Transperitoneal Repair Research Articles

No difference in midterm outcomes and complication rate between retroperitoneal and transperitoneal open aortic aneurysm repair in females.

Abdominal Aortic Aneurysms (AAA) in females are less prevalent, have higher expansion rates and experience rupture at smaller diameters than in males. Studies have compared outcomes of the retroperitoneal (RP) and transperitoneal (TP) approach in open aortic aneurysm repair (OAR) with conflicting results. No study to date has compared the two approaches solely in females. In this study we compare midterm outcomes of the RP and TP approach in females undergoing OAR. Single-center, retrospective review of all females undergoing OAR from 2010 to 2021. Patients undergoing elective, symptomatic and ruptured OAR were included. The cohort was stratified by surgical approach RP versus TP and midterm outcomes were compared amongst the groups. Outcomes included mortality, graft related, and non-graft related complications. A total of 244 patients (RP n = 133; TP n = 111) were identified. Follow-up period was 28 ± 30.7months. Baseline perioperative characteristics were similar except that more people in the RP group had ejection fraction ((EF) > 50% (82% vs 68%), p = .037). Patients who underwent RP repair had longer visceral/renal ischemia time (p = .01), larger graft diameter (18 vs 16mm; p = <0.001), were more likely to have a suprarenal clamp placed(70.5 vs 48.2; p < .001), and had decreased autotransfusion volume (611 vs 861mL; p < .01) compared to those who underwent TP repair. Number of deaths was higher in the TP group during study follow-up period (36.4 vs 23.8; p = .035), but the difference of the time to event analysis was not significant. There was no difference in all-cause survival at 36 months between RP and TP (77.8 vs 76.8; p = .045). Overall midterm complications were 9.5% in both groups. Any graft related complication was 1.8% in TP versus 3% RP (p = .69). In a multivariable model, after adjusting for age, urgency, smoking, prior aneurysm repair, and ASA level, the hazard ratio decreases with the RP approach, however this did not reach significance (p = .052). In a 12-year period of OAR in females, TP and RP results were comparable at midterm analysis. The RP approach appeared to be used more often for OAR requiring suprarenal clamping. Although the TP group had increased mortality, the difference of the time to event analysis was not significant. Midterm postoperative complications in both groups were low. This suggests that both approaches are safe in the female population and decision should be driven by anatomy and surgeon's preference.

Risk Factors for Development of Incisional Hernia after Aortic Aneurysm Repair: Secondary Analysis of the OVER Randomized Controlled Trial

Since the risk of mortality from rupture is elevated, elective repair of abdominal aortic aneurysms (AAAs) is often recommended. Currently, over 80% of elective repairs are carried out using an endovascular approach. While open repair has similar late survival and fewer reintervention outcomes when compared to endovascular repair, incisional hernia is a frequent complication with morbidity and cost implications. The Open versus Endovascular Repair (OVER) trial was the largest randomized trial of endovascular versus open repair of AAA in the United States. The purpose of this study was to determine risk factors associated with incisional hernia development following AAA repair via secondary analysis of the OVER data. This was a multisite trial conducted within the Veterans Affairs health-care system. Study participants (N=881) were enrolled from 2002 to 2008 and followed until 2011 with additional administrative data collection until 2016. Eligible patients had AAA for which elective repair was planned and randomized 1:1 to either open or endovascular repair. Incisional hernia was a prespecified end point in the OVER protocol, specifically assessed at each protocol follow-up visit. Technical details were extracted from each operative report, repair case report form(s), and adverse event form(s). Patient demographics, comorbid conditions, reported preoperative activity level, and operative details including initial approach, blood loss, and closure methods were analyzed using Bayesian hierarchical Weibull survival regression modeling. Incisional hernias were recorded among 46 participants (5.2%). The average time to hernia diagnosis was 3.5years. Of the 437 participants randomized to open treatment, 427 received an open repair including crossovers from endovascular treatment assignment. Transperitoneal repair was performed in 81%, running suture in 96%, and absorbable suture in 71% of cases. Randomization to endovascular repair was associated with reduced risk of hernia (hazard ratio [HR] 0.70, 95% credible interval [CI] 0.49-0.94). Higher activity level was associated with increased hernia risk (HR 1.39, 95% CI 1.06-1.84). Approach, suture closure techniques, body mass index, diabetes, and smoking status were not associated with increased risk of hernia development. Incisional hernia is a frequent complication associated with open repair of abdominal aortic aneurysm and commonly required reintervention. Endovascular repair was associated with reduced risk of hernia. Patients with increased activity experienced a higher incidence of hernia. However, no other modifiable patient, operative, or technical factors were found to be associated with hernia development.

