In recent years, technological developments in medicine have given rise to a whole series of new surgical techniques, particularly in minimally invasive surgery. Laparoscopic interventions reduce patient trauma, reduce the need for radical preparation of tissues, and lessen postoperative pain. They shorten the time spent in intensive care and in the hospital as a whole, lessen treatment and recovery times, and in addition, reduce overall treatment costs.
The second half of the 20th century was the boom period for minimally invasive surgery—when it developed across all surgical disciplines. This type of surgery changes the whole perspective of the procedure; it draws on knowledge acquired by performing classical open surgical interventions and benefits simultaneously from new approach techniques that provide a perfect view of the layout of organs and tissues. A disadvantage of laparoscopy and thoracoscopy, however, is a significant limitation in tactile perception—a problem that is completely eradicated in robotic procedures. A major benefit is the indisputably sparing nature of the procedure. Inspired by general surgery, minimization of surgical entries is a method that has now been applied for a number of years, including in vascular surgery.1–5 Besides classical laparoscopic techniques, the most commonly performed procedure is endovascular treatment of abdominal aortic and thoracic aortic aneurysms, and more recently, robotically assisted surgery in the region of the abdominal aorta and iliac arteries. Minilaparotomy, hand- and laparoscopically assisted procedures, fully laparoscopically and thoracoscopically guided procedures, and robotically assisted procedures are among the minimally invasive approach options also currently available to vascular surgeons.
Major developments in laparoscopic surgery in the 1990s had an impact on vascular surgery, with minimally invasive approaches used in general surgery gradually being used in vascular surgery. Robotics, which first appeared in 2000, is a state-of-the-art surgical technology.
Robotic surgery can be characterized as an operation that uses a computer-controlled robotic system. The advantage of this technique is that it does not require direct contact between the patient and surgeon while significantly enhancing the precision of the surgery by eliminating tremor from the surgeon’s hands and providing perfect three-dimensional visualization. It is now also possible to perform surgical interventions in areas hard to access using classical surgical or laparoscopic techniques, thus significantly enhancing patient safety. The introduction of robotics has led to a fundamental turning point for laparoscopic vascular surgery, which has always entailed relatively difficult manipulation with instruments and a lengthy procedure time to construct the vascular anastomosis, leading to long aortal clamping times.6–8 The robotic system removes these fundamental disadvantages of laparoscopy and opens up the possibility of expanding robot-assisted laparoscopic surgery in this area.9–13
Between November 2005 and November 2011, 225 patients underwent robot-assisted aortoiliac procedures. One hundred seventy-four patients were prospectively evaluated for occlusive diseases (ODs), 43 patients for abdominal aortic aneurysm (AAA), two for common iliac artery aneurysm, two for splenic artery aneurysm, three for hybrid procedures, and one for endoleak II treatment after endovascular aneurysm repair (EVAR). The robotic system was applied to construct the vascular anastomosis for thromboendarterectomy, for aortoiliac reconstruction with a closure patch, for dissection of the splenic artery, and for posterior peritoneal suturing. A combination of conventional laparoscopic and robotic surgeries was routinely included. A modified fully robotic approach without laparoscopic surgery was used in the last 55 cases in our series.
The transperitoneo-retroperitoneal approach (TRA), first described in 1997, is currently the most commonly used approach in traditional laparoscopic abdominal aortic surgery.14 During TRA, the retroperitoneum is opened along the descending colon, after which both the peritoneum and the colon are fixed by several stitches to the abdominal wall. This creates an effective barrier to the small bowel, allowing perfect preparation of the aorta and subsequent reconstruction. With this approach, the working area is adequate and a smaller Trendelenburg position is possible. One disadvantage is the relatively large uncovered area in the retroperitoneum, with possibly greater blood or lymph loss.
A simpler method, which is actually a combination of transperitoneal and TRA, was described in 2005. In this modification, used in aortic surgery, the small bowel and the omentum are pushed toward the diaphragm and the liver. The retroperitoneum is opened on the left side of the aorta from its bifurcation to the left renal vein alongside the left gonadal vein. The posterior peritoneum with preaortic fat and ganglia is freed, as necessary, up to the right aortic wall and stitched up to the parietal peritoneum. Thus, mobilization of the entire descending colon is not required.15
The modified transperitoneal approach is used for most robot-assisted vascular procedures. In the great majority of cases, the Da Vinci robotic system is positioned for use on the patient’s right side (Fig. 1). In most robotic vascular reconstructions, three robotic arms are used; only in the case of iliac artery aneurysm or combined aneurysmal disease of the aorta and iliac arteries and in renal artery surgery is a fourth arm used to provide retraction. Robot-assisted vascular surgery can be performed either in a combined manner using standard laparoscopy and the Da Vinci robotic system or fully robotically. During the combined procedure, the arteries are prepared laparoscopically and the vascular anastomosis is then performed robotically. In the case of a full robotic operation, all the steps in the procedure are performed robotically.
