Laparoscopic Abdominal Aortic Aneurysm Research Articles

Sexual dysfunction after elective laparoscopic or endovascular abdominal aortic aneurysm repair in men

Infrarenal abdominal aortic aneurysm (AAA) repair can lead to ejaculation and erection troubles in men. There are few studies on sexual dysfunction after endovascular repair (EVAR) but they suggest less retrograde ejaculation than after open repair. We assessed the sexual dysfunction and ejaculation troubles after elective laparoscopic repair or EVAR. We conducted a monocentric prospective study on 124 patients undergoing AAA repair between 2013 and 2015. Sexual function was evaluated using the IIEF-15 questionnaire and questions on ejaculation. Only 45 patients (36.3%) accepted to complete the IIEF preoperatively with 20-37.8% having preoperative sexual dysfunction. Among them, 21 (46.7%) accepted to complete the questionnaire at 3, 6 and 12 months. Mean age at inclusion was 65±5.6 years in the laparoscopic group and 77±10.5 years in the EVAR group (P=0.003). Erectile and sexual function were slightly improved at 12 months in the laparoscopic group (+1.4 for erectile score and +4.6 for IIEF score) with no significant difference (P=0.83 and 0.74) whereas 8 patients (61.5%) had persistent ejaculation troubles at 3 months. In the EVAR group, patients had moderate sexual dysfunction at baseline without improvement at 12 months, but only one patient reported ejaculation troubles. Most patients eligible for AAA repair present with baseline erectile and sexual dysfunction. Laparoscopic AAA repair provides no onset of erectile or sexual dysfunction but a global improvement after surgery. Ejaculation troubles are frequent and persistent at 1 year. However, EVAR treatment, doesn't allow recovering of sexual function at 1 year. 4.

Laparoscopic surgery for elective abdominal aortic aneurysm repair.

Laparoscopic surgery for elective abdominal aortic aneurysm repair.

Systematic review of perioperative outcomes following laparoscopic abdominal aortic aneurysm repair.

To collate information available in the literature regarding perioperative outcomes following elective laparoscopic abdominal aortic aneurysm repair. Electronic databases were searched and a systematic review was performed. In total, 1256 abstracts were screened, from which 10 studies were included for analysis. Perioperative and technical outcomes were analysed. In the totally laparoscopic repair of infra-renal aneurysms (n = 302), 30-day mortality ranged between 0% and 6% and in the laparoscopic-assisted cases (n = 547) ranged between 0% and 7%. Of the former group, 5-30% of cases were converted to open repair, with 6% reintervention rate, whereas there was a 5-10% conversion and 3% reintervention rate in the latter group. The outcomes from selected patients in selected centres demonstrate that elective laparoscopic repair of aortic aneurysms is feasible and comparable in safety to open repair; it remains unclear, however, whether there are substantial advantages of this method compared with open and endovascular repair.

Systematic review of perioperative outcomes following laparoscopic abdominal aortic aneurysm repair

ObjectiveTo collate information available in the literature regarding perioperative outcomes following elective laparoscopic abdominal aortic aneurysm repair.Materials and methodsElectronic databas...

Laparoscopic abdominal aortic aneurysm (AAA) repair: Conducting the learning curve safely in the UK

Laparoscopic abdominal aortic aneurysm (AAA) repair: Conducting the learning curve safely in the UK

How does elective laparoscopic abdominal aortic aneurysm repair compare to endovascular aneurysm repair?: Table 1:

A best evidence topic in surgery was written according to a structured protocol. The question addressed was how elective laparoscopic abdominal aortic aneurysm (AAA) repair compared to endovascular aneurysm repair (EVAR) in terms of survival. There were 229 papers found using the reported search, with 8 papers (5 prospective studies, 1 retrospective study, 1 randomized trial and 1 systematic review) representing the best evidence to answer the question proposed. Current evidence suggests that EVAR is the preferred surgical approach for AAA repair, due to shorter hospital stay and lower perioperative morbidity and mortality rates, as opposed to an open surgical approach. Despite this, EVAR is subject to a number of limitations, including device restrictions in patients with anatomical variations as well as increased risk of future complications stemming from device implantation. We discuss a key study that showed that complications in the EVAR group commonly included endoleak type II and graft thrombosis. More importantly, there were similar rates of complications between those patients receiving EVAR and those receiving minimally invasive aortic surgery. The evidence suggests that elective laparoscopic AAA repair has a favourable safety profile comparable with that of EVAR, with low conversion rates as well as similar mortality and morbidity rates. This has been illustrated in several studies. We discuss a prospective randomized trial of 100 patients, which compared EVAR with hand-assisted laparoscopic surgery. This study showed no deaths in either group after the procedure or at follow-up after 12 months, with similar complication rates between the groups. While the evidence suggests that EVAR is less invasive, it does not always significantly alter the postoperative course or length of hospital stay for patients. We conclude from the evidence available that elective laparoscopic AAA repair may have a role in those patients who are unsuitable for EVAR. Unfortunately, few studies exist directly comparing these two techniques, and those that do are subject to limitations, for example, study population bias, small sample sizes and a lack of comparison in the literature between the common AAA repair techniques.

Results of Laparoscopic Surgery for Abdominal Aortic Aneurysms in Patients With Standard Surgical Risk and Anatomic Criteria Compatible With EVAR

The recent Anévrisme de l'aorte abdominale: Chirurgie versus Endoprothèse (ACE) study showed that open surgery of infrarenal abdominal aortic aneurysms (AAAs) provided very good results in patients with standard surgical risk, with good anatomic results for endovascular aneurysm repair (EVAR). The goal of the current study was to show that aortic laparoscopy is a minimally invasive alternative to open surgery while avoiding the complications associated with laparotomy. From February 2002 to August 2010, the authors performed 239 laparoscopic AAA repairs. A subgroup of 99 patients with standard surgical risk presented with AAAs compatible with EVAR. The evaluation criteria of surgical risk and anatomic criteria compatible with EVAR corresponded to those edicted by the Agence Française de Sécurité Sanitaire des Produits de Santé and the Haute Autorité de Santé. The patients' database was prospective and the file analysis was retrospective. Digital data were given in median and extremes. The patient age was 68 years (range, 53-79 years). The aneurysmal diameter was 51 mm (range, 45-69 mm). Surgery and clamping times were 210 min (range, 180-520 min) and 81 min (range, 35-140 min), respectively. There were 60 aortic tubes and 39 bifurcated prostheses. Five patients (5%) required conversion. No hospital mortality occurred. Three patients presented with severe systemic complications (3%): 1 perioperative cardiac arrest on atrioventricular block grade 3, 1 case of febrile hypoxic atelectasis, and 1 colonic ischemia with transient renal failure with transient dialysis. Ten patients had a moderate systemic complication (10%): 7 transitory elevations of creatinemia, 1 pneumonia, 1 prostatitis, 1 sigmoiditis, and 1 cardiac arrhythmia/atrial fibrillation (CA/AF). Intensive care stay and hospitalization durations were 24 hours (range, 12-768 hours) and 6 days (range, 4-39 days), respectively. Four local complications occurred: 1 limb thrombosis, 1 compartment syndrome, 1 spleen rupture, and 1 parietal hematoma. On multivariate analysis, the overall procedure time was a predictive factor of severe systemic complications (P=0.02). Follow-up was 42 months (range, 1-97 months). Two patients required late surgery (2%): 1 for limb thrombosis after neuroendovascular procedure and 1 for iliac thrombosis. Morphologic tests did not show any defects at the aortic prosthesis level. The only abdominal complication was a rupture at the level of a laparotomy conversion. The 6 late deaths (6%) were not related to the AAA. This study shows that AAA laparoscopic surgery is a safe, long-lasting, minimally invasive technique in patients with standard surgical risk when EVAR can be considered.