Open Retroperitoneal Repair for Complex Abdominal Aortic Aneurysms

Open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) can be challenging. We frequently utilize the retroperitoneal (RP) approach for such cases. We audited our outcomes with the aim of establishing the utility and safety of this approach. Retrospective analysis was performed of all patients undergoing OSR of an unruptured CAAA via a RP approach in our center over a 7-year period. Data on repairs via a transperitoneal (TP) approach were collected to provide context. Demographic, operative, radiological, and biochemical data were collected. The primary outcome measure was 30-day/inpatient mortality. Secondary outcomes included the need for reoperation, incidence of postoperative chest infection, acute kidney injury (AKI) and length of stay (LOS). All patients received aortic clamping above at least one main renal artery. One hundred and three patients underwent OSR of an unruptured CAAA; 55 via a RP approach, 48 TP. The RP group demonstrated a more advanced pattern of disease with a larger median maximum diameter (65 vs. 61 mm, p= 0.013) and a more proximal extent. Consequently, the rate of supravisceral clamping was higher in RP repair (66 vs. 15%, p < 0.001). Despite this there were no differences in the observed early mortality (9.1 vs. 10%, NS); incidence of reoperation (10.9 vs. 12.5%, NS), chest infection (32.7 vs. 25%, NS), and AKI (52.7 vs. 45.8%, NS); or median LOS (10 vs. 12 days, NS) following RP and TP repair. OSR of CAAAs carries significant 30-day mortality. In patients unsuitable for fenestrated endovascular aortic repair or those desiring a durable long-term solution, OSR can be performed through the RP or TP approach. This study has demonstrated that in our unit RP repair facilitates treatment of more advanced AAA utilizing complex proximal clamp zones with similar perioperative morbidity and mortality compared with TP cases utilizing more distal clamping.

Robotic-assisted laparoscopic repair of a congenital rectourethral fistula with duplicated urethra

To describe our experience with robot-assisted laparoscopic transperitoneal repair of a congenital rectourethral fistula in a pediatric patient with a urethral duplication. The patient is a 2-year-old male with a past medical history of Tetralogy of Fallot presenting with a febrile urinary tract infection (UTI). He was diagnosed with urethral duplication and a rectourethral fistula by voiding cystourethrogram (VCUG). The parents were counseled on various options and agreed to proceed with a robotic repair. Robotic-assisted transperitoneal rectourethral fistula repair was performed. The procedure time was 229min with an estimated blood loss (EBL) of 15mL. His postoperative course was unremarkable. At his 2-week follow-up, the urethral catheter was removed and the patient was voiding normally and having normal bowel movements. Congenital rectourethral fistula with urethral duplication is a rare anomaly with only a few reports in the literature. Pediatric robotic-assisted transperitoneal rectourethral fistula repair is a technically feasible approach in infants with minimal morbidity that allows for excellent visualization and avoids open repair.

Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee.

Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia. The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality. Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.

Contemporary mortality after emergent open repair of complex abdominal aortic aneurysms

