Br. J. Surg. Vol. 62 (1975) 596-600

Aorto-iliac reconstruction with special reference to the extraperitoneal approach R A Y M O N D H E L S B Y A N D A . R. M O O S S A * SUMMARY

We have used the extraperitoneal approach for aortoiliac reconstruction for lower limb ischaemia in over 130 patients. The operative exposure is excellent. Operating time is shortened and the upset to the patient much less rhan in the transperitoneal approach. We now believe that the method is suitable for use in the majority of aorto-iliac reconstructions. Patency rate 4 years after surgery for claudication is 89 per cent,

THEsatisfactory results of aorto-iliac reconstruction are well documented in communications from many centres in different countries and stem from the pioneer work of Dos Santos, Rob and Eastcott, de Bakey, Cannon and Linton, to name but a few. Taylor (1973) has provided a valuable and realistic review of the scope and limitations of reconstructive arterial surgery and his comments and observations accord with our own experience. It is well recognized that in patients with a combination of femoropopliteal and aorto-iliac occlusive disease an aorto-iliac reconstruction will frequently increase the flow to and through the profunda femoris artery sufficiently to improve claudication or to save the limb from major amputation. When the disease is mainly confined to the aorto-iliac region, one can offer the patient a very high prospect of complete and lasting relief. It would seem to the authors that no useful purpose can be served in reporting the detailed follow-up of further patients who have undergone aortic reconstructive operations unless the results are significantly better (or worse) than those in other series. This communication adds little to the existing store of information on postoperative results but seeks to influence surgeons to modify their technique. As the proportion of our population over the age of 65 increases and since atherosclerosis is such a common disease, it is likely that the number of patients presenting for reconstructive surgery will continue to increase. The size of the load must inevitably mean that, as with urology, much of the work will need to be done by the general surgeon. Inevitably, the number of successful reconstructive operations will be approximately balanced by the need for major amputation in other patients, and it is the authors’ belief that the same surgeon should accept equal responsibility for both groups. The purpose of this report is to emphasize that aorto-iliac reconstructions can be adequately performed by general surgeons trained in vascular surgery, and to underline the advantages and the ease of the extraperitoneal approach. This approach is by no means new. Rob 596

wrote of it in 1963 and recalled that Astley Cooper had described it in Guy’s Hospital Reports in 1836. It was recommended by Stipa and Shaw (1968), Douglas (1973) and Martin and Marston (1973); nevertheless we believe that it is still not widely used by surgeons doing vascular work. We have found the exposure quick and convenient, the general upset to the patient far less marked than in the transperitoneal approach and the incidence of postoperative distension, wound dehiscence, incisional hernia and chest complications negligible. Obesity is not a contraindication but rather an indication for the use of this approach. For these reasons the extraperitoneal exposure has become our method of choice and is now used in the majority of aorto-iliac reconstructions. Preoperative assessment does not differ from that used elsewhere, except perhaps that preoperative arteriography has not always been done. In particular, if a patient presents with severe rest pain or gangrene and has an absent femoral pulse on the affected side, when the contralateral femoral pulse is present, operation might well be undertaken without a preoperative angi ogram . In the years 1961-74,330 aorto-iliac reconstructions were performed for lower limb ischaemia. During the same period 250 femoropopliteal reconstructions, over 500 lumbar sympathectomies and 375 leg amputations were done. I n addition, about 800 nonvascular operations including routine urological and gastro-enterological procedures were performed each year on an undergraduate teaching unit consisting of 2 consultants, 1 senior registrar, 1 junior trainee registrar and 1 house surgeon at the Liverpool Royal Infirmary. About 90 per cent of the arterial operations were done by one surgeon. Three basic operations-aorto-iliac disobliteration, aortofemoral bypass and, less frequently, iliofemoral bypass-were used. If the external iliac arteries were grossly diseased the problem was usually managed by an aortofemoral bypass graft rather than by disobliteration. The graft material used has been in nearly every case woven Dacron. Knitted velour Dacron has been used for iliofemoral grafts, but it is not yet available as a bifurcation. The anastomosis of graft to aorta has been either end to end or end to side-approximately an equal number of each. Prophylactic broad spectrum antibiotics (usually ampicillin) have been used routinely, being started a

* The Royal Infirmary, Liverpool. Present address of A. R. Moossa: Department of Surgery, University of Chicago.

Aorto-iliac reconstruction

Fig. 1. Position of patient for extraperitoneal exposure.

Fig. 2. Incision for extraperitoneal exposure.

Fig. 3. The internal oblique and transversus muscles are divided in the middle half of the incision, thus preserving an adequate nerve supply to the abdominal wall.

