Laparoscopic-assisted treatment of abdominal aortic aneurysm requiring suprarenal cross-clamping
Received 3 April 2009; accepted 2 June 2009.
Objective
Hand-assisted laparoscopic surgery (HALS) was previously employed to treat patients with infrarenal abdominal aortic aneurysm (IAAA). The use of HALS for juxtarenal abdominal aortic aneurysm (JAAA) has never been validated. In this study, we report our experience with this technique to demonstrate its feasibility and prove its safety in dealing with JAAA.
Methods
From October 2000 to October 2008, we have selectively treated 271 patients with abdominal aortic aneurysm with the HALS technique. Of these, 83 were JAAAs which required a suprarenal aortic clamping (group A), and 188 were IAAA (group B). General data of the two groups were analyzed for comparability purposes and operative and postoperative data were prospectively collected. Additionally, patients in group A were stratified in three classes according to their pre-existing degree of renal function impairment. Statistical significance was defined at the P < .05 level.
Results
Mean operative time was 220 minutes ± 66 in group A and 231 minutes ± 64 in group B (P > .05). The mean duration of suprarenal clamping was 28 minutes ± 6; whereas infrarenal clamping lasted an average of 25 minutes ± 5 (P > .05). Mean intraoperative blood loss was 1023 ± 584 mL for group A and 961 ± 633 mL for group B (P > .05). No conversion or 30-day postoperative mortality was recorded in either group. Sixteen percent of the patients in group A developed a postoperative complication, vs 11% in group B (P > .05). Mean postoperative stay for group A and B was 4.2 ± 1.5 and 4.2 ± 1.9 days, respectively (P > .05). Postoperative kidney function significantly worsened in 5 patients in group A (6%). A prolonged warm ischemia time (>40), pre-existing renal dysfunction, and diabetes, correlated to the development of postoperative renal insufficiency. Follow-up of patients averaged 37.9 ± 20 months. The incidence of incisional hernias in group A and B was 15.5% vs 11.1%, respectively (P > .05).
Conclusion
The HALS technique proved to be feasible and safe not only for patients with IAAA, but also for the management of patients with JAAA. No significant difference could be shown in the comparison between the two groups, apart from the expected higher rate of postoperative renal dysfunction after suprarenal clamping. In view of the demonstrated benefit of this minimally invasive approach, we believe that it should be included among the alternative options of treatment for these patients.
aDivisione di Chirurgia Vascolare, Dipartimento di Oncologia, dei Trapianti e delle Nuove Tecnologie in Medicina - Università di Pisa, Pisa, Italy
bDivisione di Chirurgia I Universitaria, Dipartimento di Oncologia, dei Trapianti e delle Nuove Tecnologie in Medicina - Università di Pisa, Pisa, Italy
Reprint requests: Andrea Pietrabissa, MD, FACS, Associate Professor of Surgery, Sezione di Chirurgia Mininvasiva, Divisione di Chirurgia Generale e Trapianti, Dipartimento di Oncologia, dei Trapianti e delle Nuove Tecnologie in Medicina, Università di Pisa, Ospedale di Cisanello, via Paradisa 2 - 56124 Pisa, Italy
ABSTRACT