Three trocars laparoscopic abdominal aortic aneurysm repair

Total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was performed in a 53-year-old woman diagnosed with an infrarenal abdominal aortic aneurysm. The operation was accomplished by a method using three trocars. The operation took 240 minutes. Blood loss was 600 mL. No complications occurred in 13 months of postoperative follow-up. These results show that total laparoscopic abdominal aortic aneurysm repair with three trocars is feasible and worthwhile.

Invited commentary

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

A comparison of total laparoscopic and open repair of abdominal aortic aneurysms

The 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. Thirty patients with AAAs treated by total laparoscopic repair between July 2003 and December 2004 (group I) were matched in a case-control fashion by morphology and American Society of Anesthesiologists class with 30 patients who underwent open AAA repair between April 1997 and May 2004 (group II). Patients who survived the intervention were followed up during 5 years. Follow-up consisted of physical examination and duplex ultrasonography at 1 month and yearly thereafter. Group I patients had an additional control computed tomography scan within the first 3 months postoperatively. Five-year cumulative survival rates were similar (group I: 83% ± 7% vs group II: 79% ± 7%; log-rank test, P = .69). No late aneurysm-related death occurred during the follow-up period. Incisional hernias were more likely to occur in group II patients (group I: 0% vs group II: 15.4%; P = .047). Incidence of postoperative sexual dysfunction was similar in both groups (group I: 22.2% vs group II: 25.0%; P = not significant [NS]). No late reintervention was recorded in group I, whereas 2 patients in group II had incisional hernia repair. At 5 years, no graft sepsis or anastomotic pseudoaneurysm was reported. This study suggests that total laparoscopic AAA repair provides good long-term results, comparable to those of open repair in terms of aneurysm-related mortality and morbidity. It may reduce the incidence of laparotomy-related complications.

Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association

From the Department of Radiology, Division of Vascular Imaging and Intervention (T.G.W., S.P.K., K.Y., S.W.), Massachusetts General Hospital, Boston, Massachusetts; Department of Medical Imaging (S.K.), Scarborough General Hospital, Toronto, Ontario, Canada; Department of Interventional Radiology (P.D.), West Allis Memorial Hospital, Milwaukee, Wisconsin; Department of Radiology, Division of Interventional Radiology (B.J.D.), University of Maryland Medical Center, Baltimore, Maryland; Department of Radiology (S.C.R.), University of California San Diego Medical Center, San Diego, California; and Department of Radiology (J.F.C.), Geisinger Health System, Danville, Pennsylvania. Received May 4, 2010; final revision received May 24, 2010; accepted July 11, 2010. Address corre-

Laparoscopic Aortic Surgery in Obese Patients

Our objective was to demonstrate the feasibility of laparoscopic abdominal aortic aneurysm (AAA) repair in obese patients and to confirm advantages observed with laparoscopic techniques in other surgical specialties regarding pulmonary and parietal complications in this population. Between November 2000 and December 2007 we performed 37 laparoscopic aortic reconstructions in obese patients (body mass index [BMI] > 30 kg/m(2)). Median BMI was 31.9 kg/m(2) (range 30.1-40). Twenty-seven patients (73%) were operated for AAA and 10 (27%) for TASC C or D aortoiliac occlusive disease. Data were gathered prospectively and analyzed retrospectively. Aortic exposure was totally laparoscopic in 36 patients (97.3%). Median operative time was 290 min (range 160-480). Median duration of clamping was 77.5 min (range 40-105). Orotracheal extubation was possible before H24 for 35 patients (95%). Median lengths of intensive care unit stay and hospital stay were, respectively, 48 hr (range 12-624) and 8 days (range 4-35). One patient (2.7%) died postoperatively because of colonic ischemia. Five systemic postoperative complications were observed in 36 patients who survived (13.5%) including major nonlethal postoperative complications in two patients (pneumopathy and acute hemodynamic lung edema). All other patients had a fast recovery, with minimal wound discomfort and rapid return to general diet and ambulation, with a median follow-up of 21.5 months (range 1-78). One patient was lost. Complete recovery was observed in 35 other patients, and all grafts were patent at last follow-up. No graft infection was observed, and none of our patients presented incisional hernia. Obesity is not an operative risk factor for laparoscopic aortic surgery. Our results confirm its feasibility and durability for this high-risk population. Laparoscopy should be considered as the technique of choice whenever direct AAA repair is planned in obese patients.

