Original article
Introduction of laparoscopic abdominal aortic aneurysm repair A. Q. Howard1,2 , P. C. Bennett1 , I. Ahmad1 , S. A. Choksy1 , S. I. P. Mackenzie3 and C. M. Backhouse1 1 Department of Vascular Surgery, 2 Iceni Centre, and 3 Department of Anaesthetics, Colchester Hospital University NHS Foundation Trust, Colchester, UK Correspondence to: Mr A. Q. Howard, Colchester Hospital University NHS Foundation Trust, Turner Road, Colchester CO4 5JL, UK (e-mail: [email protected])
Background: The aim was to review a consecutive series of patients treated with laparoscopic abdominal
aortic aneurysm (AAA) repair. These patients were compared with patients having elective open AAA repair. Methods: Demographic and operative details were collected prospectively and outcomes recorded for all patients undergoing laparoscopic or open AAA repair. Results: A total of 316 patients underwent laparoscopic (51), open (53) or endovascular (EVAR; 212) AAA repair between 2007 and 2013. The median age of patients who had laparoscopic or open repair was 72 (i.q.r. 66–75) years, and 92⋅3 per cent were men. There was no significant difference in sex distribution, age or V-POSSUM physiology score between laparoscopic and open repair. Of the 51 laparoscopic procedures, six were totally laparoscopic, 43 were laparoscopically assisted and two were converted to open repair. Pain scores were similar on days 1 and 3 after laparoscopic and open repair, even though epidurals were used in the open group, and were lower on days 5 and 7 after laparoscopic procedures. Patients who had laparoscopic repair had significantly fewer postoperative cardiorespiratory and renal complications (P = 0⋅017), and were discharged from hospital sooner (median 5 (i.q.r. 3–7) versus 8 (6–11) days; P = 0 ⋅001). Conclusion: Laparoscopic AAA repair was performed safely, and with at least equivalent outcomes to open repair, in patients unfavourable for EVAR.
Paper accepted 20 October 2014 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9714
Introduction
Laparoscopic aortic aneurysm repair (LR) has been pioneered in North America and Europe over the past two decades1 – 4 , but has only recently been developed in the UK. It gained approval from the National Institute for Health and Care Excellence5 in 2007, with special arrangements for consent, and for audit or research. LR has been slow to develop in the UK6 . There are no large randomized clinical trials to support LR over open abdominal aortic aneurysm (AAA) repair (OR). The lack of trained surgeons with the skills to perform laparoscopic dissection and repair, and the improved outcomes after endovascular aneurysm repair (EVAR)7 – 9 led others to question the need for laparoscopic repair10 . The availability of fenestrated and branched stent-graft devices, broadening the scope of EVAR to treat aneurysms with complex anatomy11 , may further reduce the number © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
of aneurysms needing an alternative method of repair. However, a significant proportion of patients (approximately 20–40 per cent) continue to undergo OR because of unsuitable anatomy for EVAR or patient choice12 – 17 . Laparoscopic aortic surgery may offer a minimally invasive alternative to OR for infrarenal and juxtarenal AAAs when EVAR is not in the best interests of the patient, that is in young, medically fit people seeking definitive repair, without the need for lifelong surveillance. Laparoscopic aortic surgery may also be a cost-effective option owing to a reduced need for level 2 and 3 critical care, and shorter hospital stay than after OR. The aim of this single-centre case series was to demonstrate that a laparoscopic aortic programme can be introduced safely into the National Health Service, with comparable outcomes to OR in patients in whom EVAR is unfavourable. BJS 2015; 102: 368–374
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Methods
Development of the laparoscopic aortic programme The laparoscopic aortic programme was started after the lead clinician had completed 2 years of laparoscopic vascular training. Mentorship during the first ten laparoscopically assisted procedures was provided by experienced laparoscopic colorectal surgeons from the institution. Subsequent mentorship was provided by Professor Marc Coggia (Ambroise Paré University Hospital, Paris, France) for four totally laparoscopic procedures. Laparoscopic vascular training continued during this 3-year interval under the auspices of the newly formed Laparoscopic Aortic Surgery Steering Group, UK (GLASS). This training included porcine laparoscopic vascular surgery (Covidien, Elancourt, Paris), regular GLASS training days with live surgery and self-directed simulator sessions.
