Discussion

Article Outline

• Copyright

Dr Brian Rubin (St. Louis, Mo). Because the training paradigms are so different across the world, can you tell us how the vascular trainees have been educated up to the point where they begin to learn their laparoscopic skills? Are these guys who have completed a residency? Are they starting right out of medical school? Just take us through your training paradigm so we know what to compare it to.

Dr Jean-Baptiste Ricco. Our trainees are fellows and 3- or 4-year residents. They begin by helping us to do the laparoscopic cases. When they realize the technical challenge of laparoscopic aortic surgery, they are more prone to accept working on simulators where they do totally videoscopic anastomoses with two pieces of polyester graft in a box. They get a score depending of the time required to complete the anastomosis and of the quality of the suturing. When they pass this test on a regular basis, we help them to do the easiest aortic anastomoses, but they must continue their daily videoscopic training. It takes them 2 years to do the easiest aortic anastomoses in the operating room. Our experience is that the sooner they begin, the quicker they learn.

Dr Enrico Ascher (Brooklyn, NY). My question is: How can one maintain his or her expertise in laparoscopic AAA [abdominal aortic aneurysm] repair if this is a pathology that most of us treat once or twice a week only?

Dr Ricco. Your point is crucial. Many surgeons who published in this field are both vascular and general surgeons with a large experience of general laparoscopic surgery. As we are only vascular surgeons, we learned with general surgeons and we did bench training and practice on cadavers. Bench training for laparoscopy is essential and should be done on a regular basis every other day. Our clinical practice started in patients having occlusive disease with self-imposed operative time limits. AAA laparoscopic procedures came afterwards. They are certainly most demanding and should be done only by surgeons with a large laparoscopic experience in referenced centers.

Dr Peter Gloviczki (Rochester, Minn). I know that Professor Fabiani was doing robotic surgery. Do you have any experience and do you see any future to use the robots in vascular reconstructions?

Dr Ricco. Robot-assisted surgery is thought to result in a better surgical performance with robotic arms that support five degrees of freedom. This may be true. But evidence is lacking, and as robot-assisted aortoiliac procedures have to be combined with laparoscopic approach, previous experience with laparoscopy remains essential even with a robot. In addition, robots have some disadvantages, including high cost and complexity of set-up. But I agree with you that robot-assisted surgery can be of value in overcoming the learning curve of laparoscopic suturing.

Dr Gregorio Sicard (St. Louis, Mo). Urologic surgery is primarily done by a retroperitoneal approach. More recently laparoscopic techniques to the kidney and the perirenal area are being used worldwide. Are you doing these transabdominal or retroperitoneally? If you are not doing it retroperitoneally, why? For aortic surgery, especially for aneurysms, I would think this is easier than by the transabdominal laparoscopic approach.

Dr Ricco. The two main technical problems of laparoscopic aortic surgery are to expose the aorta and to perform the anastomosis. For infrarenal aortic approach, we use a transperitoneal retrocolic and prerenal route in line of the Toldt fascia. In difficult cases or when suprarenal aortic clamping is needed, we use a transperitoneal left retrorenal approach with right visceral rotation. These two approaches give us a much larger working space by comparison with a left videoscopic retroperitoneal approach that is rarely used for aortic surgery except in patients with hostile abdomen and peritoneal adhesions.