Laparoscopic abdominal aortic aneurysm repair in octogenarians

Open abdominal aortic aneurysm (AAA) repair in octogenarians is considered to have higher risks of mortality and systemic complications compared with younger patients. The purpose of our work is to present our experience with total laparoscopic repair for AAA in this subset of patients. From February 2002 to February 2008, 29 octogenarian patients underwent total laparoscopic AAA repair. Median age was 82 years (range, 80-85 years). Median aneurysm size was 52 mm (range, 40-85 mm). Disease was classified as American Society of Anesthesiologist (ASA) class II in 12 patients and class III in 17 patients. Ten patients presented with past medical history of myocardial infarct (34.5%). We implanted 12 tube grafts and 17 bifurcated grafts. Twenty-six procedures were totally laparoscopic (89.6 %). Median operative time and aortic clamping time were 280 min (range, 160-480 min) and 75 min (range, 22-125 min), respectively. Two patients with juxtarenal AAA underwent suprarenal clamping. Median blood loss was 1100 cc (range, 600-3000 cc). Four patients (13.8%) needed adjunctive vascular procedures because of intraoperative complications. Two patients died in the postoperative course (6.9%). Four patients developed severe systemic non-lethal complications (14.8%, pneumopathies). Mild or moderate systemic complications were observed in 14 patients (51.8%) including transient renal insufficiencies without dialysis (13) and cardiac arrhythmia (1). Postoperative creatinine levels returned to baseline before discharge in all patients. Liquid diet was reintroduced after a median duration of 2 days (range, 1-10 days) and most patients were ambulatory by day four (range, 3-30 days). Median stays in intensive care unit and hospital were 72 hours (range, 12-1368 hours) and 11 days (range, 6-74 days), respectively. Sixteen patients (59.2%) were discharged directly to home with complete recovery. After a median follow-up of 24 months (range, 2-48 months), 23 patients are still alive and regained their baseline status. Four patients died after hospital discharge of non-vascular etiologies. Total laparoscopic AAA repair is a worthwhile but challenging procedure in octogenarians. Laparoscopy is complementary to open surgery and EVAR in this subset. These results encourage us to offer laparoscopic AAA repair in good surgical risk octogenarians.

Total Laparoscopic Repair for Abdominal Aortic Aneurysm

Surgical resection and grafting have long been the standard treatment for abdominal aortic aneurysm and provide an excellent long-term outcome. However, there is tremendous impact on patients due to the surgical invasiveness. Endovascular aortic repair using stent graft was introduced in 1991. After refinement of the techniques and technology, endovascular aortic repair was approved by most health authorities and is associated with less periprocedural morbidities. In between these two extremes, some surgeons endeavored to create an alternative and perform less invasive surgeries. Hand-assisted laparoscopic aortic surgery and laparoscopic-assisted aortic surgery were introduced in 1996. In 2001, total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was first performed in Canada. Till now, only a few vascular units in North America and Europe perform these delicate techniques. We report our first case of total laparoscopic abdominal aortic aneurysm repair. Laparoscopic aortic surgery provides better visualization of the aneurysm neck, less bowel manipulation and avoidance of hypothermia. The minimal invasiveness could translate to better perioperative outcome. To our knowledge, this is also the first case report in Asia. The detailed techniques are described.

