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Totally laparoscopic bypass surgery for aortoiliac occlusive disease in China

GUO, Lian-rui; GU, Yong-quan; QI, Li-xing; TONG, Zhu; WU, Xin; GUO, Jian-ming; ZHANG, Jian; WANG, Zhong-gao

doi: 10.3760/cma.j.issn.0366-6999.20131091
Original article

Background Totally laparoscopic aortic surgery is still in its infancy in China. One of the factors preventing adoption of this technique is its steep learning curve. The objective of this study was to evaluate the feasibility and safety of laparoscopic surgery for aortoiliac occlusive disease (AIOD).

Methods From November 2008 to November 2012, 12 patients were treated for severe AIOD with a totally laparoscopic bypass surgery at our university hospital. The demographic data, operative data, postoperative recovery data, morbidity and mortality were analyzed and compared with those of conventional open approach.

Results Twelve totally laparoscopic aortic surgery procedures, including two iliofemoral bypasses (IFB), three unilateral aortofemoral bypasses (UAFB), and seven aortobifemoral bypasses (ABFB), were performed. Conversion to open procedures was required in three patients. The mean operation time was 518 (range, 325-840) minutes, mean blood loss was 962 (range, 400-2500) ml, and mean aortic anastomosis time was 75 (range, 40-150) minutes. Compared with conventional open approach for aortofemoral bypasses performed concomitantly during this period, laparoscopic patients required fewer narcotics and a shorter in-hospital stay and earlier recovery. Postoperative complications developed in four patients, including a single patient with transient left hydronephrosis, ischemic colonic fistula and pneumonia, residual aortic stenosis proximal to the anastomotic site, and asymptomatic partial left renal infarction. All patients recovered and were discharged on postoperative Days 7-14 except one patient that died of respiratory failure on Day 46. All grafts were patent with follow-up imaging performed by Duplex examination, with a mean follow-up time of 10.7 (range, 2-61) months.

Conclusion Totally laparoscopic bypass surgery is a feasible and safe procedure for AIOD, but attention needs to be paid to improve laparoscopic skills of vascular surgery in order to minimize morbidity during the learning curve of this advanced procedure.

Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing 100053, China (Guo LR, Gu YQ, Qi LX, Tong Z, Wu X, Guo JM, Zhang J and Wang ZG)

Chin Med J 2013;126 (16): 3069-3072

Correspondence to: Dr. GU Yong-quan, Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing 100053, China (Tel: 86-10-83198605. Fax: 86-10-83125113. Email:

(Received April 23, 2013)

Edited by GUO Li-shao

Although laparoscopic techniques have been widely used since 1982, when gynecologist K. Semm performed the first laparoscopic appendectomy,1 a similar development of laparoscopic techniques did not occur in vascular surgery until 1993, when Dion et al performed the first case of laparoscopic-assisted aortobifemoral bypass.2 The totally laparoscopic aortobifemoral bypass was first reported by Dion et al3 in 1996, who aimed to achieve outcomes equivalent to the standard open aortobifemoral bypass but with the advantages of minimally invasive techniques. After this seminal report, several case series reported the adoption of this minimally invasive technique;4-8 however, general acceptance of laparoscopic aortic surgery in the broad vascular surgery community has been rather slow and generally confined to a few large medical centers. In China, we are the first to perform totally laparoscopic aortic bypass for aortoiliac occlusive disease (AIOD), and have completed the largest case series to date. We present our initial experience evaluating the feasibility and safety of total laparoscopic bypass surgery for AIOD and compared the results with open aortofemoral bypasses performed in our department during the same period.

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The inclusion criteria for the totally laparoscopic technique were patients with AIOD who could not be treated by, or failed treatment with, percutaneous transluminal angioplasty and stenting. Patients with morbid obesity and/or previous abdominal surgery and/or highly calcified aorta that might not be securely clamped were excluded, as were patients with significant comorbid medical problems such as severe cardiac, pulmonary, or renal disease. Informed consent was obtained from all patients. The records of these patients were reviewed retrospectively.

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Surgical technique

All procedures were performed by the same operating team. A transperitoneal left retrocolic retrorenal approach was used for all patients, as previously reported by Coggia et al.9 All patients received general anesthesia. The patient was placed in dorsal decubitus position, with a pillow placed behind the left flank; the operating table was rotated maximally to the right, to an approximate slope of 70-80 degrees. The lower extremities were flexed 30° and positioned parallel to each other. After induction of pneumoperitoneum through a Veress needle to a pressure of 12-14 mmHg, a laparoscope with a 30° view was inserted below the umbilicus. After abdominal exploration, the remaining five to six trocars were introduced into the left abdomen under video control (Figure 1). Dissection began with incising the left paracolic gutter up to the splenic flexure, and then developing the avascular plane medially to reach the aorta, elevating the left colon and kidney, and thus performing a right medial visceral rotation. Exposure of the infrarenal aorta was then achieved distally to the common iliac arteries. Particular attention was required in identifying and isolating lumbar branches and the inferior mesenteric artery to avoid bleeding; preoperative lateral aortography helped to localize these arteries, which were occluded with clips. Multiple 3-0 polypropylene (Prolene Ethicon; Johnson & Johnson, USA) sutures knotted on PTFE pledgets were prepared.