597

Raymond Helsby and A. R. Moossa

/

Fig. 4. Exposure of lower abdominal aorta and common iliac arteries.

few hours preoperatively and continued for 4 days. Originally heparin was given intraoperatively, but for the past 2 years a single loading dose of 10 000 units is injected intravenously before the induction of anaesthesia. Since the introduction of this latter method there has been no clinical evidence of pulmonary embolism, and indeed no clinical evidence of major deep venous thrombosis in the lower limb following aorto-iliac reconstruction. For the extraperitoneal exposure certain points need emphasis. The left side of the patient must be tilted slightly upwards on sandbags and the ipsilateral arm supported (Fig. 1). Our incision differs somewhat from that described by Rob (1963) and resembles that of Rutherford Morrison. The skin incision is sickleshaped with the upper end curving medially to the costal margin (Fig. 2). The external oblique muscle and aponeurosis is split along the line of its fibres. The underlying internal oblique and transversus muscles are then divided with diathermy in the middle half of the incision. The fibres in the upper and lower quarters of the incision are not divided, and this seems to preserve an adequate nerve supply to the abdominal wall (Fig. 3). The rectus muscle is not divided. The use of a Goligher self-retaining retractor is absolutely essential and overcomes the problem of retraction to which Rob (1963) refers in his paper. The instrument has been modified by us to provide different depths of blade, and it is no exaggeration to say that it saves one assistant-an important factor in many hospitals where skilled assistance is not always readily available. Abdominal packs are not required, only a small dab, with radio-opaque strip, being placed behind each blade of the retractor (Fig. 4). The abdominal incision is closed with a split tube drain. Redivac drains are used for groin incisions. It is quite possible through this incision to obtain an adequate exposure for 598

disobliteration of the abdominal aorta and both common iliac arteries or, alternatively, for transection of the aorta, proximal disobliteration and end-to-end attachment of a bifurcation graft. Small aneurysms have also been resected through this approach. The distal graft anastomosis is performed in the groin, end to side, to the common femoral artery opposite the origin of the profunda femoris artery. When a bypass graft is inserted local common femoral disobliteration is often performed, and occasionally some type of profundaplasty. Left lumbar sympathectomy was performed concomitantly in the majority of operations by coagulation of the lower lumbar ganglia with diathermy. Postoperatively each patient received 500ml of low molecular weight dextran (Rheomacrodex) daily for the first 3 days. Postoperative care is in the general surgical ward and is the routine for any abdominal operation. No patient in the extraperitoneal group has required treatment in an intensive therapy unit. Anticoagulants are not used postoperatively. Because the peritoneum is not opened, convalescence is remarkably easy. A nasogastric tube is usually inserted by the anaesthetist during the operation, and in the majority of cases is removed 24 hours later. Limited oral fluids are commenced on the first postoperative day, and are increased with the onset of intestinal activity. The length of stay in hospital after surgery has been shortened by 2 or 3 days but it is our practice to keep the patient in hospital until the twelfth day when the skin sutures are removed. Patients are much more mobile in the early postoperative period and discomfort is little more than that experienced after herniorrhaphy or appendicectomy.

Results Two hundred and three patients were followed up for this report, 90 having undergone the extraperitoneal operation and 1 1 3 being operated on by the transperitoneal approach. One hundred and twenty-five patients (62 per cent) presented with intermittent claudication and the remaining 78 (38 per cent) with severe rest pain or established gangrene. Most of the latter patients had superficial femoral occlusions in addition to their aorto-iliac disease. Severe hypertension was uncommon but some elevation of the diastolic pressure was found in one-third of the patients. Electrocardiographic evidence of coronary artery disease was noted in 25 per cent of all the patients. More than a quarter of the patients were aged over 60 years. Operative mortality Seven patients died within 1 month of operation, a mortality rate of 3.5 per cent. Five of the 7 patients had presented with rest pain or gangrene. Three deaths occurred in the extraperitoneal group (90 patients) and 4 in the transperitoneal group (103 patients). The causes of the deaths were: pulmonary embolism 2, cerebrovascular accident 2, coronary thrombosis 1, bronchopneumonia 1, haemorrhage into duodenum 1.

Aorto-iliac reconstruction Lote postopcr'citice deaths Forty-three patients (20 per cent) died at intervals between 3 months and 9 years postoperatively, 13 of these having survived for 5 years. Twenty-four (56 per cent) were certified as having died from coronary thrombosis and 5 from a cerebrovascular accident. In 22 of these 43 patients the grafts were patent at the time of death. The low patency rate in this group may well relate to the fact that 32, or three-quarters, of the late deaths were in patients who presented with rest pain or gangrene and had more extensive disease. Reoperntion Early reoperation was performed on 7 patients in the claudication group in whom re-thrombosis had occurred. Three patients had been treated by the extraperitoneal approach and 4 by the transperitoneal approach. Four were successfully treated by thrombectomy and 3 by some further reconstruction. Late reoperation was performed on 15 patients-8 from the extraperitoneal group and 7 from the transperitoneal group. The operations done were 6 axillofemoral grafts (all of which have subsequently thrombosed), 2 excisions of false aneurysms, 1 thrombectomy and replacement of one limb of a bifurcation graft in 6 patients. Postoperatioe complications The postoperative complications are set o u t in Table I . It will be seen that complications were twice as frequent in the transperitoneal group as in the extraperitoneal group, There have been no haematomas in the groin since Redivac drains have been used. The table cannot convey the much smoother convalescence of patients who have been treated by the extraperitoneal approach.

