Total laparoscopic juxtarenal abdominal aortic aneurysm repair
Article Outline
Objectives
This study describes our experience of total laparoscopic juxtarenal abdominal aortic aneurysm (JAAA) repair.
Methods
Between February 2002 and October 2007, we performed 148 total laparoscopic AAA repairs, including a subset of 13 patients who underwent a laparoscopic JAAA repair. Median age was 70 years (range, 50-81years). Median aneurysm size was 55 mm (range, 50-80 mm). Eight patients were in American Society of Anesthesiologist class II, and five were in class III. We used laparoscopic transperitoneal left retrorenal approaches and suprarenal clamping in all patients.
Results
We implanted tube grafts in nine patients and bifurcated grafts in four. No conversions to open repair were required. Median operative time was 260 minutes (range, 180-355 minutes). Total median aortic clamping time was 77 minutes (range, 36-105 minutes). Median suprarenal clamping time was 24 minutes (range, 9-37 minutes). Median blood loss was 855 mL (range, 215-2100 mL). No patients died. One patient had a postoperative coagulopathy with hemorrhagic syndrome. Five patients had moderate systemic complications, including four renal insufficiencies without dialysis and one grade I ischemic colitis. Liquid diet was reintroduced after 1 day (range, 1-7 days). Most patients were ambulatory by day 3 (range, 2-17 days). Median lengths of stay were 48 hours (range, 12-336 hours) in the intensive care unit and 10 days (range, 4-30 days) in the hospital. With a median follow-up of 19 months (range, 1-36 months), patients had complete recovery without graft anomalies.
Conclusion
Total laparoscopic JAAA repair is feasible and worthwhile for patients. Prior experience in laparoscopic aortic surgery is essential to perform these challenging procedures. Despite these encouraging results, a greater experience is required to ensure the benefit of this technique compared with open repair.
Abdominal aortic aneurysms (AAA) are juxtarenal when they extend up to but do not involve the renal arteries.1, 2 Juxtarenal abdominal aortic aneurysms (JAAA) represent between 5% and 20% of open surgical procedures for AAA repair.3, 4 Open repair is a reliable and durable technique to treat JAAA.1, 2, 4, 5, 6, 7 The mortality rate varies between 2.1% and 21%. Complications relate to duration of renal ischemia, bleeding, and large abdominal or retroperitoneal approaches. The benefit of laparoscopy focuses on decreasing the surgical trauma of abdominal approaches while performing a reliable aneurysmorrhaphy and bypass graft interposition. Taking advantages of our experience in laparoscopic aortic surgery,8, 9 we introduced this technique for JAAA. This article reports our experience with total laparoscopic JAAA repair.
Material and methods
Between February 2002 and October 2007, we performed 13 total laparoscopic JAAA repairs. This represents 8.8% of the 148 total laparoscopic AAA repairs performed in our center (Ambroise Paré University Hospital) during the same time period. We did not include in this series patients operated on in other centers. Demographic and clinical data were collected prospectively.
Laparoscopic approach
Laparoscopic exposure of JAAA was through a transperitoneal retrorenal approach.10 In summary, patient was placed in a right lateral decubitus position with an inflatable pillow (Pelvic-Tilt, O.R. Comfort, LLC, Glen Ridge, NJ) behind the left flank and maximal right rotation of the operating table. After the pneumoperitoneum was created and the ports were positioned (Fig 1), the peritoneum was incised in the left paracolic gutter. Retrorenal dissection led to complete right medial visceral rotation. Dissection of the infrarenal aorta was conducted from the left iliac to the left renal artery. Dissection beyond the left renal artery required sectioning of the left crus of the diaphragm.
Fig 1.
Drawing shows the patient position, sites of trocar insertion, and basic setup of operating room equipment and personnel. Personnel are the operating surgeon, A; assistant for the laparoscope, B; assistant for instrumentation, C; and nurse, D. Trocar sites are for the 45° laparoscope, 1; operator instruments, 2 and 3; assistant instrumentation, 4 and 5; laparoscope and assistant instrumentation, 6; endoretractor, 7; and proximal aortic clamp, 8.