Total Laparoscopic Aortic Surgery Versus Minimal Access Techniques: Review Of More Than 600 Patients

In the following paper we describe our experience with a large number of patients in which either a laparoscopic assisted procedure or a total laparoscopic operation was performed. From 1996 until 2005 a total number of 638 aortic patients were operated on using a total laparoscopic or a laparoscopic assisted approach. A total laparoscopic operation was accomplished in 236 cases. A laparoscopic assisted aortic operation was performed in 402 patients. In aneurysm patients a tube graft was more frequently implanted. Thirty-day mortality was significantly higher in patients with a total laparoscopic abdominal aortic aneurysm repair (3.0%) compared to a laparoscopic assisted procedure (1.8%). There was no significant difference in mortality in patients with occlusive disease and a total laparoscopic aortofemoral bypass versus a laparoscopically assisted operation. The same tendency could be observed when analyzing the incidence of major perioperative complications. Again we found no significant difference in patients with occlusive disease yet more severe complications directly related to the operation in patients with a total laparoscopic aneurysm repair. There was a significantly increased complication rate in total laparoscopic aortoiliac repair with a bifurcated prosthesis compared to a tube graft repair: a tendency we could not observe in aneurysm patients with a laparoscopic assisted operation. Our data also show that there is a lot of room for technical improvements such as stapling devices or special grafts to reduce total operating times as well as the period of aortic crossclamping. The routine use of a minilaparotomy can hardly be a solution considering the technical drawbacks such as impaired vision and long term complications like ventral hernias. Compared to open surgery the midterm results of laparoscopic aortic procedures are promising. The time has come to prove that good results can be obtained in more than a few specialized centers.

Total laparoscopic versus conventional abdominal aortic aneurysm repair: A case-control study

This study was designed to identify differences in the per- and postoperative outcomes between total laparoscopic and open surgical repair of abdominal aortic aneurysms (AAA). We reviewed 30 patients who underwent total laparoscopic AAA repair between July 2003 and December 2004 (group I). This group was matched in a case-control fashion by AAA morphology and American Society of Anesthesiologists class with a group of 30 patients who underwent conventional AAA repair between April 1997 and May 2004 (group II). Proportions and categoric data were compared with a chi(2) test. Continuous data were compared with a Mann-Whitney test. The two groups had comparable characteristics of age and cardiovascular risk factors. The number of tube and bifurcated grafts was 13 for group I and 17 for group II. Median operative time was 255 minutes (range, 170 to 410 minutes) in group I and 200 minutes (range, 130 to 410) in group II (P <.001). Median aortic clamping time was 80 minutes (range, 35 to 110 minutes) in group I and 50 minutes (range, 24 to 150 minutes) in group II (P < .0001). Total blood loss was 1600 mL (range, 400 to 4000 mL) for group I vd 1000 mL (range, 100 to 2900) for group II (P < .01). The mortality rate was 3.3% for group I (1 patient) vs 6.6% (2 patients) for group II (NS). There were no significant differences between the two groups in terms of postoperative systemic complications (23.3% vs 30%, NS) and local and vascular complications (10% vs 3.3%). Duration of ileus (2 vs 3 days, P < .05), return to normal diet (4 vs 8 days, P < .0001), day of ambulation (3 vs 4 days, P < .05) and dose of narcotics (3.5 mg vs 28.5 mg, P < .05) were significantly lower in group I. Median length of intensive care unit stay was similar between the two groups (48 hours). Median hospital stay was lower in group I but without significant differences with group II (9 vs 11 days, NS). This case-control study provides preliminary results that short-term outcomes of total laparoscopic AAA repair are comparable with those of open surgery. Peroperative data demonstrate that laparoscopy is more technically demanding than open repair. However, the technical challenge of laparoscopy does not worsen the postoperative course.

Undiagnosed Aorto-caval Fistula During Total Laparoscopic Abdominal Aortic Aneurysm Repair: A Cause of Conversion

Total laparoscopic aortic repair is evolving and is now the technique of choice for the treatment of infrarenal abdominal aortic aneurysms (AAA) in our department. With growing experience, surgeons will be confronted with the same peroperative situations than open surgery. We report a case of total laparoscopic AAA repair with peroperative diagnosis of aorto-caval fistula (ACF).