FONO W-UP Of the 78 patients presenting with rest pain or gangrene, 24 (30 per cent) came to amputation. Forty-six patients were alive and 35 (86 per cent) of them had relief of symptoms for a year or more, 13 being symptom-free at 4 years and 6 for over 7 years. It seems satisfactory to note that 70 per cent of the painful legs were saved from amputation. Of the 125 patients presenting with claudication, 13 had died. Only 3 patients lost a limb-2 at 2 years and 1 at 7 years after operation. We decided to report only the results of the 69 patients who had undergone surgery at least 4 years previously. In 62 (89 per cent) of these t h e reconstructions had remained patent ( I for 13 years, and 12 for over 7 years). However, only 42 patients (61 per cent) were totally symptomfree. The remaining 20 patients (28 per cent) were significantly improved in that some calf claudication was experienced but only after walking fairly long distances. We submit, therefore, that patency rates alone may not indicate complete success of a surgical procedure. The results, not surprisingly, were better in the patients whose disease was mainly confined to the aorto-iliac segment.

Table I: POSTOPERATlVE COMPLICATIONS ExtraTransperitoneal peritoneal Total group group (203 (90 patients) (1 13 patients) patients) Complications Bronchopneumonia Coronary thrombosis Cerebrovascular accident Deep vein thrombosis (symptomatic) Pulmonary embolus (symptomatic) Haemorrhage into duodenum Paralytic ileus Wound dehiscence Retroperitoneal haemorrhage Incisional hernia Minor wound sepsis Haematoma in groin Femoral aneurysm False femoral aneurysm Neuralgic pain Total

-

2 2

4 3 2

3

7

10

2

5

7

-

1

1

-

2 1

2 1

1 1

-

3

1

-

-

3 2

3 5 4

-

1

-

2 2

1 2 2

15

33

48

3 4

-

1

Discussion These results are comparable with those in other series and satisfy us that aorto-iliac reconstruction for atherosclerosis is a worthwhile procedure, bearing in mind that one is dealing with only a part of a generalized, progressive and frequently lethal disease. Certainly the operation, in our hands, is more worthwhile than femoropopliteal grafting procedures. We could find no significant difference in the long term results following the two types of operative exposure. However, both junior doctors and nursing staff agree that the postoperative convalescence of those treated by the extraperitoneal approach is noticeably smoother and easier. Operating time is significantly shortened by this approach, both the exposure and the closure being considerably quicker. This, for us, is an important consideration since these operations were done as part of a normal general operating list. References (1973) The ischaemic limb. J . R . Coil. Surg. Edinb. 18, 259-274. GASPARD D. J . , COHEN J. L . and GASPAR M. K. (1972) Aorto-ilio femoral thromboendarterectomy vs. bypass graft. Arch. Surg. 105, 898-901. INAHARA T. (1972) Endarterectomy for occlusive disease of the aorto-iliac and common femoral arteries. Am. J . Surg. 124, 235-243. IRVINE W. T., BOOTH R. A. D. and MYERS K . (1972) Arterial surgery for aorto-iliac occlusive vascular disease. Early and late results in 238 patients. Lancet 1, 738-741. MARTIN P . and MARSTON J . A. P. (1973) Peripheral vascular disease. In: TAYLOR s. (ed.) Recent Advances in Surgery. Edinburgh, Churchill Livingstone, pp. 404405. MOZERSKY D. J., SUMNER D. s. and STRANDNESS D. E. ( I 972) Long term results of reconstructive aortoiliac surgery. Am. J . Surg. 123, 503-509.

DOUGLAS D.

599

Raymond Helsby and A. R. Moossa

w. F. and CANNON J. A. (1970) An aorto-iliac endarterectomy case series followed 10 years or more. Surgery 67,5--17. ROB c. G. (1963) Extraperitoneal approach to the abdominal aorta. Surgery 53, 87-89. STIPA s. and sHAW R. s. (1968) Aorto-iliac reconstruction through a retro-peritoneal approach. J. Cardiouasc. Suug. 14, 224-236. TAYLOR G. w. (1973) Chronic arterial occlusion. I n : BIRNSTINGL M. (ed.) Peripheral Vascular Surgery, London, Heinemann, pp. 21 1-234. PILCHER D. B., BARKER

600

s. H. and (1974) Aorto-iliac surgery: a comparative study between thromboendarterectomy and bypass. J. Cardioansc. Siirg. 15, 352-3 55. WATT J. K., GILLESPIE G., POLLACK J. G . and REID w. (1974) Arterial surgery in intermittent claudication. Br. Med J. 1, 23-26.

VAN LENT D., KUIJPERS P. J., SKOTNICKI

MEYER I.

Aorto-iliac reconstruction with special reference to the extraperitoneal approach.

We have used the extraperitoneal approach for aorto-iliac reconstruction for lower limb ischaemia in over 130 patients. The operative exposure is exce...
411KB Sizes 0 Downloads 0 Views