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Laparoscopic Aortic Surgery for Aneurysm and Occlusive Disease: Technique and Results
Introduction
Today the vast majority of aortic and iliac vascular procedures can be performed by endovascular techniques, yet there are still some indications where open surgical repair or a less invasive technique is indicated. Some of these procedures can be performed using video endoscopic approaches.
Currently two laparoscopic approaches are available for abdominal vascular surgery: total laparoscopic aortic surgery in patients with occlusive disease and hybrid techniques that combine laparoscopy with endovascular techniques to treat failing endografts. We also have to distinguish between a total laparoscopic approach versus a laparoscopic assisted procedure.
The role that laparoscopic surgery will play in vascular surgery must be determined in the context of randomized controlled trials (RCTs). At present it is not realistic to believe that laparoscopic surgery will be widely adopted and implemented by the vascular surgical community because of alternative procedures that are easier to perform and have low morbidity. Although the potential to avoid the cost and inconvenience of lifelong surveillance that is required to monitor and address complications that develop following endovascular interventions is enticing, new laparoscopic instruments and technology that make intracorporeal suturing, hemostasis, and clamping easier are needed to help spur continued interest in laparoscopic vascular surgery and facilitate the performance of these techniques by more vascular surgeons.
Laparoscopy has played a crucial role in the development of abdominal surgery over the past three decades as it is generally perceived as a less invasive treatment modality. Advances in catheter-based interventions have similarly raised an overall level of enthusiasm in minimally invasive vascular treatment strategies. Although endovascular intervention is commonly regarded as the less invasive treatment modality in the treatment of occlusive and aneurysm conditions, laparoscopic intervention has played an increasingly important role in the contemporary treatment paradigm of vascular disease management. Laparoscopy can be incorporated into vascular surgery in several ways, including (1) hand-assisted laparoscopic surgery (HALS), where the nondominant hand is placed intracorporeally to assist with dissection and anastomosis; (2) laparoscopically assisted dissection with mini-incision, where the vascular anastomosis is performed using open surgical techniques; and (3) total laparoscopic surgery, where the dissection and vascular anastomosis are performed under pneumoperitoneum.
Just as there are many ways in which the aorta can be exposed during open surgery, aortic exposure can also be accomplished in several ways laparoscopically. Several examples of these approaches include (1) a direct midline transperitoneal approach, (2) a retrocolic intraperitoneal approach, (3) a retrorenal intraperitoneal approach, and (4) a retroperitoneal approach. The advantages and disadvantages of each of these techniques are published in the literature and are not the focus of this chapter; suffice it to say that there are proponents and opponents of laparoscopically assisted procedures, hand-assisted procedures, and totally laparoscopic procedures and of the various exposures. To date, the majority of the vascular community does not accept that the acquisition of laparoscopic skills is warranted because unless there are dramatic advances in the ease with which laparoscopic suturing, clamping, control of bleeding, and hemostasis can be accomplished, it is unlikely that laparoscopic procedures will gain the widespread popularity that endovascular interventions enjoy. However, not all patients are amenable to endovascular repair, and laparoscopic aortic repair may have a niche indication in select cases. Anatomic limitations are the impetus behind the pursuit of other minimally invasive therapeutic alternatives in vascular surgery.
Techniques
Laparoscopic Aortobifemoral Bypass
Laparoscopic procedures are best performed in designated minimally invasive operating suites with monitors placed enabling the entire team to follow the case. Our preference is for the surgeon and two assistants to stand on the patient's right side. The patient is placed on a vacuum bag to maintain him or her in the right lateral decubitus position during the procedure. To optimize displacement of the viscera, the table is also tilted to achieve a right-sided 70-degree rotation. Six or seven laparoscopic ports are used, depending on the size of the patient ( Fig. 44.1 ). The first 11-mm trocar is placed through a left paramedian incision, two finger widths from the umbilicus, and is used to establish the pneumoperitoneum (12 mm Hg). A 45-degree optic (Storz Endoscopy, Tuttlingen, Germany) is the preferred camera system. Three or four more trocars are placed four finger widths apart from each other along this line. The trocars are used for passage of the optic, dissection instruments, laparoscopic sponge sticks, and needle drivers. During the initial retrorenal or retrocolic dissection, the optic is placed in one of the upper paramedian ports. Another trocar is placed in the left subcostal position in the midclavicular line for passage of the optic during dissection of the aorta and performance of the proximal anastomosis. Trocars are also placed paralleling the left inguinal ligament for passage of the distal aortic or iliac clamps and the suction-irrigation apparatus. A trocar placed laterally in the left flank is used for the kidney retractor to facilitate exposure during the proximal anastomosis. A subxiphoid trocar serves for placement of the proximal aortic clamp (Storz Endoscopy).
