Invited commentary

Abstract

The concept of laparoscopic aortic surgery, as initially envisioned by Dion and Gracia in the early 1990s, was attractive: durability of a classic aortic repair without the collateral damage of the open operation. Against the usual storm of condemnation and skepticism (“I do it open, it takes me 50 minutes, and I make a tiny incision anyway”), the young surgical technique was perfected, appropriate training courses were organized, and the industry responded with accustomed instrumentation. The naysayers grew nervous about the need to adopt, exhorted by persisting uncertainty about the long-term results of the competing method, endovascular aneurysm repair (EVAR). As we know, the endovascular revolution instead turned unstoppable, as devices and techniques improved consistently and all vascular meetings turned endovascular. Laparoscopic aortic surgery, in the mean time, was banned to the back rooms to never remotely approach mainstream status. Stating that, “multicenter randomized prospective studies are not yet possible because only few centers have the [laparoscopic] expertise to perform such a study,” the authors underscore the problem. So why this lack of adapters? For one, the very patient categories that could benefit from laparoscopic aortic aneurysm repair, those with “easy” necks and iliacs, constitute the exact target population of EVAR. Another problem is the large number of different laparoscopic approaches that have been described so far, four in this report alone: transperitoneal retrorenal, transperitoneal retrocolic, retroperitoneoscopic, and transperitoneal direct, in addition to hand-assisted laparoscopic, laparoscopy-assisted open, and robot-assisted laparoscopic techniques. Failure of a certain consensual approach to finally surface, is usually a sign of poor maturation of a surgical technique. I could go on: the shallow learning curve, the poor ergonomics, cost issues, and last but not least, patient safety: for most earthly laparoscopists, a bleeding catastrophe during an aortic repair is a lot harder to control in a closed abdomen. With the number of centers declining, our own group has recently suspended the robot-assisted laparoscopic aortic program mainly due to a lack of suitable patients in the endovascular era. Different stages of development from an idea toward an established surgical procedure have been represented in the so-called IDEAL framework (idea–development–exploration–assessment–long-term study).1McCulloch P. Altman D.G. Campbell W.B. Flum D.R. Glasziou P. Marshall J.C. et al.No surgical innovation without evaluation: the IDEAL recommendations.Lancet. 2009; 374: 1105-1112Abstract Full Text Full Text PDF PubMed Scopus (1190) Google Scholar Laparoscopic aortic aneurysm repair, according to this format, has faltered somewhere in the exploration phase, as the authors have proven only one thing: it can be done, with good long-term results, in their hands. For maturation into an established technique, however, reproducibility and (randomized) assessment are required. Because I have witnessed Dr Coggia's unparalleled laparoscopic skills, I know the presented results will be hard to match. Therefore, unless a new generation of laparoscopic aortic surgeons arises, perhaps with the use of second- and third-generation surgical robots, I am afraid laparoscopic aortic surgery is destined to remain a small chapter in vascular surgery's history. A comparison of total laparoscopic and open repair of abdominal aortic aneurysmsJournal of Vascular SurgeryVol. 55Issue 6PreviewThe feasibility of total laparoscopic abdominal aortic aneurysm (AAA) repair has been well established. In a previous case-control study, we showed that the postoperative courses of total laparoscopic and open AAA repairs were similar. The purpose of this study was to compare the long-term results of these techniques in the same cohort of patients. Full-Text PDF Open Archive