Total Laparoscopic Aneurysm Repair – Preliminary Experience

Ralf Kolvenbach

Laparoscopic assisted aortic aneurysm resection  requiring a mini laparotomy can be performed as a routine procedure.  We report now our preliminary experience with a total laparoscopic approach to treat patients with infrarenal abdominal aortic aneurysms.  We also wanted to test whether a masterslave robot could facilitate the total laparoscopic procedure.

Material and Methods:
A prospective, consecutive  number of 50 patients was evaluated. A transperitoneal left retrocolic access was used to expose the aorta. If possible a tube graft repair was performed. The aortic anastomosis was sutured totally laparoscopically with the surgeon standing on the right side of the operating table. In 10 consecutive patients the anastomosis was sutured with the help of the Zeus robot.
Results:
After excluding 3 cases who required suprarenal crossclamping  47 patients were operated using a total laparoscopic  approach. A totally  laparoscopic operation could successfully be performed in 39 patients with aneurysms.
In 8 patients ( 17 % ) conversion to a laparoscopic hand assisted operation with a 7 cm minilaparotomy was required.
The robot was used to perform the aortic anastomosis in 10 patients. In 8 patients a tube graft repair could  successfully be performed totally laparoscopically. In the remaining patients a bifurcated graft was implanted laparoscopically. The mean operating time was 227 min in the laparoscopy group and 242 min in those patients where the anastomosis was sutured with the help of the Zeus Robot. Mean crossclamping time was 81.4 + 31 min. None of the patients died perioperatively.  Major complications occurred in 3 patients ( 6.3 % ) . The overall morbidity was 14.8   % including one patient who  required temporary hemodialysis postoperatively.
The time to suture the aortic anastomosis was significantly shorter in the robotic group (40.8 + 4 min )  yet total operating time was longer in this group due to the technical complexity of the robotic device.  Patients with a total laparoscopic procedure asked for significantly less analgesics and could regain full mobility earlier compared to  those patients where a minilaparotomy after conversion to HALS was required.

Conclusion:
Total laparoscopic aneurysm resection can be offered to the majority of patients in our institution. The robot still requires further refinements to reduce operating times and the aortic crossclamping period.  We now have the technique and the instrumentation to offer laparoscopic aneurym surgery as a minimal invasive alternative to patients unsuitable for endovascular aneurysm repair.

Fig . I

Placement of trocars

Fig. II

Operating surgeon standing on the right side of the patient

Fig III

A Line of retroperitoneal dissection

B Suspension sutures to keep left kidney out of the way 

C Deployable aortic clamp 

D Distal anastomosis in a patient with a tube graft repair

Fig IV

Zeus Robot with robot arms attached to the operating table

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