Endoscopic aortofemoral bypass reconstruction: experimental and clinical results

Abstract

According to the present experiences, the new videoendoscopic vascular instrument systems have fulfilled the basic requirements for performing videoendoscopic aortoiliac surgery. The animal studies (n = 25) showed clearly, that the piglet is a reproducible and favourable model to acquire the basic surgical techniques for videoendoscopic aortoiliac surgery, since its retroperitoneal anatomy is similar to that of humans. The transabdominal-retroperitoneal approach on human cadavers (n = 6) was soon abandoned, since particularly in obese cases it caused burdensome sliding of the intestine into the operative field adjacent to the renal vessels. The intensive investigations on human cadavers (n = 20) has meanwhile allowed us to constantly expose the aorta above the inferior mesenteric artery up to the left renal vessels without the need to sacrifice the inferior mesenteric artery (total operating time: 3-4.5 hours, aortic reconstruction averagely 42 minutes). The prolonged operating time during the extraperitoneal approach, especially in case of accidental tearing of the retroperitoneum has led us to evaluate the transabdominal paracolic approach (n = 6). This procedure with right-sided positioning of the patient offers a broad operating area and retains the intestine in the right side of the abdomen throughout, thus reducing the operating time in our initial 6 cases to a mean of 2.9 hours (range: 2.5-3.5 hours). As to our limited clinical experience and in accordance to other surgical groups the video assisted aortoiliac surgery (n = 12) by performing a small abdominal incision for the aortic anastomosis under direct vision seems to be an alternative procedure to the total videoendoscopic aortoiliac surgery (n = 7). Further experimental research, consistent development and refinement of videoendoscopic vascular instruments and prospective evaluation of the different videoendoscopic approaches to the aortoiliac vessels are necessary to evaluate the use of the videoendoscopic surgical technique, to clarify its advantages and to probably generalize the procedure in the near future.