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Combined Laparoscopic and Endovascular Treatment of Aortic Diseases
Endoleaks, endotension, and graft migration are the major problems of endovascular aneurysm repair (EVAR) when treating abdominal aortic aneurysms (AAAs). There are patients with endotension and aneurysms that increase in diameter without any evidence of patent lumbar arteries or a patent inferior mesenteric artery (IMA). Endovascular coiling of patent lumbar arteries or of the IMA is cumbersome, often requiring several treatment sessions by experienced interventionists. Laparoscopy offers a minimal invasive and expeditious alternative to graft explantation as well as to the time-consuming endovascular approach to treat type II endoleaks and endotension.
Laparoscopic treatment options for patients with endograft complications include clipping of the IMA and of lumbar arteries to treat type II leaks, laparoscopic downsizing of large aneurysms, laparoscopy-guided direct vascular access, and total laparoscopic conversion after failed EVAR and laparoscopy to facilitate complex total laparoscopic aortic procedures.
Laparoscopic techniques can be used to treat patients with type II endoleaks after EVAR. Lumbar arteries as well as the IMA can be occluded with clips. Yet the major advantage is that the aneurysm after EVAR can be remodeled laparoscopically. For example, the thrombus can be removed, which permits wrapping of the endograft as in a Creech procedure. Considering that thrombus is not an inert substance but a place for macrophages generating free oxygen radicals, which further weaken the aortic wall, the removal of thrombus material as occurs in open surgery can potentially enhance graft incorporation. Using special suturing techniques, the endoprosthesis can be attached to the aortic wall, preventing graft migration. This can be combined with a banding procedure to enlarge the landing zone and to prevent neck dilatation.
Operative Technique
A pneumoperitoneum is established and the abdomen is inspected. A transperitoneal retrocolic access combined with medial mobilization of the left kidney is preferred ( Figure 1 ). Alternatively, the left kidney can be left in situ. For more complex total laparoscopic operations like conversion after EVAR, up to eight trocars are required.
The retrorenal access described permits complete transperitoneal exposure of the abdominal aorta and, when necessary, suprarenal clamping. When an endograft has been in place for several months, there is quite often a dense inflammatory retroperitoneal reaction. In very rare cases under these circumstances a transperitoneal approach must be chosen.
The origin of the IMA is identified and the artery is divided between clips. When clips are too small to safely occlude the IMA, a vascular stapler is used. This facilitates further mobilization of the aorta. The aneurysm and the aortic neck are identified. As many lumbar arteries as are accessible are clipped on the left side of the aorta. Because access to the right-sided lumbar arteries is often very difficult because of the inflammatory changes, we now prefer a more direct approach, stitching lumbar arteries from inside as is done during open surgery.
Laparoscopic Remodelling of the Aorta After Endovascular Aneurysm Repair
The principal laparoscopic steps are performed without clamping the aorta because this would damage the endograft. Instead, transfemorally under fluoroscopic guidance, an aortic balloon occlusion catheter is introduced from the groin through a hemostatic sheath. This balloon is inflated before the sac of the aneurysm is incised to stabilize the graft inside the aorta. The balloon is inflated to prevent dislodging the endograft when taking out the thrombus.
The sac of the aneurysm is incised and opened with laparoscopic scissors in an H -shaped configuration ( Figure 2 ). The graft is inspected using the magnification of the 30-degree endoscope to exclude any damage of the fabric or stents. Laparoscopic graspers and a 10-mm suction–irrigation device are used to remove the thrombus material. Patent lumbar arteries are stitched from within using Vicryl sutures. The surgeon is standing on the right side of the patient. In addition to these steps, bioglues can be injected into the sac of the aneurysm to accelerate graft incorporation and to prevent any backbleeding from the lumbar arteries ( Figure 3 ). With a laparoscopic running suture (2–0 Prolene), the sac of the aneurysm is closed, wrapping the aorta tightly around the endograft.
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