Laparoscopic Ligation of Inferior Mesenteric Artery for Treatment of Type II Endoleak

Abstract

Introduction: Treatment options regarding type II endoleaks primarily from inferior mesenteric artery (IMA) origin are controversial, and there is ongoing debate about the safest and most effective approach.1–3 We present the case of a 53-year-old man with multiple comorbidities who underwent an uncomplicated endovascular repair of a 6.3-cm abdominal aortic aneurysm and then presented 3 months later with abdominal pain and a palpable abdominal mass. Computed tomography (CT) revealed the presence of a type II endoleak and an increase in aneurysm size from 6.3 to 8.2 cm. After failed attempt to stop endoleak with coil embolization, the patient underwent laparoscopic ligation of IMA for treatment of his type II endoleak. Our video with a running time of 4 minutes and 51 seconds demonstrates a successful laparoscopic ligation of the IMA for the treatment of type II endoleak. Operative Technique: The patient was brought into the operating room and was induced using general anesthesia. A Foley catheter was inserted. He was placed in right lateral decubitus position to allow displacement of bowel away from the aorta. He was given a dose of preoperative antibiotics and all pressure points were padded appropriately. His abdomen and flank were prepped and draped in sterile fashion. A 1-cm cut down was made just to the left of the umbilicus and the peritoneum was entered using Hasson technique. The Hasson trocar was introduced, and CO2 insufflation was begun to a pressure of 15 mm Hg. An additional 10-mm lower midline trocar was placed as well as two 5-mm trocars, one epigastric, and one suprapubic. The base of the mesentery was exposed to observe as well as aorta. Next, the peritoneum overlying the aortic aneurysm sac was incised with the ultrasonic scalpel. Dissection continued and the IMA was then circumferentially dissected. A laparoscopic doppler was used to confirm that this was an arterial structure. The artery was ligated using several 10-mm clips and doppler confirmed that there was indeed no more flow in this vessel. Floseal was used for additional hemostasis for oozing from the aneurysm sac. The 10-mm trocar was closed with 0 Vicryl suture and all ports were removed under direct observation. The patient was discharged home on postoperative day 4 without any complications. A 10-week follow-up CT scan showed resolution of endoleak from IMA and aneurysm sac shrinkage from 8.2 to 6.4 cm. Conclusion: Placement of the patient in lateral decubitus position is key for adequate exposure of the aorta and IMA. This video demonstrates that laparoscopic ligation of IMA is a successful treatment option for endoleaks of IMA origin. No competing financial interests exist. Runtime of video: 4 mins 51 secs