Figure 1.

Figure 1.

After the patient was given 5000 IU of heparin intravenously, the proposed site for anastomosis was clamped proximally and distally. A 2.5 to 3.0 cm arteriotomy was performed. Preclotted Dacron grafts were used. The diameter of the graft was 8 or 9 mm for iliofemoral bypasses (IFB) and unilateral aortofemoral bypasses (UAFB), and either 16 mm×8 mm or 18 mm×9 mm for aortobifemoral bypasses (ABFB). The vascular prosthesis was beveled to enable a smooth end-to-side aorta-prosthesis anastomosis, and introduced into the abdomen through one of the trocar sites. A long, curved atraumatic grasper was inserted through the left groin and gently moved through the retroperitoneum under video control, The graft limb was then grasped and pulled down to the left groin. The aorta-prosthesis anastomosis was begun with two hemicircumferential running sutures which were previously knotted onto pledgets and then tied together intracorporally. The clamps were successively opened, and the anastomosis was tested for hemostasis (Figure 2). The right limb of the graft was brought down with the help of a curved atraumatic grasper introduced through the right groin. The patient was returned to a dorsal decubitus position, and the prosthesis-femoral artery anastomoses were performed with the typical open technique. Laparoscopic inspection of the left colon was then performed to assess its viability. At closure a closed-suction drain was positioned near the prosthesis. The mesocolon and small intestine fell back into place as soon as the patient was returned to the dorsal decubitus position. The abdominal fascia was closed around the trocar port sites.

Figure 2.

Figure 2.

Postoperative monitoring and care was provided in the same fashion as was after open procedures; drains were removed within 24-48 hours, and the patients were discharged after a CT scan (Figure 3) and healing of inguinal incision sites.

Figure 3.

Figure 3.

During the same period, 18 patients underwent conventional open aortofemoral bypass for AIOD in our department. All open procedures were transperitoneal. Patients' preoperative data of both totally laparoscopic and open aortobifemoral bypasses groups are summarized in Table 1. The two groups were compared with regard to operative and postoperative data (Table 2). In addition, complications in both groups were reported.

Table 1

Table 1

Table 2

Table 2

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Statistical analysis

An independent statistician performed all advanced statistical analyses. Comparison of categorical variables between two groups was calculated by the χ2 test, and comparison of continuous variables used independent-samples t test. Count data were summarized as frequencies and continuous variables as means±standard deviations. A P-value of <0.05 was considered to be statistically significant. Statistical Analysis Software (SPSS) version 16.0 (Chicago, IL, USA) was used for the statistical analysis.

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From November 2008 to November 2012, we treated 12 AIOD patients with totally laparoscopic bypass surgery, including two IFB, three UAFB, and seven ABFB. All the patients were male, with an average age of 59.5 (range, 52-70) years. Indications included disabling claudication in eight patients (67%), ischemic rest pain in two patients (17%), and minor tissue loss in two patients (17%). Eight patients were active heavy smokers (67%), five were hypertensive (42%), six were diabetic (50%), and two had a past history of myocardial infarction (17%). Patients were classified in accordance with the TransAtlantic Inter-Society Consensus document (TASC) classification for AIOD; type C lesions were present in 4 patients and type D lesions in eight patients. Preoperative data are summarized in Table 1. Five patients underwent combined revascularization procedures, including three infrainguinal bypasses and two femoral endarterectomies. The operative data and outcome are summarized in Table 2.

Conversion to open surgery occurred in three patients. Patient 1 underwent conversion for acute bleeding from the inferior mesenteric artery just after finishing the aorta-prosthesis anastomosis. Patient 2 underwent conversion for intraoperative perforation of the descending colon when tunneling the right graft limb secondary to difficulty in retracting the inflated bowel. An emergency repair was done without spillage, but on Day 5 a colostomy was performed due to an ischemic colonic fistula proximal to the injury site. The patient restarted oral feeding on Day 10. Patient 6 underwent conversion for bleeding (estimated blood loss 2500 ml) proximal to the bypass anastomosis, at an aortic clamp site that was heavily calcified, near the end of the bypass surgical procedure. This patient also had intraoperative graft thrombosis requiring thromboembolectomy.

The mean operating time was 518 (range, 325-840) minutes, the mean aortic anastomosis time was 75 (range, 40 150) minutes, and the mean estimated blood loss was 962 (range, 400-2500) ml. The mean postoperative length of stay in the hospital was 12.9 days.