Laparoscopic aneurysmorrhaphy
The steps for laparoscopic JAAA aneurysmorrhaphy are similar to those for infrarenal AAA repair.9 In summary, a proximal laparoscopic clamp (Storz-Endoscopie France, Guyancourt, France) was placed through the flank port (Fig 2). We placed a stitch into the left part of the aneurysmal sac, which was used to (1) retract the aorta on the right side during external control of the lumbar and sacral medial arteries and (2) open the aneurysmal sac after the aortotomy. The right and left iliac arteries were occluded with laparoscopic clamps introduced percutaneously in the left iliac fossa. We used sequential steps for suprarenal clamping to decrease the time of renal ischemia.
Fig 2.
Drawing shows the positioning of suprarenal laparoscopic clamp through a port introduced in the left flank. A retractor maintains the viscera in the right part of the abdomen.
When the juxtarenal aorta was free of thrombus, we first placed an infrarenal clamp. After aneurysmorrhaphy, we placed a second clamp above the renal arteries and removed the first clamp. This maneuver allowed a target zone for the proximal anastomosis close to the renal arteries. Time of renal ischemia was then the time needed for the proximal anastomosis alone. When the juxtarenal aorta was unusable for clamping before aneurysmorrhaphy, we used suprarenal clamping first.
If the preparation of the target zone of the proximal anastomosis allowed enough length below the renal arteries, we placed a second infrarenal clamp and removed the suprarenal clamp. Time of renal ischemia was the time needed for proximal anastomosis. If preparation of the infrarenal aorta did not allow enough length to move the clamp after aneurysmorrhaphy (Fig 3), we also performed the proximal anastomosis under suprarenal clamping. The time of renal ischemia was then the time needed for aneurysmorrhaphy and the proximal anastomosis.
Fig 3.
Operative view shows preparation of the infrarenal aorta for proximal anastomosis under suprarenal clamping. The arrow is pointing to the left renal artery.
Laparoscopic bypass graft interposition
Bypass graft interposition used tube grafts or bifurcated Dacron grafts (Gelweave or Gelsoft-Plus, Vascutek-Terumo, Inchinnan, Scotland). Anastomoses were performed with two hemicircumferential polypropylene running sutures previously knotted on Teflon pledgets (DuPont, Wilmington, Del). A Teflon cuff was used to reinforce the suture line if the aorta was thin or brittle (Fig 4). Both ends of the thread were tied intracorporeally.9, 11 For tube grafts, anastomoses were totally laparoscopic. For bifurcated grafts, distal anastomoses were totally laparoscopic when the target zones of implantation were the common iliac arteries or the left external iliac artery. In other cases, we used elective groin or iliac incisions. Whenever possible, distal anastomoses were performed first to decrease the total aortic clamping time.
Fig 4.
(A), Operative view shows the proximal anastomosis with a Teflon cuff to reinforce the suture line and (B) after unclamping. The arrow points to the left renal artery.
Closure
After the prosthesis was unclamped, we checked hemostasis and colon viability, as previously reported.9 On closure, two suction drains were positioned near the prosthesis. The viscera fell back into place once the patient was returned to the dorsal decubitus position. Ports were removed under laparoscopic control. The abdominal fascia of the holes for the ports was closed with absorbable sutures.
Preoperative data
Helical computed tomography (CT) scans were obtained in all patients. We defined JAAA when the AAA had no infrarenal neck. We excluded patients with infrarenal AAA and only polar renal arteries arising from the aneurysmal sac. Patients were assessed in accordance with American Society of Anesthesiologists (ASA) classification. In addition, all patients underwent stress echocardiography and pulmonary, hepatic, and renal function tests. Renal insufficiency was defined when the creatinine level was >1.5 mg/dL. Gradation of its severity was in accordance with Society for Vascular Surgery (SVS) criteria of grade 1 for creatinine levels 1.5 to 2.4 mg/dL and grade 2 for 2.5 to 5.9 mg/dL.12 Coronarography was indicated for patients with abnormal stress echocardiography results.