Transabdominal approach with laparoscopic ports inserted into the left side of the abdomen in cephalocaudal ‘rectangular grid’ format. Surgeons and scrub nurse are positioned on the left side of the patient with laparoscopic camera held by robotic camera assistant (FreeHand 2; Freehand 2010, Cardiff, UK)
Fig. 1
Laparoscopic surgical technique
a
Under general anaesthesia (without nitrous oxide) and after establishing a pneumoperitoneum, the patients were positioned in right lateral tilt at 45–80∘ from horizontal depending on the chosen approach (80∘ for retrocolic, retrorenal; 45∘ for anterior transperitoneal). After establishing a pneumoperitoneum with a disposable 12-mm laparoscopic port in the umbilicus, six laparoscopic reusable trocars (Karl Storz Endoscopy (UK), Slough, UK) were inserted into the left side of the abdomen in cephalocaudal ‘rectangular grid’ format (Fig. 1 and 2).
Transabdominal approach In the transabdominal approach, the lead surgeon and assistant were on the left side of the patient (Fig. 1 and 2). This approach exposed the infrarenal aorta in a similar fashion to open surgery. The periaortic peritoneum was incised along the left side of the aneurysm to create a barrier suspended on sutures through the anterior abdominal wall, used to hold the small bowel to the right side of the abdominal cavity. Retroperitoneal approach For the retroperitoneal approach, the lead surgeon and assistant were on the right side of the patient (Fig. 3). Retroperitoneal dissection for the left retrocolic or left retrocolic, retrorenal approach was commenced 2 cm lateral and parallel to the white line of Toldt, and followed the avascular surgical planes adjacent to the left psoas muscle, ureter and the retrorenal Zuckerkandl’s fascia to the aortoiliac arteries. Once adequate exposure of the aortic aneurysm, aortic neck and iliac arteries had been achieved, © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
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Positioning of laparoscopic ports and theatre staff for the transabdominal approach. Port 1 is made with a peritoneal incision under direct vision using a Hasson port (12 mm); subsequent ports (10 mm) are inserted under camera vision in the numerical order shown. The lead consultant (A) and assistant surgeon (B) carry out laparoscopic dissection from the patient’s left. Screens (a and b) are positioned on the right of the patient and a robotic camera holder (FreeHand 2; Freehand 2010, Cardiff, UK) is used with camera ports, which are mainly on the left side of the abdomen. A scrub nurse (C) and assistant scrub nurse (D) stand on the right of the patient
Fig. 2
laparoscopic clamps (Karl Storz Endoscopy (UK); B. Braun Medical, Sheffield, UK) were positioned but not deployed. The inferior mesenteric artery and easily accessible lumbar arteries were controlled with laparoscopic clips (Challenger Ti/ Ti-P®; B. Braun Medical). www.bjs.co.uk
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Positioning of laparoscopic ports and theatre staff for the retroperitoneal approach. Port 1 is made with a peritoneal incision under direct vision using a Hasson port (12 mm); subsequent ports (10 mm) are inserted under camera vision in the numerical order shown. The lead consultant (A) and assistant surgeon (B) carry out laparoscopic dissection from the patient’s right. Screens (a and b) are positioned on the left of the patient and a robotic camera holder (FreeHand 2; Freehand 2010, Cardiff, UK) is used with camera ports, which are mainly on the left side of the abdomen. Scrub nurse (C) and assistant scrub nurse (D) stand on the left of the patient
Fig. 3