Postoperative complications developed in four patients. Patient 1 had an asymptomatic transient left hydronephrosis which healed well after drainage. Patient 2 had to undergo a colostomy on Day 5 due to an ischemic colonic fistula proximal to a colonic injury site, and also suffered aspiration pneumonia on Day 21, which ultimately caused respiratory failure and patient death on postoperative Day 46. Patients 10 and 12 had juxtarenal aortoiliac occlusion that required Fogarty catheter thrombectomy during laparoscopic surgery. Patient 10 had a severe residual aortic stenosis proximal to the anastomosis site that was treated with endovascular stenting on postoperative Day 12; patient 12 had a small partial asymptomatic left renal infarction that was incidentally found on a CT scan. The other patients recovered with a smooth postoperative course and were discharged from the hospital between postoperative Days 5 and 14.

All patients that were discharged from the hospital were followed with standard follow-up and care. The mean time of follow-up was 10.7 (range, 2-61) months. All grafts were patent on physical examination and Duplex evaluation. The clinical Rutherford grade improved in all patients. The mean resting ankle-brachial index was increased from 0.43 (range, 0.2-0.6) preoperatively to 1.0 (range: 0.9-1.2) postoperatively.

Comparisons were made between totally laparoscopic and open aortobifemoral bypasses (Table 2). Because the significant learning curve involved, we divided the 12 laparoscopic patients into two subgroups: patient 1-6 and patient 7-12 and compared the patient 7-12 laparoscopic subgroup with open aortobifemoral bypasses (Table 3).

Table 3

Table 3

Major complications of the open aortobifemoral bypasses group included that one patient developed pneumonia, one patient developed myocardial infarction, one suffered stroke, and all discharged without death. The open bypass group showed a less operative time but the laparoscopic bypass group (especially the last 6 patients subgroup) showed a shorter intensive care unit stay, earlier diet beginning, and the laparoscopic patients were remarkably observed smooth recovery with less wound discomfort.

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The aim of laparoscopic aortic surgery is to combine the excellent and durable results of conventional open arterial bypass surgery with the advantages of a less invasive laparoscopic approach. Initially, laparoscopic procedures were performed with the assistance of a minilaparotomy through which aortic anastomoses were performed under direct vision with conventional instruments.2 More recently, totally laparoscopic procedures have been developed to enhance the major advantage of minimally invasive surgery with a faster recovery; these totally laparoscopic approaches have been performed both for complex AIOD6,8,9 and infrarenal aortic aneurysms7 with faster recovery, minimal wound discomfort, and fewer respiratory complications compared with conventional open surgery. As recommended treatment by the TASC,10 we usually treat TASC A and B lesions with endovascular procedures. However, for TASC D lesions, open aortic bypass has been the standard treatment for its long term patency and <3% mortality, despite its substantial systemic morbidity,10 as well as relatively slow postoperative recovery. In 2008, we were the first group in China to treat extensive AIOD with total laparoscopic aortic repair, after extensive training in the porcine model.11

The primary difficulties with laparoscopic infrarenal aortic surgery are the exposure of the abdominal aorta and the performance of laparoscopic anastomoses.8 The transperitoneal retrocolic-retrorenal approach described by Coggia et al9 is the only approach that we have used as it offers easy and wide exposure of the infrarenal aorta, even including the suprarenal aorta.9 As expected with initial experience, the operative time and aortic anastomosis time were much longer than that usually observed in open aortic bypass.2,5,6,9,12,13 With experience, we had reduced operative time, morbidity, and blood loss, leading to reduced numbers of cases requiring conversion despite increased case complexity. However, our experience shows that circumferential aortic calcification should be treated as a relative contraindication for this technique, especially if suprarenal clamping is not technically possible, or early in one's experience. Other contraindications should include obesity, untreatable coronary lesions, severe cardiac insufficiency, and renal insufficiency.12

One difficulty with the transperitoneal left retrocolic approach is the tunneling of the right graft limb. We solved this problem by exploring more distally along the aorta to the bifurcation, shortening the tunnel length, and reducing the tunneling time to approximately 5-10 minutes. We also found the treatment of juxtarenal aortic occlusion quite challenging, with the main obstacles being renal ischemia and difficulty in exposure. We solved this problem by performing a high infrarenal clamp placement, rather than suprarenal clamp placement, and then performing thromboembolectomy from the graft limb after the creation of the aorta-prosthesis anastomosis and limb tunneling.

Due to the technical challenges and the associated steep learning curve,14 no randomized controlled trials have been performed to show the cost-to-benefit ratio of laparoscopic aortic surgery compared with open or endovascular techniques. Despite the lack of trials, several authors have reported the advantage of a shorter hospital stay, fewer respiratory complications, quicker resumption of intestinal transit, less analgesia requirements, and fewer abdominal wall complications, as we observed. We estimate that the steep learning curve of this procedure requires 25-30 cases.14 The totally laparoscopic aortic technique is an alternative approach to reduce morbidity in selected AIOD patients, but multi-centre randomized trials and long term follow-up will be needed to prove the benefit of this procedure.

Acknowledgements: The authors thank Prof. Alan Dardik (in Yale University School of Medicine) for his help in correcting all the English in the paper.

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aortoiliac occlusive disease; aortic laparoscopy; aortofemoral bypass

© 2013 Chinese Medical Association