ObjectiveMortality after open repair for emergent complex abdominal aortic aneurysm (AAA) is poorly defined. This study evaluated the 30-day mortality of open complex AAA repair performed for rupture or other emergent indication using a national surgical registry. We subsequently identified factors associated with mortality. MethodsThe targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing open repair for juxtarenal and suprarenal AAAs or type IV thoracoabdominal aneurysms (TAAAs) for rupture or other emergent indication from 2011 to 2017. Univariate analyses were performed using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Multivariable logistic regression was performed to identify factors independently associated with mortality. ResultsWe included 374 patients who underwent an emergent complex open AAA repair during the study period. There were 142 (38%) cases performed for rupture with hypotension, 141 (38%) for rupture without hypotension, 40 (11%) for symptomatic AAA, and 51 (14%) for another indication. The distribution by aneurysm type was 224 juxtarenal AAAs, 122 suprarenal AAAs, and 28 type IV TAAAs. Overall, there was a 30-day mortality of 32% (118 deaths). For those with juxtarenal AAA repair, 67 (30%) patients died within 30 days; there were 38 (31%) deaths within 30 days in those with suprarenal AAA, and 13 (46%) deaths within 30 days in those with type IV TAAA. On univariate analysis, preoperative variables associated with death were increasing age, use of a transperitoneal surgical approach, lower preoperative estimated glomerular filtration rate, low baseline albumin concentration (<3.5 g/dL), need for preoperative transfusion, low body mass index (<18.5 kg/m2), and hypotension at presentation. Intraoperative variables associated with mortality were supraceliac clamp location and concurrent renal revascularization. On multivariable analysis, factors independently associated with death included rupture with associated hypotension (reference: other emergent indication; adjusted odds ratio [AOR], 3.28; confidence interval [CI], 1.75-5.41; P < .001), age >60 years (reference: <60 years; AOR, 1.59; CI, 1.18-2.13; P = .002), longitudinal laparotomy incision (reference: retroperitoneal; AOR, 3.28; CI, 1.75-6.16; P < .001), and supraceliac cross-clamp (reference: clamp above one renal artery; AOR, 2.14; CI, 1.31-3.50; P = .003). ConclusionsNearly one-third of patients die within 30 days of emergent open complex AAA repair. Mortality is particularly high for patients with type IV TAAAs, approaching 50%. Predictors of 30-day mortality include rupture with associated hypotension, increasing age, supraceliac clamp location, and longitudinal transperitoneal repair approach. These results will help inform surgical decisions preoperatively and intraoperatively.

Laparoscopic and robotic transperitoneal repair of retrocaval ureter: A comparison of the surgical outcomes from two centres with a comprehensive literature review.

Background:The use of minimally invasive surgical approaches for the repair of retrocaval ureter (RCU) has been increased in time. However, the results of the robotic approach have not yet been compared with those of open or laparoscopic approaches. We aimed to compare the results of laparoscopic and robotic transperitoneal repair of RCU from two centres.Patients and Methods:Initially, we performed a systemic literature search using MEDLINE/PubMed and Google Scholar about the RCU. Finally, a comparison of the efficacy and outcomes of the laparoscopic and robotic transperitoneal approaches for RCU repair was performed with the results of two centers.Results:The mean age was 27.5 ± 3.6 years. The mean operative time was 147 ± 63.6 min. The median estimated blood loss was 100 (20–423.9) ml. The median drain removing time and hospital stay were 2 (2–3) and 3 (2–4) days, respectively. The mean follow-up period was 17.85 ± 14.6 months. All of the parameters were similar between the laparoscopic and robotic repair groups except for the mean operative time. It was significantly shorter in robotic repair group than those of laparoscopic repair group (P = 0.02). Furthermore, a ureteral stricture of the anastomotic segment was detected in a patient treated with laparoscopy during the follow-up.Conclusions:Robotic transperitoneal approach may shorten the operative time enabling a greater comfort in repair of RCU.

Retroperitoneal approach to the abdominal aorta: Tips and tricks

In the era of endovascular repair of abdominal aneurysms (AAA) the use of traditional open surgical repair of AAA is declining. The preferred option for patients with AAAs who are young or have challenging anatomy that is not suitable for Endovascular repair is open surgical repair. Most Vascular Surgical units are familiar with the transperitoneal (TP) approach to AAA. Another useful approach to AAA is retroperitoneal (RP). Our unit has found RP a more suitable approach for repairing the AAAs with challenging anatomy and in patients with poor physiological function. RP approach provides excellent access to the juxta/supra renal aorta. In addition, patients undergoing RP have less post-operative morbidity and shorter hospital stay compared to those undergoing TP repair. Our unit recommends RP approach as the preferred option to repair AAAs unsuitable for endovascular repair. Given the relative lack of familiarity with this technique as it is not widely practised, we have described the technique/our experience and its advantages over conventional open surgery.

