At the Carpe Diem Angiologica meeting held in Barcelona, pioneers Yves Alimi and Yves-Marie Dion presented on laparoscopic aortoiliac surgery.
Yves Alimi spoke at length to Vascular News after the meeting to give his views on the state of laparoscopic aortoiliac surgery “From the first laparoscopic aortic reconstruction performed by Yves-Marie Dion (Quebec) in 1993, several other surgical teams, especially in Europe, have tried to develop these new techniques. We [the Department of Vascular Surgery, Centre Hospitalier Universitaire Nord Marseille, France] began in 1996 by several studies on pigs in order to gain the experience in laparoscopic surgery (as we have an exclusively vascular surgical activity), to determine the best aortic laparoscopic approach and to develop new instrumentation (like laparoscopic aortic clamps, laparoscopic intestinal retractor, etc). We then performed a clinical study in 1998, first on patients treated for occlusive disease and secondly for AAA repair. We have treated 81 patients so far with interesting results.
According to Alimi, the main benefits are:
“In Europe and especially in France, a lot of surgical teams are disappointed with the results of the endografts and are trying to find another minimally invasive way to treat their patients,”explained Alimi. “Most of them are beginning to use a minilaparotomy through a transperitoneal (with the HandPort for example) or through a retroperitoneal approach.
“The use of the camera is very helpful but requires a training, which was already accomplished by the youngest surgeons who did their residency in gastrointestinal surgery.
“Some other teams think that a totally laparoscopic technique is the goal and are presenting good results but still with long operative and clamping times. The need for new instruments is stronger each day and will help to perform these techniques in the near future.Vascular News then asked Alimi whether a minilaparotomy is preferable? “In the beginning of my experience, I tried to perform a totally laparoscopic procedure. I then compared the first 15 patients who underwent a totally laparoscopic procedure with the following 15 patients who had a totally laparoscopic aortic dissection associated with a minilaparotomy to perform the aorto-prosthetic anastomosis; the latter had a significantly shorter operative and clamping times and above all a better recovery (J Vasc Surg 2001;33:469-75). This is the reason why we have chosen to perform a laparoscopic dissection followed by a minilaparotomy in the last 51 patients,”said Alimi.
“However, my belief is that a totally laparoscopic procedure will soon be possible, especially for patients treated for severe aortoiliac occlusive disease with an end-to-side aorto-prosthetic anastomosis. Our goal is to develop new instruments that will avoid the need for a minilaparotomy and will allow the performance of an aorto-prothetic anastomosis with a short clamping time.
Alimi, then explained that with experience, some initial contraindications are not considered any more, these include:
However, he did say: “We are still not performing these procedure in emergency (ruptured) AAA, in cases of thoracoabdominal aortic aneurysm and of previous extensive surgery (such as left colectomy) due to the abdominal adhesions. We are also not proposing these techniques in high-risk patients (Type IV of the American Society of Anaesthesiology classification).
He went on to describe how no laparoscopic aortic surgery is possible without laparoscopic aortic clamps, since the use of conventional clamps is responsible for large leak of CO2 gas. “One of our first goal was to develop these clamps. We have decided to keep the length, the size of the jaws, and the force of the conventional clamps, but we modified the body, which is round with a distal articulation. In the second generation of clamps presently available, the diameter of the body decreases from 12 to 10 mm and the design is better.”All these laparoscopic clamps are placed through a 10mm incision of the abdominal wall, without trocar. We have also developed a whole series of releasable clamps that can be placed on the aorta collaterals (renal, iliac, mesenteric arteries, etc) at the beginning of the procedure and removed at the end; these clamps are placed through a port, which can be used for other purposes during the intervention. Since we have decided at the beginning of our experience to use a transperitoneal route during our laparoscopic procedures for a better aortic exposure (especially of the right aortic wall), bowel retraction was a concern. We then developed a laparoscopic intestinal retractor after a study on cadavers (Surg Endosc 2000: 14; 915-7). This device is made with a 2.5 mm diameter metallic rod with a distal part designed to follow the mesenteric root. A 12 x 25 cm net, with a 2cm revers knitted in one of its long edges, is placed in the abdomen through a trocar. The revers is then slipped around the metallic rod in order to maintain the net at the floor of the abdominal cavity. The intestine is then gathered to the right part of the abdomen and the net is applied on the bowel and fixed with 3 to 4 threads to the right part of the abdominal wall, gathering the intestine out of the working area.
Alimi continued: “In our series of patients, this device allowed us to avoid the Trendelenburg position of the operating table (eliminate the risk of lung atelectasia and cerebral oedema) and to reduce the CO2 pressure from 14 to 8mmHg (reducing the risk of metabolic acidosis and oliguria).
“We are now focusing our research activity to develop new tools allowing us to perform laparoscopic aorto-prosthetic anastomosis, with a short clamping time.
On the subject of training, Alimi stated that there is now a large demand from vascular surgeons.
He has so far organised nine english and french-speaking workshops in the European Institute of Telesurgery (Strasbourg, France). During these three-days seminars, 34 vascular surgeons perform each day a laparoscopic aortic reconstruction in living pigs on 17 totally equipped operative tables. International experts are invited to share their experience and to help the participants during their practical activity. Alimi has also organised two English-speaking seminars on cadavers in Marseille. Several other training centres are also available in Hamburg (Germany) and in Quebec (Canada).
On the future of laparascopic aortiliac surgery, Alimi had this to say: “We will soon publish an article underlining the good early and mid-term results of a preliminary series of patients who underwent a laparoscopic aortic reconstruction for occlusive disease and AAA. In my opinion, these techniques will become the first choice in good and moderate risk patients, with good life expectancy.
“As it occurred in the past in gastrointestinal surgery, we are now moving from large incisions to a transitory period of minilaparotomy. I am convinced that totally laparoscopic procedures will be routinely performed in the future, using new devices. There is a wide potential for new technology development in laparoscopic aortoiliac surgery,”said Alimi.
At the Carpe Diem Angiologica meeting, Yves-Marie Dion said that for many surgeons, starting with the use of a laparoscopy-assisted technique provides a safer environment and preceptorship should ideally be available. Once the surgeon is confident manipulating laparoscopic instruments, he can then progress to totally laparoscopic surgery perhaps beginning with a relatively easy case like an ilio-femoral bypass. Then aortoiliac procedures for occlusive and aneurismal disease could be done.
“We encourage surgeons to participate in congresses devoted to minimally invasive vascular surgery, which give an opportunity for interaction in terms of bringing their own contribution and/or by allowing them to learn advancements in the field,”said Dion.
In summary, laparoscopic vascular surgery has a bright future in terms of treatment of occlusive and aneurismal aortoiliac disease. It could also have a role to play for certain patients who receive an endovascular graft.