Laparoscopically assisted procedures In laparoscopically assisted procedures, access for graft suturing was via a minilaparotomy (transverse or left transrectus longitudinal incision) made between two port incisions. Warm moist packs and a Norfolk and Norwich retractor were inserted; after injection of intravenous heparin (3000–5000 units) the aneurysm was repaired in an identical fashion to OR. During laparoscopically assisted repair, the lateral ports were kept in situ for use of the laparoscopic suction/irrigation cannula (Porges SAS, Centre d’Affaires, La Boursidière, France), and the 45∘ laparoscope (Karl Storz Endoscopy (UK)) was used to provide illumination and additional monitor view. The aneurysm sac and peritoneum were closed in standard fashion, as for OR. The minilaparotomy was closed with nylon sutures. Since 2013, closure of the left transrectus incision incorporated a 5–8-cm wide mesh placed behind the rectus muscle within the rectus sheath. Totally laparoscopic procedures In totally laparoscopic procedures (without minilaparotomy), the remaining lumbar arteries were controlled after intravenous injection of heparin, and the proximal aortic © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
Laparoscopic monitor image showing the aortic clamp (Karl Storz Endoscopy UK, Slough, UK) positioned around the proximal aorta neck. The infrarenal aortic aneurysm can be seen clearly on the left side of the monitor screen
Fig. 4
clamp was deployed (Fig. 4). This was followed by iliac artery clamping, incising the aneurysm, removing thrombus, preparing anastomotic sites, and flushing the iliac arteries with heparinized saline. The graft (Gelsoft™; Vascutek, Inchinnan, UK) was inserted via a laparoscopic port and the anastomoses were performed intracorporally with reinforced sutures (Gore-Tex®; W. L. Gore and Associates, Livingston, UK). Complete haemostasis was attained before the prophylactic application of Tisseal® sealant (Baxter Healthcare, Thetford, UK) to the anastomoses and dissection planes. The left colon and kidney were held in the left paracolic gutter while the patient was rotated back to the supine position. Port sites were closed with polydioxanone sutures.
Patient recruitment All patients with an AAA were discussed at a vascular multidisciplinary meeting to check their suitability for EVAR, OR and LR. Suitability criteria for each method of aneurysm repair included: aneurysm morphology and anatomy of access vessels, patient age, co-morbidity, and predicted mortality with OR based on cardiopulmonary exercise testing (CPEX) results. Subjects deemed suitable for all procedures were given written information and counselled on the potential benefits and risk of complications with each procedure. The practice was to favour EVAR if the patient was aged 75 years or more, and/or predicted mortality based on CPEX was greater than 5 per cent. In patients aged less than 75 years, with a predicted risk of death below 5 per cent, open surgery was favoured if aneurysm morphology was suitable for all methods of treatment. Although patients were counselled on all procedures, this had the potential to include selection bias. www.bjs.co.uk
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Patients deemed anatomically unsuitable for EVAR were counselled on the risks of OR and LR only. Following counselling, patients were given time to consider the different treatment options before giving written consent for treatment. All patients having open or laparoscopic procedures since commencement of the laparoscopic aortic programme in 2007 were included in this study. Demographic details and vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (V-POSSUM) physiology scores were collected for patients having OR and LR. The presence of diabetes mellitus and hypertension was established from the medical history, and review of medication. The diagnosis of ischaemic heart disease was made if there was radiological or electrocardiographic evidence in the hospital notes at the time of admission for surgery. Peripheral arterial disease was diagnosed if there was radiological evidence in the hospital notes or documented evidence of an ankle : brachial pressure index below 0⋅9. The diagnosis of chronic kidney disease was made on the basis of serum creatinine level performed as part of the preoperative assessment. Cardiorespiratory and renal postoperative complications were recorded prospectively, and were based on a combination of clinical, biochemical and radiological evidence.
Pain scoring A visual analogue scale (VAS, maximum score 10) was used to measure postoperative pain on days 1, 3, 5 and 7 after surgery18 .