Laparoscopic Transperitoneal Approach for Vesicovaginal Fistula Repair: the First Experience

Objective: To report our first experience in transperitoneal laparoscopic repair of vesicovaginal fistula in Dr. Hasan Sadikin Hospital.&#x0D; Method: A 31-year-old female presented with vesicovaginal fistula&#x0D; after cesarean section. Patient complained of urinary incontinence&#x0D; since 5 years ago. After a failed trial of conservative treatment with&#x0D; catheter drainage, a transperitoneal laparoscopic repair was performed.&#x0D; Initially, cystoscopy was performed to confirm the fistula location&#x0D; and for bilateral ureteric catheterization. A 4-port technique&#x0D; was performed with the patient in lithotomy position and slightly&#x0D; Trendelenburg. Without opening the bladder, the fistula tract was&#x0D; excised and the bladder was separated from the anterior vaginal&#x0D; wall. Both the bladder and vaginal walls were then closed separately&#x0D; using intracorporeal suturing, interposed with the omentum.&#x0D; Result: Total operative time was 270 minutes. Normal diet was resumed on day 1, drain was removed on the first day after surgery,&#x0D; and the patient was discharged on the second day with an indwelling&#x0D; catheter. Surgical wound showed good cosmetic result and no&#x0D; leakage was identified from cystogram after 2 weeks. The catheter&#x0D; was removed after 2 weeks.&#x0D; Conclusion: Laparoscopic transperitoneal repair of vesicovaginal&#x0D; fistula with omentum inteposition is feasible in Dr. Hasan Sadikin&#x0D; Hospital with good outcome, short hospital stay, and good cosmetic&#x0D; result.&#x0D; [Indones J Obstet Gynecol 2014; 4: 223-225]&#x0D; Keywords: laparoscopy, vesicovaginal fistula

Laparoscopic transperitoneal approach for vesicovaginal repair : The first experience in Hasan Sadikin Hospital

Introduction : Obstetric fistula is a severe and debilitating condition occurring throughout the developing world. Although there are no accurate data on the incidence and prevalence of the condition, the majority of vesicovaginal fistulas develop after gynaecologic surgery, with transperitoneal hysterectomy accounting for 90% of cases. Several techniques are available for repairing the fistulas. Transperitoneal approaches give good results even for difficult posterior located fistulas, but are associated with increased morbidity compared with the transvaginal approach. We performed a laparoscopic repair and omentum interposition. Objective : To report our first experience in transperitoneal laparoscopic repair of vesicovaginal fistula in Hasan Sadikin Hospital. Patient and Method : A 31-year-old female presented with vesicovaginal fistula after sectio caersaeran. After a failed trial of conservative treatment with catheter drainage, a transperitoneal laparoscopic repair was performed. Cystoscopy was performed initially to confirm the fistula location and for bilateral ureteric catheterization. A 4-port technique was performed with the patient in the position with her legs in lithotomy position. Without opening the bladder, the fistula tract was excised with separation of the bladder from the anterior vagina wall. Both the bladder and vagina walls were then closed separately using intracorporeal suturing with an interpositional omentum. Result : Total operative time was 270 min. Normal diet was resumed on day 1, drain was removed on post operatif day 1 and patient was discharged on the second day with an indwelling catheter. Good cosmetic result on wound operation and no leakage under cystogram after 2 weeks. The catheter was removed after 2 weeks. Conclusion : Laparoscopic transperitoneal repair of vesicovaginal fistula with omentum inteposition is feasible in Hasan Sadikin Hospital with good outcomes, short hospital days, and good cosmetics result. Keywords : Fistula vesico vaginal, laparoscopic.

Short-term outcomes following endovascular and open surgical repair of abdominal aortic aneurysms

Objectives: Endovascular repair of abdominal aortic aneurysms (AAA) has become the treatment of choice in the last decade. Perioperative morbidity and mortality are decreased along with the decreased hospital length of stay and decreased costs. We aimed to evaluate short-term outcomes and to compare conventional outcomes in patients undergoing either endovascular or open transperitoneal surgical repair. Materials and Methods: Totally, 46 consecutive patients presenting with the diagnosis of AAA between October 2012 and February 2014 were prospectively studied. Patients were grouped into two: elective endovascular (n = 24) and elective open repair (n = 22). Perioperative and in-hospital mortality rates, patient demographics, procedural details, postoperative follow-up data were collected. Results: Hospital stay was significantly shorter after endovascular AAA repair ( P < 0.01). Endovascular technique was associated with shorter and less invasive perioperative hospital course and fewer postoperative complications. Conclusions: Endovascular repair may be an effective treatment of choice with low mortality and morbidity rates for the patients who are elderly and are at high-risk for surgery and those who are anatomically suitable, through the advances in graft technology.

