Time could be saved by using two 3-0 polypropylene sutures blocked with a pledget at the end, as originally described by Coggia and colleagues.[6] Tunneling was performed under laparoscopic control dorsal to the ureter after exposure of the femoral arteries in the groin.

Reasons for conversion to a minilaparotomy were outlined before surgery. According to our self-established guidelines, they included an aortic cross-clamping time of more than 2 hours and a total operating time exceeding 4 hours. In these cases, we converted to a laparoscopic hand-assist procedure, in which the anastomosis was performed under the pneumoperitoneum but with the nondominant hand of the surgeon inserted into the abdomen.[7–10] Other reasons for conversion included extensive adhesions, a severe calcified aorta, and uncontrollable blood loss. The mean value and standard deviation of the mean are given in the table below ( Table 1 ). When appropriate, nonparametric tests were used to describe a statistical significance of p < .05.

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