Statistical analysis Data were summarized using mean(s.d.) or median (i.q.r.) values for continuous variables, with analysis using Student’s t test and the Mann–Whitney U test respectively. The χ2 test was used for analysis of categorical data. P < 0⋅050 was deemed significant. Data were analysed using Minitab® 16 (Minitab, State College, Pennsylvania, USA) Results
Between 2007 and 2013, 316 patients underwent elective AAA repair; 212 (67⋅1 per cent) underwent EVAR, 51 (16⋅1 per cent) had LR (6 totally laparoscopic, 43 laparoscopically assisted, 2 converted to open surgery) and 53 (16⋅8 per cent) had OR. All LRs were done by the same surgeon. For the purpose of quality assurance and patient safety after introduction of the laparoscopic aortic programme, comparison of patient demographics, aneurysm morphology, operative characteristics and postoperative recovery © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
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Demographic comparisons of patients undergoing laparoscopic or open abdominal aortic aneurysm repair
Table 1
Age (years)* Sex ratio (M : F) Hypertension Diabetes mellitus Current smoker Ever smoker Ischaemic heart disease Chronic kidney disease 3‡ COPD Peripheral arterial disease V-POSSUM physiology score†
Laparoscopic repair (n = 51)
Open repair (n = 53)
P§
72 (66–75) 48 : 3 28 (58) 1 (2) 15 (31) 20 (42) 16 (33) 3 (6) 9 (19) 4 (8) 16⋅2(2⋅7)
72 (66–76) 48 : 5 30 (63) 5 (10) 4 (8) 7 (15) 12 (25) 6 (13) 6 (13) 9 (19) 16⋅6(2⋅7)
0⋅708¶ 0⋅467 0⋅676 0⋅092 0⋅005 0⋅003 0⋅369 0⋅294 0⋅399 0⋅136 0⋅549#
Values in parentheses are percentages (n = 48) unless indicated otherwise; values are *median (i.q.r.) and †mean(s.d.). ‡Moderately reduced kidney function. COPD, chronic obstructive pulmonary disease; V-POSSUM, vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. §χ2 test, except ¶Mann–Whitney U test and #Student’s t test.
was made between the LR and OR groups. No statistically significant difference was found in age, sex distribution or V-POSSUM score between the two groups (Table 1).
Aneurysm characteristics Among the 104 laparoscopic and open AAA repairs, 29 aneurysms (27⋅9 per cent) were morphologically suitable for EVAR; patients aged below 75 years with a predicted mortality risk of less than 5 per cent were advised against EVAR. There were similar proportions of juxtarenal and infrarenal aneurysms in LR and OR. LR procedures had longer aortic clamp times and operating times than OR, with no difference in the proportion of bifurcated and tube grafts (Table 2).
Laparoscopic repair The LR group included 43 laparoscopically assisted and six totally laparoscopic repairs. Following proctorship of four totally laparoscopic procedures, two more were performed. It became apparent that these procedures had a steeper learning curve and the operations took much longer (median 450 (375–660) min versus 325 (270–383) min for laparoscopically assisted repairs; P = 0⋅016), exposing patients to the additional risk of perioperative complications. The decision was made to concentrate on developing experience with laparoscopically assisted repair. The laparoscopic approaches used were: retrocolic (5, 10 per cent), retrocolic, retrorenal (17, 33 per cent) and anterior (29, 57 per cent). The minilaparotomy incisions used for the laparoscopically assisted procedures (including www.bjs.co.uk
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Aneurysm and operative characteristics of laparoscopic or open abdominal aortic aneurysm repair
Table 2
Laparoscopic repair (n = 51) Aneurysm characteristics AAA diameter (cm)* Aneurysm neck size (mm)† Juxtarenal Infrarenal Pararenal Suitable for EVAR‡ Operative data Aortic clamp time (min)† Total duration of operation (min)† Graft type Bifurcated Tube Blood loss (ml)† Scar length (cm)†
Open repair (n = 53)
Comparison of postoperative pain and duration of hospital stay after laparoscopic or open abdominal aortic aneurysm repair
Table 3
P§
6⋅0(0⋅8)
6⋅8(1⋅4)
0⋅001¶
20 (10–30)
13 (8–25)
0⋅109#
8 (16) 42 (82) 1 (2) 19 (37)
12 (23) 41 (77) 0 (0) 10 (19)
0⋅368 0⋅872
90 (63–120)
76 (57–105)
0⋅048#
330 (270–390)
240 (180–300)
15 (29) 36 (71) 1400 (700–1900) 14 (12–16)
17 of 49 (35) 32 of 49 (65) 1120 (738–2300) 30 (25–35)
0⋅037
< 0⋅001#
Laparoscopic repair (n = 51)
Open repair (n = 53)
10 (20)
42 of 51 (82)
< 0⋅001‡
3 (2–5) 3 (1–3) 1 (0–2) 0 (0–1⋅5) 1 (1–2⋅5)
4 (2–7) 4 (2–5) 3 (1–5) 1⋅5 (0–4⋅25) 2 (1–3)
0⋅256 0⋅061 < 0⋅001 0⋅013 0⋅027
5 (3–7)
8 (6–11)
Epidural use* Pain score (maximum 10) Day 1 Day 3 Day 5 Day 7 Duration of critical care stay (days) Duration of hospital stay (days)
P†
0⋅001
Values are median (i.q.r.) unless indicated otherwise; *values in parentheses are percentages. †Mann–Whitney U test, except ‡χ2 test.