The patient is placed on his or her right side at a 30- to 45-degree angle, in a mild Trendelenburg position (10–15 degrees), with the left arm lying along the length of the body. Trocar positioning is slightly different from that of conventional laparoscopy because of the volume of the articulating robotic arms. The pneumoperitoneum is secured via a minor left subcostal incision with an abdominal pressure of 12 mm Hg. A 12-mm trocar for the robotic arm is introduced. The next two 12-mm trocars are inserted below the costal margin between the midclavicular and the anterior axillar line. The last three 12-mm ports are inserted on the posterior axillar line (Fig. 2). The first triad of trocars is used for robotic arms; the second triad is for the central endoscopic aortic clamp, peripheral clamp, or balloon closing catheters; and the middle one is for the assistant’s instruments. We usually use six ports, with one extra on the left suprainguinal area in case of an AAA—the second assistant’s port.
The first 170 cases were treated using a combination of laparoscopic and robotic surgery. Dissections of the aorta and iliac arteries were performed laparoscopically, and the robotic system was used to construct the anastomoses, to perform thrombendarterectomy, and for posterior peritoneal suturing.
During a fully robotic vascular procedure, all steps are performed robotically only. The subrenal aorta and both common iliac arteries are exposed, and the inferior mesenteric artery (IMA) is usually temporarily clipped, except in AAA resection. In patients who have had an AAA, the IMA is interrupted and visible LAs are clipped. After the aneurysmal sac is opened, the robotic technique is used to internally control the remaining LAs with free 4-0 shortened polytetrafluoroethylene stitches (Fig. 3). In the case of aortofemoral bypass, tunneling is performed from one or both sides of the groin under the direct view of the laparoscopic video camera using a long DeBakey aortic vascular clamp.
A conventional knitted Dacron vascular prosthesis (Albograft; Sorin Biomedica Cardio, SpA, Saluggia, Italy), with attached shortened 3-0 or 4-0 Gore-Tex suture (W.L. Gore & Associates, Flagstaff, AZ USA), is inserted into the abdomen through a 12-mm trocar.
The robotic system is used particularly to construct the central anastomosis (twice for both anastomoses in the case of tube grafts and thrice in the case of aortoiliac graft), to perform thromboendarterectomy, and in most cases of posterior peritoneal suturing (Fig. 4–6). The role of the assistant at the patient’s side is limited to assisting during the dissection, maintaining hemostasis, and in ensuring traction on the running sutures performed by the robot.
Our experience to date allows us to claim that vascular anastomosis can be performed robotically both on the aorta and the pelvic artery with good results and, in fact, more easily than with classical laparoscopic surgery. Another possible procedure is the removal of atherosclerotic masses from the lumen of the aorta or pelvic arteries that could cause narrowing of the vessels; the robotic system can thus be used for thromboendarterectomy of large vessels and subsequent patch grafting of the desobliterated arteries.
A no less interesting area of robotic surgery is AAA surgery. In this particular case, the robot is used to do vascular anastomoses, remove thrombotic masses from the aneurysmal sac, ligate the lumbar arteries (LAs) that bleed back when the sac is opened, and finally, close off the sac of the aortic aneurysm after reconstruction. All the previously described procedures end with the robotic suturing of the retroperitoneum in the abdominal cavity. A further interesting application of the robotic system is in the reconstruction of visceral arteries, for example, splenic artery aneurysm surgery and renal artery reconstruction, as well as hybrid procedures, the first of which has also been added to our range of robotic vascular surgery interventions (Fig. 7). We can use the Da Vinci Surgical System for robotic ligation of the IMA or LAs and for treatment of a persistent endoleak from the IMA or LA into the aneurysm sac after EVAR. Retrograde flow from IMA or LA may be observed initially because spontaneous thrombosis frequently occurs. A persistent type II endoleak should be treated when the aneurysm increases in size after EVAR.
In robotic surgery, a hybrid procedure may involve a combined vascular and general surgical procedure or a purely vascular intervention. The combination with general surgery may involve robotic vascular surgery, for example, an aortofemoral bypass or AAA and umbilical hernia or hernia in the scar of a previous laparotomy.
