Laparoscopic aortofemoral bypass grafting:: Human cadaveric and initial clinical experiences

Purpose: Postoperative complications are mainly related to the surgical trauma derived from the extensive abdominal incision and dissection after a conventional aortofemoral bypass grafting procedure. In an attempt to reduce postoperative complications, a concept of video-endoscopic vascular surgery on the infrarenal aortoiliac artery has been developed. On the basis of our experience with the practicability of video-endoscopic vascular surgery in the pelvic region in an animal study and in a pilot study of human cadavers, the purpose of this report was to describe three different methods that we evaluated on human cadavers and that we partly applied to patients. Methods: In this experimental study, three different approaches were used to perform video-endoscopic aortofemoral bypass grafting. We performed an observational trial on human corpses (n = 24) with the transabdominal-retroperitoneal approach (TARA), the extraperitoneal approach (EPA), and the transabdominal left paracolic approach (TAPA). The EPA also was applied to patients with aortoiliac occlusive diseases. Results: The TARA on cadavers (n = 4) soon was abandoned because it caused a burdensome sliding of the intestine into the operative field adjacent to the renal vessels, particularly in cases with obese subjects. In comparison, the TAPA (n = 6) with right-sided positioning of the patient retained the intestine in the right upper abdomen throughout the procedure. Until a surgeon actually is acquainted with the anatomic landmarks and the laparoscopic preparation technique, the EPA (n = 14) is a challenging procedure that necessitates thorough training. As with the TAPA, the EPA represents a procedure that reveals constant exposure of the operating field, even in cases with obese subjects. In the clinical observational study (n = 7), aortobifemoral bypass grafting was achieved totally laparoscopically with the EPA. The mean operating time was 6.5 hours and ranged from 3 to 10 hours. Blood transfusions were necessary after surgery in three patients (range, I to 3 red packed blood cells). One patient, who had had occlusion of the inferior mesenteric artery, died of ischemic colitis at postoperative day 10. The other patients had uneventful postoperative courses with minor wound discomfort. Conclusion: Laparoscopic vascular surgery seems to be a promising procedure to minimize postoperative complications. On the basis of our experience, we do not favor the TARA. Because it necessitates steep Trendelenburg positioning to displace intra-abdominal organs, the TARA is not an appropriate approach, particularly in obese and cardiopulmonary frail cases. Contrarily, the TAPA and the EPA deliver potentially better results in terms of exposing the operative field and thus reducing operating time and perioperative morbidity rates. A prospective cadaveric and clinical trial may be justified to further evaluate the use of these surgical techniques.