Intraoperative data
Intraoperative data included operative and clamping times, blood loss, and body temperature at the end of the procedure. We defined total aortic clamping time as the time elapsed between aortic clamping and unclamping of the first iliac or femoral artery. Conversion to open repair was defined by the need of a laparotomy to complete the procedure. When required, this laparotomy is performed with the patient still in the right lateral decubitus position, and the incision is placed between the holes for endoscope and left iliac fossa (ports 1 and 5).
Postoperative data
All patients were placed in the intensive care unit (ICU) immediately after the procedure and taken back to their room as soon as hemodynamic, respiratory, and biologic indicators were normalized. Mortality and morbidity were reported according to SVS criteria.12 Postoperative renal insufficiency was considered as a systemic complication when the peak postoperative creatinine level led to a worsening of the preoperative renal grading score.
Results
Preoperative data
There were 12 men and one woman, with a median age of 70 years (range, 50-81 years). Eight patients were classified as ASA II and five were at ASA III. Four patients (31%) had grade 1 renal insufficiency. Two patients had severe chronic obstructive pulmonary disease (COPD), with forced expiratory volume in 1 second of <1.2 L. Median aneurysm size was 55 mm (range, 50-80 mm). Two patients had aneurysms associated with severe aortoiliac occlusive disease.
Intraoperative data
We implanted nine tube grafts, two biiliac, and two bifemoral grafts (Table I). No patient required conversion to open repair. One patient underwent a femoropopliteal bypass for occlusive lesions.
Table I. Intraoperative data
| Patient No. | Bypass type | Operative time, min | Total clamping time, min | Suprarenal clamping time, min | Blood losses, mL | Events/combined surgery |
|---|---|---|---|---|---|---|
| 1 | Tube graft | 250 | 77 | 27 | 1500 | |
| 2 | Bifurcated aortobiliac | 340 | 83 | 10 | 500 | |
| 3 | Bifurcated aortobifem | 355 | 36 | 37 | 2000 | Femoropopiteal bypass |
| 4 | Tube graft | 180 | 68 | 30 | 1100 | |
| 5 | Tube graft | 260 | 94 | 9 | 1100 | |
| 6 | Tube graft | 215 | 87 | 14 | 2100 | |
| 7 | Tube graft | 270 | 105 | 18 | 800 | |
| 8 | Tube graft | 240 | 60 | 30 | 850 | |
| 9 | Tube graft | 215 | 100 | 20 | 215 | |
| 10 | Bifurcated aortobiliac | 330 | 60 | 24 | 1500 | |
| 11 | Bifurcated aortobifem | 270 | 45 | 25 | 855 | |
| 12 | Tube graft | 270 | 96 | 35 | 550 | |
| 13 | Tube graft | 180 | 73 | 13 | 500 |
The median operative time was 260 minutes (range, 180-355 minutes). Total median aortic clamping time was 77 minutes (range, 36-105 minutes). Median suprarenal clamping time was 24 minutes (range, 9-37 minutes). Median blood loss was 855 mL (range, 215-2100 mL). The median body temperature at the end of the operation was 36.7°C (range, 35.5°-37.9°C).
Postoperative data
No in-hospital deaths occurred (Table II). A severe systemic nonlethal complication occurred in one patient (7.7%), whose indication for surgery was a growing and painful JAAA that reached 8 cm diameter. Five months before, he underwent a coronary angioplasty with a coated stent for unstable angina. He was treated with clopidogrel and aspirin until the procedure. Laparoscopic JAAA repair was uneventful, with suprarenal clamping time of 24 minutes and blood loss of 1500 mL. We observed a postoperative hemorrhagic syndrome, probably due to the double antiplatelet therapy. The patient required intensive medical care and a prolonged ICU stay but no reintervention. His further postoperative course was uneventful.