0⋅571
Cardiorespiratory and renal complications after laparoscopic or open abdominal aortic aneurysm repair
Table 4 0⋅752# < 0⋅001#
Values in parentheses are percentages unless indicated otherwise; values are *mean(s.d.) and †median (i.q.r.). ‡Patients aged less than 75 years, medically fit and with a predicted mortality risk of less than 5 per cent on cardiopulmonary exercise testing were considered unfavourable for endovascular aneurysm repair (EVAR). AAA, abdminal aortic aneurysm. §χ2 test, except ¶Student’s t test and #Mann–Whitney U test.
Laparoscopic repair (n = 51)
Open repair (n = 53)
Cardiac Respiratory Renal
3 (6) 5 (10) 2 (4)
9 (17) 9 (17) 4 (8)
Overall
10 (20)
Values in parentheses are percentages.
22 (42)
*χ2
P*
0⋅017
test.
conversions) were: transverse (13), midline (5) and transrectus (27). Median scar length, regardless of incision, was 14 (12–16) cm. All recent patients had an anterior laparoscopic approach and a transrectus minilaparotomy incision was performed through the aortic anastomoses. This approach offered a view of the anatomy similar to that in OR and allowed surgeons in training to develop their competence in aortic dissection and open anastomoses. Thirty-six patients received straight grafts and 15 had bifurcated grafts. Operations with a straight graft took less time (median 300 (270–360) versus 390 (345–510) min; P = 0⋅001), with similar aortic clamp times and blood loss. The first ten patients having LR were treated similarly to those undergoing OR, and all had epidurals inserted during induction of anaesthesia for postoperative analgesia. Similarly, the introduction of oral fluids and diet followed the path of OR procedures initially. After analysis of the first ten patients, epidurals were no longer inserted, and eating and drinking was commenced on day 1. Comparing postoperative pain scores among the first ten patients, who had epidural analgesia, with the remaining 41 patients who had LR without epidurals, there were no significant differences in VAS pain scores on day 1 (median
2 versus 3), day 3 (3 versus 2), day 5 (1 versus 1) or day 7 (0 versus 0). Pain scores were similar after LR and OR on days 1 and 3, despite epidural use in the OR group, but on days 5 and 7, patients reported significantly less pain after LR than OR (P < 0⋅001 and P = 0⋅013 respectively) (Table 3). Patients who had LR were also discharged from hospital sooner (median length of hospital stay 5 (3–7) versus 8 (6–11) days for OR; P = 0⋅001). The duration of postoperative stay after LR was shorter for the last 17 patients than for the first 17 in the series (3⋅5 (3–6) versus 7 (5⋅5–9) days; P = 0⋅005). One patient in each group died during the first 30 days after operation. The death after LR occurred on day 5 following the development of acute atrial fibrillation, pulmonary embolus and ischaemic bowel that necessitated colectomy. The death after OR was a consequence of acute pulmonary oedema following a cardiac event. One patient in each group developed limb ischaemia requiring thromboembolectomy, and one in each group developed compartment syndrome that required fasciotomy. There were significantly fewer cardiorespiratory and renal complications after LR than OR: ten (20 per cent) versus 22 (42 per cent) respectively (P = 0⋅017).