Laparoscopic Transperitoneal Approach for Vesicovaginal Repair : The First Experience in Hasan Sadikin Hospital

&#x0D; &#x0D; &#x0D; Background. Obstetric fistula is a severe and debilitating condition occurring throughout the developing world. Although there are no accurate data on the incidence and prevalence of the condition, the majority of vesicovaginal fistulas develop after obstetric procedure, with delayed labour accounting for 90% of cases. Several techniques are available for repairing the fistulas. Transperitoneal approaches give good results even for difficult posterior located fistulas, but are associated with increased morbidity compared with the transvaginal approach. We performed a laparoscopic repair and omentum interposition. The objective of this article is to report our first experience in transperitoneal laparoscopic repair of vesicovaginal fistula in Hasan Sadikin Hospital.&#x0D; Method. A 31–year–old female presented with vesicovaginal fistula after sectio caersaeran because of de- layed labour. After a failed trial of conservative treatment with catheter drainage, a transperitoneal laparoscopic repair was performed. Cystoscopy was performed initially to confirm the fistula location and for bilat- eral ureteric catheterization. A 4–port technique was performed with the patient in the position with her legs in lithotomy position. Without opening the bladder, the fistula tract was excised with separation of the bladder from the anterior vagina wall. Both the bladder and vagina walls were then closed separately using intracorporeal suturing with an interpositional omentum.&#x0D; Results. Total operative time was 270 min. Normal diet was resumed on day 1, drain was removed on post operative day 1 and patient was discharged on the second day with an indwelling catheter. Food cosmetic result on wound operation and no leakage under cystogram after 2 weeks. The catheter was removed after 2 weeks.&#x0D; Conclusion. Laparoscopic transperitoneal repair of vesicovaginal fistula with omentum inteposition is feasible in Hasan Sadikin Hospital with good outcomes, short hospital days, and good cosmetics result. Still need more same cases before a final conclusion&#x0D; &#x0D; &#x0D;

Aortoduodenal fistula after transperitoneal repair of an inflammatory abdominal aortic aneurysm: A case report

Introduction: An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Case Report: A 77-year-old Caucasian male who underwent a conventional repair of an inflammatory infrarenal aortic aneurysm, was readmitted with hematemesis only six weeks after surgery. Gastroscopy and computed tomography angiography indicated an aortoduodenal fistula and urgent aortic reconstruction was performed. An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Conclusion: An aortoduodenal fistula seldom occurs as early after conventional transperitoneal open aneurysm repair as in our case. The early occurrence of the aortoduodenal fistula can be explained by the inflammatory character of the aneurysm.

Transvesicoscopic Repair of Vesicovaginal Fistula: Short Term Follow-Up

Introduction: We report our series of patients with VVF treated by transvesicoscopic approach. We analyzed the outcome of this repair in women of reproductive age group. Materials and methods: Patients of reproductive age group with VVF formed the study group. Only single fistulas which were <10 mm in diameter and situated in the supratrigonal region were included. Patients were randomized to undergo either laparoscopic transperitoneal or transvesicoscopic repair. Results: During the study period Jan 2009 to Dec 2012, 15 women underwent laparoscopic repair of VVF. Eight of these women underwent laparoscopic transperitoneal repair, whereas the remaining seven underwent transvesicoscopic repair. Conclusions: Transvesicoscopic as well as laparoscopic transperitoneal repair of VVF carries all the advantages of laparoscopy including minimal invasiveness, less morbidity, shorter hospital stay, early recovery, and better cosmetic appearance. Women in the reproductive age group return to early sexual activity and have a decreased incidence of urinary voiding dysfunction at 6 months follow-up.