Table II. Postoperative data
| Variable | Results |
|---|---|
| Mortality | 0 |
| Systemic complications, No (%) | 6 (46.2) |
| Severe | 5(38.5) |
| Mild or moderate | 1(7.7) |
| Local complications, No (%) | 1(7.7%) |
| Diet, mean (range) days | 1(1-7) |
| Ambulation, mean (range) days | 3(2-17) |
| Length of stay, mean (range) | |
| Intensive care unit, hours | 48(12-336) |
| Hospitalization, days | 10(4-30) |
Five patients (38.5%) had mild or moderate systemic complications. Renal insufficiencies developed in four patients (31%) but resolved without dialysis. Two of these patients had preoperative grade 1 renal insufficiencies. Postoperative creatinine levels returned to baseline before discharge in all but one patient. Another systemic complication was grade 1 ischemic colitis. One patient presented a local complication limited to a superficial infection of a groin that resolved with local treatment.
Apart from these complications, the patients had fast recoveries. Pain complaints were minimal, with a median dose of narcotics of 1 mg (range, 0-42 mg). The nasogastric tube was removed at the end of the procedure. A liquid diet was reintroduced after a median duration of 1 day (range, 1-7 days). Most patients were ambulatory by day 3 (range, 2-17 days), with minimal wound discomfort. Median lengths of stay were 48 hours (range, 12-336 hours) in the ICU and 10 days (range, 4-30 days) in the hospital.
All patients are still alive, with a complete recovery after a median follow-up of 19 months (range, 1-36 months). No abdominal wall hernias developed. No hemodynamic or morphologic anomalies were observed on follow-up duplex ultrasound studies and CT scans. No patients required dialysis.
Discussion
Minimally invasive procedures have entered the field of JAAA repair, especially endovascular aneurysm repair (EVAR) and hybrid techniques. EVAR is widely used for infrarenal AAA but needs complex procedures with fenestrated stent grafts for JAAA.13, 14 In pioneering centers, early results of these procedures seem satisfactory. Uncertainties remain on mid- and long-term results, especially concerning type I endoleaks and narrowing of visceral vessels.2 Hybrid technique with relocation of renal arteries, followed by EVAR, has been published in isolated case reports.15, 16 Surgical trauma of this procedure remained substantial, and we did not observe its widespread use.
Laparoscopy is a new alternative for JAAA repair. The purpose of laparoscopy is to avoid large abdominal incisions, thus decreasing pain and intestinal and pulmonary complications. The technical challenge of total laparoscopic JAAA repair is exposure of the suprarenal aorta and performance of aneurysm repair with acceptable times for total and suprarenal clamping.
