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.
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).
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.
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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Keywords:© 2013 Chinese Medical Association
aortoiliac occlusive disease; aortic laparoscopy; aortofemoral bypass