Concurrent Transperitoneal Repair for Incidentally Detected Inguinal Hernias During Robotically Assisted Radical Prostatectomy

To report our experience with concurrent intraperitoneal inguinal herniorrhaphy using prosthetic mesh during robotically assisted radical prostatectomy (RARP) for incidentally discovered inguinal hernias. We performed a retrospective review of 1118 consecutive RARPs performed by one surgeon between July 2005 and July 2011. Cases that included concurrent hernia repair were compared with a group of patients matched 1:1 for age, body mass index, and year of surgery, who underwent RARP alone (controls). A total of 91 patients underwent 113 concurrent inguinal hernia repairs during RARP. Twenty-two patients (24%) underwent bilateral repair. Of the 69 patients undergoing unilateral repair, 41 (45%) underwent left-sided repair, and 29 (31%) underwent right-sided repair. Thirty-five (38%) patients had previous inguinal hernia repair. Body mass index of cases and controls were 27.5 ± 3.4 and 27.8 ± 3.1 kg/m(2), respectively. Mean operative time in cases was 185 ± 28 minutes vs 168 ± 31 minutes in controls (P <.001). Estimated blood loss was 170 ± 61 mL for cases vs 194 ± 82 mL for controls (P = .03). No differences were observed in length of stay or prevalence of postoperative complications. There was 1 hernia recurrence, which necessitated repeat repair 1 year after surgery. No mesh infections or other complications related to hernia repairs were observed. Inguinal hernias are a common intraoperative finding during RARP. Concurrent repair appears safe and effective with only a slight increase in operative time, and no increase in morbidity.

Laparoscopic Transperitoneal Repair of Pediatric Diaphragm Eventration Using an Endostapler Device

Minimally invasive repairs of pediatric diaphragm eventration have been well described via a thoracoscopic approach, oftentimes requiring single-lung ventilation and tube thoracostomy, with the disadvantage of not being able to clearly visualize what lies beneath the diaphragm. We describe a novel pediatric diaphragm eventration repair using a laparoscopic transperitoneal approach and an endostapler device. We also describe our initial experience with this technique. Four pediatric diaphragmatic eventration patients underwent laparoscopic transperitoneal repair using an endostapler device. Repairs were performed in both male and female patients with right-sided eventrations. We approach the repair in a transperitoneal fashion using inverting sutures at the apex of the diaphragm to create tension toward the pelvis. Subsequently, an endostapler is used to remove the redundant portion of diaphragm, leaving a repaired, taut diaphragm. The median age at operation was 10.5 months. The median operative time was 70 minutes. There was no mortality, surgical complications, or recurrence at a median follow-up of 17 months. This laparoscopic approach allows for clear visualization of the intraabdominal organs and, at least in our early experience, a very simple, straightforward operation. Additionally, with the use of the endostapler, the redundant, often weakened diaphragm is removed, leaving the native, healthy diaphragm behind, resulting in a reliable and reproducible repair. This repair should be considered as a feasible alternative approach to the more traditional open and thoracoscopic repairs.

Aortic Endograft Infection With Aortoduodenal Fistula Associated With Adjacent Vertebral Body Mycobacterial Osteomyelitis (Pott's Disease)

Aortoenteric fistulas (AEFs) are a rare complication of infrarenal abdominal aortic aneurysm repair. They occur in <1% of aortic grafting procedures, result from graft defects, foreign bodies, and trauma, and are associated with a high mortality rate. We report a complex AEF associated with vertebral body osteomyelitis, likely secondary to tuberculous infection. A 78-year-old man presented with a 2-week history of abdominal pain, fever, and anemia. Past surgical history is significant for open repair of infrarenal abdominal aortic aneurysm followed later by an endovascular repair of a proximal para-anastomotic aneurysm. Computed tomography angiography revealed air in the aneurysm sac, without evidence of endoleak. The posterior aspect of the aneurysm was noted to be in continuity with a destructive osteomyelitis of the second lumbar vertebral body and an adjacent psoas abscess. Percutaneous drainage revealed purulent fluid containing mixed enteric flora. With fluoroscopic guidance, injection of contrast in the aortic sac drainage catheter demonstrated complex fistulous communications from the aortic sac to the overlying small intestine. After a course of drainage, antibiotic therapy, and parenteral nutrition, the patient underwent a transperitoneal repair of the AEF with duodeno-duodenectomy and wide debridement of the aortic sac and Dacron graft. Pathology revealed giant cell granulomas, highly suggestive of tuberculosis.