The simplest combination in purely vascular hybrid procedures is angioplasty with vascular reconstruction or lumbar sympatectomy with iliofemoral or aortofemoral bypass. Other possible combinations are endovascular intervention (eg, thoracic aortic stent graft) with revascularization of a visceral artery (eg, renal) and aortofemoral reconstruction with renal artery endarterectomy.
Two hundred seventeen cases (96%) were successfully completed robotically; one patient’s surgery was discontinued during laparoscopy because of heavy aortic calcification. In seven patients (3%), conversion was necessary. The 30-day mortality rate was 0.4%, and nonlethal postoperative complications were observed in 10 patients (4.4%). One AAA patient died of multiorgan failure during the postoperative period. In this case, only robotic aortoiliac dissection was performed, with no initial laparoscopic aortic clamping or robotic vascular anastomosis. The operation was converted to open surgery because of unfavorable anatomic findings and the consequent open AAA surgery was technically problematic with a long clamping time.
Patients with serious medical problems and those who had previously undergone major abdominal surgery were excluded from the clinical study. The disease was classified in accordance with the American Society of Anesthesiologists (ASA) classification. Patients with ASA IV to V, significantly abnormal cardiac, pulmonary, hepatic, and renal test results, were not offered a robot-assisted procedure. They included five aortoiliac thromboendarterectomies with a prosthetic patch and 24 iliofemoral, 69 aortounifemoral, and 76 aortobifemoral bypasses (ABFBs). Forty-two patients were treated for AAA, two for common iliac artery aneurysms, and two for splenic artery aneurysms (Fig. 8). Two patients underwent renal artery reconstruction, and one patient underwent endoleak II treatment after AAA repair. In two cases, the finding was inoperable because of severe aortic calcification and aortitis. Two operations in the group were hybrid. One was a combination of incisional hernia prosthetic mesh repair with ABFB, and in the second case, an iliorenal bypass with thoracic stent graft in a patient with symptomatic type B aortic dissection with unilateral right renal artery stenosis was performed.
As most vascular surgeons, we treat TransAtlantic InterSociety Consensus (TASC) A and B lesions with endovascular procedures. In the case of our robot-assisted patients, we preferred to treat TASC C and D with surgery.
The patient group was made up for 173 men and 52 women, with a mean age of 64 years (range, 38–79 years).
The conversion to standard surgery was caused by prolonged bleeding from the LAs or from the central anastomosis during AAA surgery.
The first converted patient had postoperative fever, and methicillin-resistant Staphylococcus aureus was detected from the central venous catheter and hemoculture. In this case, antibiotics were applied during a 6-week period. One patient had an incisional hernia in the port 9 months after the first operation, which was treated under local anesthesia, and five late graft limb occlusions required a thrombectomy and a prosthetic profundaplasty. The next two complications were hydronephrosis caused by pressure from the ureter on the arms of the aortofemoral reconstruction that passed over the urinary ducts. In this patient, stents were first introduced into both urinary ducts, then a release of the ureter through reduced extraperitoneal incisions was subsequently performed as a single procedure. We saw one asymptomatic occlusion of the aortorenal bypass.
On one occasion (0.4%), a technical failure of the robotic equipment occurred during the operation, and the procedure was therefore completed laparoscopically. Two cases (0.9%) had to be abandoned for an inoperable finding in the subrenal and suprarenal area (calcified aorta and severe aortitis). The individual types of vascular reconstruction are listed in Table 1. Details of the patient cohort are provided in Table 2, and perioperative and postoperative data are provided in Table 3.
The median operating time was 227 minutes (range, 150–360 minutes), with a median clamp time of 56 minutes (range, 21–120 minutes). Median anastomosis time was 28 minutes (range, 12–60 minutes). Median blood loss was 670 mL (range, 50–4000 mL), median intensive care unit stay was 1.5 days (range, 1–5 days), median ventilator support was 7 hours (range, 0–48 hours), and the median hospital stay was 5 days (range, 4–10 days). If we separate data for patients treated for OD and for aneurysm, the median clamping time was 39 minutes for the first group and 76 minutes for the second group. The median anastomosis times were not significantly different between patients treated for OD and aneurysms: 24 and 28 minutes, respectively. Nearly all patients began a liquid diet 1 day after surgery and a solid diet at 2.5 days.
