Laparoscopic aortic surgery: Techniques and results

Patient is shown in the right lateral decubitus position for a total laparoscopic retrocolic transperitoneal approach. 1, Operating surgeon; 2, first assistant; 3, second assistant.

A, Position of the ports for retrocolic transperitoneal approach is shown. 1, Retractor/proximal clamp; 2, coagulating scissors/needle holder; 3, blunt grasping forceps; 4, suction system; 5, blunt grasping forceps/distal clamp; 6, 30° angled viewing endoscope. B, Operative view shows operators and the position of ports for a total laparoscopic retrocolic prerenal transperitoneal approach.

Aortic exposure through a left retrocolic prerenal approach with the patient in the right lateral decubitus position. The intestinal loops collect on the right side of the abdomen, with the mesocolon forming an apron. This technique provides a stable exposure of the aorta.

A, Complete exposure of the aorta, iliac arteries, and inferior mesenteric artery through a left retrocolic prerenal approach. B, Cross-clamping of the suprarenal aorta for extensive occlusive disease and calcification of the infrarenal aorta (same approach).

Aortic anastomosis is performed with a prepared 18-cm-long polypropylene 3-0 suture with one end sutured to a pledget to avoid having to tie the first knot.

End-to-side totally laparoscopic aortic anastomosis with a 3-0 polypropylene running suture using curved jaws and axial handle needle holder.

Total laparoscopic direct transperitoneal exposure as done in open surgery with the use of a self-expandable bowel retractor. The net is used to gather up and to retract the bowel loops.