Interleukin-6 production is reduced by the extraperitoneal approach in elective abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) repair through a transperitoneal approach induces a systemic interleukin-6 (IL-6) response which may be related to manipulation of the bowel and mesenteric traction. This study investigates the effect of avoiding intestinal manipulation on IL-6 production by comparing the use of extraperitoneal and transperitoneal approaches in elective infrarenal AAA repair. Patients undergoing elective AAA repair were randomized into either transperitoneal (n=10) or extraperitoneal (n=8) groups. Samples of systemic and portal blood were collected intraoperatively before, during and after aortic cross clamping. In addition, systemic blood samples were obtained pre-induction, post-induction, and 6, 12, 24, and 48 hours after abdominal incision. Plasma IL-6 concentration was measured using a bioassay based on the proliferation of IL-6 dependent B9 Hybridoma cells (sensitivity of assay is 30–40 pg/ml). In the extraperitoneal group, IL-6 was not detected in either the portal or systemic circulations intraoperatively. With the transperitoneal group, IL-6 was detected in 15 of 40 (38%) portal, and 8 of 40 (20%) systemic intraoperative samples (p<0.001,x2 test). Postoperatively, IL-6 was detected in only 14 of 32 (44%) samples taken during the 48 hours after extraperitoneal repair but in 35 of 40 (88%) samples after transperitoneal repair (p<0.001,x2 test). At 6 hours, the systemic IL-6 concentration was significantly higher in the transperitoneal group (p<0.01, Mann-WhitneyU test). No correlation was seen between the plasma IL-6 concentration and aortic clamp time, duration of operation, or amount of blood lost or transfused. These results supports the suggestion that intestinal manipulation plays an important role in driving the systemic inflammatory response that may be seen after transperitoneal AAA repair.

Elective infrarenal abdominal aortic aneurysm repair - transperitoneal, retroperitoneal, endovascular?

We retrospectively analyzed the peri-operative outcome of 210 consecutive patients undergoing elective infrarenal abdominal aortic aneurysm (AAA) repair according to the surgical approach: transperitoneal (TP; 63 patients), retroperitoneal (RP; 81 patients) and endovascular (EV; 66 patients) repair. Concerning gender, AAA diameter and classification of the American Society of Anesthesiologists (ASA score) all groups were comparable; the median age in the EV group was significantly higher (78 years vs. 68 years and 67 years, respectively, P=0.001). Mortality rates were 0% for TP, 1.2% for RP and 3% for EV repair (n.s.). Morbidity rates did not significantly differ between the groups. In specialized centres mortality rates of elective infrarenal aneurysm repair are low - regardless of the surgical approach. In such centres the best treatment options for each patient as to the surgical approach as well as peri-operative management can be provided individually.

Retroperitoneal Repair of Abdominal Aortic Aneurysm Reduces Bowel Dysfunction

To assess the effect of intestinal manipulation and mesenteric traction on gastro-intestinal function and postoperative recovery in patients undergoing abdominal aortic aneurysm (AAA) repair. Thirty-five patients undergoing AAA repair were randomised into 3 groups. Group I (n = 11) had repair via retroperitoneal approach while Group II (n = 12) and Group III (n = 12) were repaired via transperitoneal approach with bowel packed within the peritoneal cavity or exteriorised in a bowel bag respectively. Gastric emptying was measured pre-operatively (day 0), day 1 and day 3 using paracetamol absorption test (PAT) and area under curve (P(AUC)) was calculated. Intestinal permeability was measured using the Lactulose-Mannitol test. Aneurysm size, operation time and PAT (on day 0 and day 3) were similar in the three groups. On day 1, the P(AUC) was significantly higher in Group I, when compared with Group II and Group III (P = .02). Resumption of diet was also significantly earlier in Group I as compared to Group II and Group III. The intestinal permeability was significantly increased in Group II and Group III at day 1 when compared with day 0, with no significant increase in Group I. Retroperitoneal repair was also associated with significantly shorter intensive care unit (P = .04) and hospital stay (P = .047), when compared with the combined transperitoneal repair group (Group II and III). Retroperitoneal AAA repair minimises intestinal dysfunction and may lead to quicker patient recovery when compared to transperitoneal repair.