Total laparoscopic infrarenal aortic aneurysm repair: Preliminary results

We describe our initial experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. Between February 2002 and September 2003, we performed 30 total laparoscopic AAA repairs in 27 men and 3 women. Median age was 71.5 years (range, 46-85 years). Median aneurysm size was 51.5 mm (range, 30-79 mm). American Society of Anesthesiologists class of patients was II, III and IV in 10, 19, and 1 cases, respectively. We performed total laparoscopic endoaneurysmorrhaphy and aneurysm exclusion in 27 and 3 patients, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 27 patients. We operated on 2 patients via a tranperitoneal left retrorenal approach and 1 patient via a retroperitoneoscopic approach. We implanted tube grafts and bifurcated grafts in 11 and 19 patients, respectively. Two minilaparotomies were performed. In 1 case, exposure via a retroperitoneal approach was difficult and, in another case, distal aorta was extremely calcified. Median operative time was 290 minutes (range, 160-420 minutes). Median aortic clamping time was 78 minutes (range, 35-230 minutes). Median blood loss was 1680 cc (range, 300-6900 cc). In our early experience, 2 patients died of myocardial infarction. Ten major nonlethal postoperative complications were observed in 8 patients: 4 transcient renal insufficiencies, 2 cases of lung atelectasis, 1 bowel obstruction, 1 spleen rupture, 1 external iliac artery dissection, and 1 iliac hematoma. Others patients had an excellent recovery with rapid return to general diet and ambulation. Median hospital stay was 9 days (range, 8-37 days). With a median follow-up of 12 months (range, 0.5-20 months), patients had a complete recovery and all grafts were patent. These preliminary results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. However, prior training and experience in laparoscopic aortic surgery are needed to perform total laparoscopic AAA repair. Despite these encouraging results, a greater experience and further evaluation are required to ensure the real benefit of this technique compared with open AAA repair.

Total laparoscopic abdominal aortic aneurysm repair with reimplantation of the inferior mesenteric artery

We performed a total laparoscopic reimplantation of the inferior mesenteric artery (IMA) during laparoscopic infrarenal aortic aneurysm repair. The postoperative course was uneventful, and angiograms showed a patent IMA after reimplantation. To our knowledge, total laparoscopic reimplantation of the IMA in human beings has not previously been described.

Laparoscopy-assisted aneurysm resection as a minimal invasive alternative in patients unsuitable for endovascular surgery

Objective: So far, endovascular surgery has been the only minimal invasive way to treat patients with abdominal aortic aneurysms (AAAs). With hand-assisted laparoscopic surgery (HALS), laparoscopic transperitoneal endoaneurysm repair can be performed through a 6-cm mini-incision only. We wanted to evaluate whether this laparoscopic technique can be offered as a minimal invasive alternative in patients unsuitable for endovascular AAA repair. Material and Methods: Forty patients were referred for endovascular AAA repair. Three patients had to be excluded from the study. Endovascular AAA exclusion was finally performed in 13 patients. Laparoscopic AAA resection was performed in 24 patients. Hand-assisted laparoscopic surgery with transperitoneal access and endoaneurysm repair was accomplished in all patients unsuitable for an endovascular procedure. The outcome after endovascular repair was compared with the outcome of patients who underwent laparoscopy. Results: In the laparoscopic group, conversion to an open procedure was necessary in one case. One patient in this group died (4.1%) postoperatively. There were four complications in each group. In the endovascular group we had one endoleak type II and one graft thrombosis, which required a reoperation. After endovascular treatment, patients were transferred significantly less frequently to the intensive care unit, and they could resume oral feeding earlier. Mobilization and postoperative hospital stay did not differ significantly between the groups. Conclusion: Laparoscopic AAA resection with the use of the technique described can be routinely offered to patients unsuitable for endovascular AAA exclusion with excellent long-term results similar to open surgery. A controlled study is clearly indicated to evaluate the role of laparoscopic techniques in aneurysm surgery. (J Vasc Surg 2001;34:216-21.)