Purpose: We report four cases of laparoscopic vascular procedures (two iliofemoral bypasses, one aortobifemoral bypass, and one aortoiliac endarterectomy) performed with a technique that does not require insufflation of the peritoneal cavity with gas. Methods: Initially in the porcine model and later in patients, we developed a laparoscopic technique with a mechanical arm used to mechanically elevate the abdominal wall, creating a working cavity. Conventional vascular instruments were used in combination with laparoscopic devices. Five to seven ports were needed for the procedures (four to six ports of 0.5 to 1.5 cm and one incision of 4.0 cm). Exposure was maintained by use of reticulating fan retractors and laparotomy sponges. End-to-side technique was used for all graft anastamoses (cross-clamp time of 40 to 70 minutes). Distal anastamoses were performed through an open femoral incision. Operative time was 5 hours (iliac procedure) and 7 hours (aortic procedure). Results: All patients were ambulating and tolerating a regular diet within 24 hours (iliac procedures) or 48 hours (aortic procedures) after operation. They were discharged home on the second (iliac procedures) or third (aortic procedures) postoperative day. Within 1 week they had resumed normal daily activities. No complications occurred, and no blood bank products were transfused. When compared with the standard surgical approach, gasless laparoscopic technique gave a faster postoperative recovery with less pain and decreased the risk of wound herniation, dehiscence, and infection. From a laparoscopic standpoint, the use of disposable instruments was minimized and the theoretical risk of CO2 embolism eliminated. Conclusion: These four cases demonstrate that laparoscopic vascular bypass procedures are feasible and that the accepted advantages of laparoscopy can be extended to patients undergoing vascular surgery.
