An Italian view of laparoscopic aortoiliac surgery


Mauro Ferrari, who is organising a section in the SICVE for minimally invasive techniques, gave Vascular News an update on laparoscopic aortoiliac surgery in Italy.

“I believe that laparoscopic aortoiliac surgery (LAIS) is still a newborn, although four years have passed since the first paper was published. Nevertheless, the interest in the last one or two years has not really increased as much as people like me or the pioneers (Dion, Edoga, Kolvenbach, Alimi) probably expected,” said Ferrari on laparoscopic aortoiliac surgery as a whole. “Few centres in Europe (and probably less in the US) are currently performing laparoscopic aortoiliac surgery. On the other hand, the confidence towards LIAS (in these centres) is growing, as is satisfaction with the results.

He then described the state of laparoscopic aortoiliac surgery in Italy. “In Italy, I organised a meeting -Video-assisted aortic surgery- (October 2001) with about 250 surgeons attending the scientific sessions. The pioneers previously mentioned were invited speakers and they said that in their countries they probably wouldn’t have the possibility to gather so many people.

Ferrari then provided details of the new section in the SICVE for minimally invasive techniques. “The goal of this section is to improve the knowledge of the minimally invasive techniques (mainly laparoscopic) through training courses with the help of simulators, ‘hands-on’sections and watching already trained surgeons at work. In Pisa, we will start at the beginning of 2003 with such a programme and the courses will be managed by a vascular surgeon and a very experienced laparoscopic (non-vascular) surgeon.

Vascular News then asked Ferrari is a mini-laparotomy preferable? “At present, I believe that a mini-laparotomy without laparoscopy (as, for instance, as William Turnipseed does) gives the same results in terms of patient’s recovery, length of hospital stay, etc. Moreover, mini-laparotomy has some advantages for surgical time (it is generally quicker than laparoscopy, although some laparoscopic vascular surgeons – like Ralf Kolvenbach – are very fast) and costs.

“According to me, the laparoscopic techniques so far applied are not totally satisfactory; we need to develop specially designed instruments and tools to overcome the usual unsolved problems (time-consuming vascular anastomosis, back bleeding from lumbars after opening the aneurysmal sac). After that, we will be able to do a totally laparoscopic AAA repair. To reach this goal the present technique is to be considered a step, or better, a bridge to. Of course, to be trained in laparoscopic techniques is also necessary: this means that surgeons performing only minilaparotomies (without laparoscopy) might be, at that time, out of the game.

Ferrari then issued a warning: “In my opinion, surgeons willing to approach this technique have to be careful. There is a significantly long learning curve with some broadening of surgical time and blood losses. This should push to select easy cases for the first 30 (more or less) operations.

“For already trained surgeons, laparoscopy should be avoided for redo aortic operations (excluding the endovascular procedures) and when visceral arteries reconstruction is planned together with the aortic procedure. Other troublesome situations are hostile abdomens, inflammatory aneurysms, presence of bilateral iliac aneurysms involving the whole common segments, the patency of many lumbar arteries, but these are not absolute contraindications because surgical expertise can help to overcome the difficulties (for instance approaching the aneurysm by the retroperitoneal route in case of hostile abdomen or inflammatory aneurysms).

He then discussed how the development of tools has helped advance the surgery. “Probably, a laparoscopic intestinal retractor is more useful for some laparoscopic vascular surgeons than for others. In other words, surgeons (as Alimi) using a transperitoneal (non-hand-assisted) route need an intestinal retractor; surgeons that favour a retroperitoneal route (such as John Edoga) probably will never use that tool. Generally speaking, everyone is looking to solve a problem from his personal point of view. This is very important and all these contributions will allow the laparoscopic aortoiliac surgery to grow and to move towards the final goal.

In Pisa, Ferrari and his team are trying to develop three projects:

  • A stapler for lumbar arteries
  • An hybrid aortic prosthesis (for simultaneous laparoscopic and endovascular use)
  • A laparoscopic system to secure the proximal part of an endoprosthesis to the aortic neck

In addition to the Italian initiatives, Ferrari wants to be able to organise some international courses, during 2003, in Pisa. “According to our programme (which is still in development) some of the pioneers of vascular laparoscopy will be part of the faculty.

Finally, Vascular News asked Ferrari what he saw as the future for laparoscopic aortoiliac surgery? “Basically: combining laparoscopic and endovascular techniques for helping the latter to have better results (for instance: avoiding the distal migration or rescuing a failing endoprosthesis because of type 2 endoleaks) and totally laparoscopic AAA repair.”