Laparoscopic exposure of the suprarenal aorta is achieved through a transperitoneal retrorenal approach.10 This approach uses a complete right medovisceral rotation and allows a large exposure of the abdominal aorta, but is contraindicated when the left renal vein is retroaortic or in cases of perisplenic adherences. If the transperitoneal retrorenal approach is unusable, a laparoscopic transperitoneal retrocolic approach could be used. This allows exposure of the suprarenal aorta,17 but we have not used it yet for JAAA with suprarenal clamping. A drawback of the retrocolic approach for JAAA repair is the left renal vein, which crosses the juxtarenal aorta. Its division is possible but could induce renal insufficiency.2 Other videoscopic approaches of the abdominal aorta, either retroperitoneoscopic or transperitoneal direct, seem inappropriate for laparoscopic JAAA repair. These approaches have major drawbacks, especially the reduced working space and the limited exposure of the suprarenal aorta.18, 19
Suprarenal clamping time is the second main challenge of total laparoscopic JAAA repair because the subsequent renal ischemia creates the risk of renal insufficiency.3, 4, 20 Suprarenal clamping times obtained in our series were close to figures for open surgery and below the threshold for preservation of renal function.20 Whenever possible, we used sequential suprarenal clamping, which allowed us to decrease the time of renal ischemia.1, 5, 7, 21 If suprarenal clamping is required before aneurysmorrhaphy and proximal anastomosis, control of important back bleeding from lumbar arteries, either with stitches or staples, could be time consuming and add to time of renal ischemia. In such difficult cases in which suprarenal clamping could be long, conversion to open repair is required even if it takes few additional minutes. We must emphasize that 50% of patients with postoperative renal impairment had preoperative renal insufficiencies, which is an unavoidable risk factor in patients with JAAA.2, 5, 6
Total aortic clamping times were similar to those reported during laparoscopic infrarenal AAA repair.9, 21, 22 The use of a stapler device for the aorta–prosthetic anastomosis could be interesting to decrease clamping time. However, a recent article on an aortic stapler reported an open aortic anastomosis time of about 10 minutes, which is close to figures of open surgery.23 We can expect longer times for laparoscopic anastomoses, but for the moment, however, stapler devices are not yet available for laparoscopic aortic surgery which precludes further discussion at this time. Moreover, these devices need at least 15 to 20 mm of aortic neck length to allow the anastomosis and are not usable for JAAA.
Severe systemic complications in our series compare favorably with figures of open surgery.2, 6 We did not observe pulmonary complications, even in patients with severe COPD. The incidence of pulmonary complications is about 20% to 30% after open JAAA repair.2, 6 This benefit of laparoscopy could relate to several factors, including avoidance of a large abdominal incision, reduced pain, quicker gastrointestinal motility, and faster postoperative physiotherapy. We already observed an important decrease of pulmonary complications after laparoscopic aneurysm repair, and this benefit seems valid after laparoscopic JAAA repair despite the need for larger approaches.9, 21
Postoperative recovery demonstrates the benefit of laparoscopy in terms of pain, return to diet, and ambulation. Previous series have already demonstrated that these well-known advantages of laparoscopy were also valid after laparoscopic aortic surgery.8, 9, 21, 24, 25, 26, 27, 28, 29, 30
We did not observe adverse events after a median follow-up of 19 months. These data are similar to those of open repair and demonstrate the mid-term reliability of laparoscopic JAAA repair. We note the lack of abdominal wall dehiscence, which is a well-known advantage of laparoscopy.9, 21 Laparoscopic repair uses the gold standard aneurysmorrhaphy with bypass graft interposition, and we can expect excellent long-term results.2, 4, 5, 6 However, further experience is needed to draw firm conclusions.
Patient selection is mandatory before total laparoscopic JAAA repair. Contraindications are (1) ruptured and inflammatory aneurysms, (2) need for complex renal or visceral arteries reconstructions, or both, and (3) patients unfit for aortic surgery. In cases of associated severe and diffuse occlusive lesions of visceral arteries not amenable to endoluminal techniques, an open procedure would be preferable. For the moment, need for concomitant renal arteries revascularization is a contraindication for laparoscopic repair because it can lead to additional time of renal ischemia. All these limits are not absolute and could evolve with growing experience and future improvements.
Conclusions
On the basis of this series, total laparoscopic JAAA repair is feasible and worthwhile for selected patients. Laparoscopy focuses on reduction of the operative trauma while performing a reliable and durable JAAA repair. These results encourage us to offer laparoscopy for JAAA repair whenever possible, but a greater experience is required to ensure the real benefit of this technique. We want strongly to emphasize that surgeon who wants to perform laparoscopic JAAA repair has to (1) gain expertise in laparoscopic infrarenal AAA repair and (2) remember that in cases of operative difficulties, conversion to open repair is always feasible.
Author contributions
References
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Competition of interest: none.
PII: S0741-5214(08)00262-0
doi:10.1016/j.jvs.2008.02.021
© 2008 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
