Total laparoscopic bypass for aortoiliac occlusive lesions:: 93-case experience

Objectives. We describe our experience with a new technique of total laparoscopic bypass surgery to treat aortoiliac occlusive lesions. Material and methods: From November 2000 to December 2003, 93 total laparoscopic bypass procedures were performed to treat TASC (TransAtlantic Inter-Society Consensus document) grade C or D aortoiliac occlusive lesions. We also reimplanted 2 inferior mesenteric arteries, and performed 3 prosthesis-superior mesenteric bypasses and 2 suprarenal aorta endarterectomies. Our technique includes a sloping right lateral decubitus installation, which enables a simple transperitoneal left retrocolic or retrorenal approach to the infrarenal abdominal aorta. In patients with a hostile abdomen a retroperitoneal videoscopic approach was used. Aorta-prosthesis laparoscopic anastomoses are performed simply, which averts any trauma to the suture material. Results. Patients included 76 men and 17 women, with median patient age 61 years (range, 38-79 years). The approach to the aorta was always possible, in particular, in obese patients. It enabled stable aortic exposure during performance of the laparoscopic aorta-prosthesis anastomosis. Median operative time was 240 minutes (range, 150-450 minutes). Median aortic clamping time measured to unclamping of the first prosthetic limb was 67.5 minutes (range, 30-135 minutes). Median duration of aorta-prosthesis anastomosis was 30 minutes (range, 12-90 minutes). The longest durations were mainly observed during the learning curve. Thirty-day postoperative mortality was 4% (4 of 93 patients). Two patients died of myocardial infarction. One patient with American Society of Anesthesiologists grade 4 disease operated on to treat critical ischemia died of multiple organ system failure, and 1 patient died of colonic ischemia. Major nonlethal postoperative complications were observed in 4 patients, and included lung atelectasia in 2 patients, graft infection in 1 patient operated on emergently to treat aortic occlusion, and secondary spleen rupture at day 5 in 1 patient. Median hospital stay was 7 days (range, 2-57 days). With a mean follow-up of 19 months (range, 1-37 months), complete recovery was observed in 89 patients, and all grafts were patent. One patient had kinking of a prosthetic limb at the groin, and in 1 patient Staphylococcus epidermidis graft infection developed, which was treated with in situ replacement with a rifampin-bonded graft. Conclusion: Total laparoscopic aortic bypass is feasible. In patients with TASC C and D aortoiliac occlusive lesions, short-term outcomes are comparable to those with conventional aortic bypass. After the initial learning curve, laparoscopic technique may reduce the operative trauma of aortic bypass.