The use of robots in vascular surgery is thought to result in a better surgical performance. Cau et al16 describe and evaluate the results of laparoscopic aortic surgery. Median clamping time varied here from 60 to 146 minutes. From a practical point of view, the greatest advantage of the robot-assisted procedure has proved to be the speed of construction of the vascular anastomosis. This has helped to eliminate the greatest disadvantage of laparoscopic vascular reconstruction—lengthy clamping time. Reducing the time needed to construct the anastomosis also shortens the period of temporary ischemia of the lower limbs while the aortal clamps are being placed. These times are now comparable to those of standard vascular surgery and provide all the advantages of minimally invasive surgical techniques. Patients mainly benefit through shorter hospitalization periods and an early return to their normal activities and working life, which, in most cases, is not significantly restricted. Another important factor is the excellent cosmetic result. A further advantage of this method is that it can also be used with obese patients, where standard interventions are technically demanding and often involve problems with the healing of wounds after laparotomy.
When this method was first introduced, particularly in the early stages, mostly younger patients with no associated disorders were indicated. As the team’s experience increases, the circle of candidates suitable for robotic-assisted procedures is constantly being widened. However, operations on the abdominal aorta are generally extremely traumatic for patients and are associated with a high level of risk, particularly for polymorbid patients with more serious forms of ischemic heart disease and failing renal and respiratory functions. Patients with acute forms of obstructive pulmonary disease are not suitable for either laparoscopic or robot-assisted procedures, given the need for a capnoperitoneum. A contraindication for capnoperitoneum automatically entails a contraindication for laparoscopic-robotic vascular procedures. On the other hand, we had a successful outcome in two patients with severe left ventricular dysfunction after myocardial infarction (25 and 29%). They underwent robot-assisted procedures with low-pressure pneumoperitoneum (8–10 mm Hg).
Patients should also not be indicated for these interventions after major intra-abdominal operations with numerous peritoneal accretions, but adhesions after previous laparotomy may sometimes help create a clear working field. Obesity is no longer a major contraindication (Fig. 9).
Robotic surgery is today developing into a multidisciplinary modality used by surgical departments that deal with the soft tissue structures in the abdominal or thoracic cavities. It also has all the advantages of minimally invasive methods. It is specifically used for general abdominal surgery, gynecology, urology, oncosurgery, thoracic, vascular, and cardiac surgery. Robotic surgery centers are generally established as a separate multidisciplinary operating theater, shared among the individual specialists, to perform field-specific procedures.17–20
Robot-assisted surgery was first introduced in cardiac surgery. Although the Da Vinci system has been used by a variety of disciplines for laparoscopic procedures, including cholecystectomies, mitral valve repairs, radical prostatectomies, reversal of tubal ligations, and many gastrointestinal surgeries, nephrectomies, and kidney transplantations, the use of robots in vascular surgery is still relatively rare.
Few people can now imagine general surgery or gynecology without laparoscopic techniques, although this was not initially the case. In addition to advancements in knowledge of anatomy, physiology, biochemistry, and a number of other related disciplines, this development was boosted by modern light and image transfer technologies, the development of the chip camera, and other innovations. The growing experience of physicians with robotic surgery brings new benefits. The increasing success and use of robotics will lead to a growth in the need for trained physicians with the appropriate licenses to provide patients with complex medical services. Many professional medical societies and training programs use this type of technology to assess the ability of health care professionals during the certification procedure.
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This article by Štádler et al describes an impressive single-center experience with 225 consecutive patients with aortoiliac vascular disease during a 6-year period who were treated with robot-assisted laparoscopic vascular procedures. Several different disease entities were treated, including aortoiliac occlusive disease, abdominal aortic aneurysms, and iliac artery aneurysms. The outcomes from this innovative surgical approach are noteworthy. There was a 3% conversion rate, and the 30-day mortality rate was 0.4%. Nonlethal postoperative complications were 4.4% (10 patients).
The authors describe an evolution of their technique during the series. The first evolutionary modification was converting from a totally retroperitoneal approach to a modified transperitoneal and retroperitoneal approach. This avoids mobilizing the entire descending colon. The second modification was the evolution to a fully robotic approach. A combined laparoscopic and robotic approach was used in the first 170 patients. The remainder of the patients received a fully robotic approach using six or seven ports. The authors state that the vascular anastomoses are easier to complete robotically versus laparoscopically.
Robotic repair of the infrarenal aorta and iliac arteries for complex vascular disease represents a significant step forward in minimally invasive vascular surgery. Endovascular stents and stent grafts have also played an important role in expediting patient recovery. There are still patients with complex aortoiliac anatomies that are not amenable to endovascular repair. For these patients, a new and significantly less invasive alternative to open surgery has been developed.