The left hemicolon, including the splenic flexure, is mobilized medially. The technique of medial mobilization to separate the abdominal contents from the retroperitoneal space was originally described by Dion and colleagues. The line of Toldt is used as a landmark when the lateral attachments of the sigmoid colon are being incised. Incomplete mobilization of the splenic flexure may result in splenic injury during retraction, particularly in cases with adhesions from previous surgery. We use a left hemicolic retrorenal approach in most patients. This approach permits expeditious exposure of the aorta while avoiding mobilization and potential devascularization of the ureter. This approach also provides access to the suprarenal aorta. A special table-mounted laparoscopic holding system and fan retractor (Storz) are sufficient to maintain aortic exposure, even in obese patients. A large lumbar branch tethering the left renal vein on the lateral surface of the aorta is sectioned to allow complete retraction of the kidney. If thromboendarterectomy of the juxtarenal aortic stump is necessary, it is prudent to have suprarenal control; thus dissection is extended proximally. In patients with aortoiliac occlusive disease (AIOD), only the aorta proximal to the origin of the inferior mesenteric artery (IMA) is dissected to avoid damaging the lumbosacral nerves adjacent to the aortic bifurcation.
Deployable clamps (Storz Endoscopy) can be used to occlude the distal aorta; in this way, only the port for the proximal aortic clamp is obstructed with an instrument. The first assistant holds the camera and also helps put the tissue on tension with a grasping clamp. Alternatively, the first assistant provides suction and retraction while the second assistant folds the optic.
Lumbar arteries are controlled extraluminally from the left side using a laparoscopic clip applier (Tyco Healthcare, Mechelen, Belgium). After the left-sided lumbar arteries are clipped and divided, the adjacent right-sided lumbar arteries can be clipped. The limbs of a bifurcated graft are ligated with number 2 silk, the graft body is cut short in the appropriate configuration for the proximal anastomosis, and the prosthesis is passed intracorporeally. The right limb of the bifurcated graft is tunneled to the right groin to achieve a certain degree of stabilization of the prosthesis. Alternatively, the first assistant stabilizes the graft with a grasper. Tunneling to the left groin is not performed initially to minimize loss of pneumoperitoneum. In case of end-to-end aortic anastomosis, closure of the distal aortic stump is performed with a running polypropylene (Prolene) suture with pledgets. Coggia and colleagues have described fixing pledgets to 3-0 Prolene sutures to avoid the need for tedious laparoscopic knot tying. Stapled closure of the distal aortic stump is possible, but hemostasis is usually unsatisfactory. In patients with an end-to-side anastomosis, an aortotomy is performed and the anastomosis is started posteriorly with a 12-cm 3-0 Prolene suture. A second suture is taken anteriorly, and both are tied together intracorporeally. A laparoscopic nerve hook is useful to put the suture line on tension. The first assistant can follow the suture with an atraumatic DeBakey clamp (Storz) and suction blood that may be obscuring the operating field.
Laparoscopic Repair of an Abdominal Aortic Aneurysm
The initial retrorenal dissection is similar to that for laparoscopic aortobifemoral bypass (ABF). Dissection of the infrarenal aorta proceeds from the left iliac to the left renal artery. If needed, dissection of the juxtarenal aorta is possible from a retrorenal approach.
Lumbar arteries are clipped extraluminally either before cross clamping or after the aneurysm is clamped and the sac is decompressed. The ostia of arteries that are still bleeding after incision of the aneurysm sac are stitched with pledgeted laparoscopic 2-0 polyglactin 910 (Vicryl) sutures and secured with a titanium clip. The IMA is identified and, depending on the extent of backflow or the need for better exposure of the right iliac artery, can be ligated with a 12-mm endovascular GIA stapler (TSW 35, Autosuture, United Kingdom) or reimplanted. For an end-to-end anastomosis, the aorta is completely transected. Transection is carefully performed under laparoscopic visualization with a 45-degree-angled laparoscope to avoid any injury to lumbar arteries or veins. If anatomically suitable, tube grafts are inserted. When the iliac arteries are too calcified to permit stapling, the ostium of the common iliac artery (CIA) can be oversewn with a running 3-0 Prolene suture. Alternatively the common iliac artery can be blocked with a balloon catheter.
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