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Discussion
Preliminary results from this laparoscopic aortic aneurysm programme suggest that the procedure can be done safely with at least equivalent outcomes to OR. There remains a lack of controlled data comparing outcomes following LR and OR for AAA, and prospective series of consecutive cases cannot be used to conclude whether or not there is any benefit to patients who have LR. However, in the present series patients who had LR had less postoperative pain, fewer cardiorespiratory and renal complications, and a shorter hospital stay, commensurate with other reports19 . Commencing any new surgical procedure potentially exposes patients and surgeons to the consequences of unforeseen error. It is vital that introduction of a new operative technique is conducted with approval, mentorship, prospective audit, governance, and procedure planning directed at patient safety. A decision was made to focus on laparoscopically assisted rather than totally laparoscopic repair, in order to keep operating times and difficulty to a minimum. With experience, the proportion of totally laparoscopic repairs will increase, with a reciprocal reduction in the time required for laparoscopic aortic dissection, similar to reports from other laparoscopic vascular surgeons1 – 4,20 – 24 . The decision to adopt the current standard surgical approach was made after the first 33 LRs. Following this, all subsequent LR procedures used the anterior approach with a transrectus incision. The anterior approach is very similar to that used in open surgery, which could decrease the learning curve and increase training opportunities for specialist registrars. The present experience is similar to the early series published by Coggia and colleagues3,4,21,22 , who demonstrated an initial learning curve with subsequently improved laparoscopic AAA repair outcomes. Once technical competence in a procedure has been reached, there may be a temporary deterioration in performance25 . This could be because the surgeon might undertake more difficult procedures, or may suffer from overconfidence resulting in lapses in technique or judgement25 . In the present consecutive series of laparoscopic aortic surgery, both conversions from LR to OR for uncontrollable lumbar artery bleeding, along with the only death, occurred between patients 20 and 27 in the series, which supports this possible occurrence25 . A number of authors2 – 4,20 – 24,26 from mainland Europe and North America have reported outcomes of LR comparable to those of OR. Without a large randomized trial, it is difficult to compare LR and OR directly. Sufficient expertise must be gained in the laparoscopic procedure before controlled testing can occur. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
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The main limitations of this study are the small sample size, and lack of randomization into LR and OR cohorts. The relatively small proportion of open and laparoscopic procedures performed since 2007 (32⋅9 per cent of all AAA repairs) is comparable to other reports12 – 17 and reflects the fact that the majority of patients have EVAR. Since the beginning of 2013, fenestrated procedures done in the hospital may have led to fewer aneurysms being anatomically unsuitable for EVAR. The authors’ laparoscopic aortic programme is in development, which is why patients were not randomized to LR or OR. The purpose of the present study was to demonstrate that LR can be introduced safely with outcomes at least as good as those of OR. An element of selection bias for inclusion in this study was likely as the policy was to counsel against EVAR if the patient was aged under 75 years with a predicted mortality rate of less than 5 per cent, even if anatomically suitable. However, this policy affected both the LR and OR groups. It is possible that larger aneurysms in the OR group were also the result of selection bias. Acknowledgements
The authors are grateful for the mentorship and support given by M. Coggia (Ambroise Paré University Hospital, Paris, France) and K. Poskitt (Cheltenham General Hospital, Cheltenham, UK). Disclosure: The authors declare no conflict of interest. References 1 Kolvenbach R, Puerschei A, Fajer S, Lin J, Wassiljew S, Schwierz E et al. Total laparoscopic aortic surgery versus minimal access techniques: review of more than 600 patients. Vascular 2006; 14: 186–192. 2 Nio D, Diks J, Bemelman WA, Wisselink W, Legemate DA. Laparoscopic vascular surgery: a systematic review. Eur J Vasc Endovasc Surg 2007; 33: 263–271. 3 Coggia M, Cerceau G, Di Centa I, Javerliat I, Colacchio G, Goeau-Brissonniere OA. Total laparoscopic juxta-renal abdominal aortic aneurysm repair. J Vasc Surg 2008; 48: 37–42. 4 Coggia M, Javerliat I, Di Centa I, Alfonsi P, Colacchio G, Kitzis M et al. Total laparoscopic versus conventional abdominal aortic aneurysm: a case–control study. J Vasc Surg 2005; 42: 906–911. 5 National Institute for Health and Clinical Excellence. Interventional Procedures Programme. Interventional Procedure Overview of Laparoscopic Repair of Abdominal Aortic Aneurysm. IP382. https://www.nice.org.uk/guidance/ipg229/resources/ laparoscopic-repair-of-abdominal-aortic-aneurysm-interven tional-procedures-overview2 [accessed 6 November 2014].
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6 Nott DM, Crinnion J, Benson J, Carne A, Gunning P. Laparoscopically assisted abdominal aortic aneurysm repair. Lancet 1999; 22: 1765–1766. 7 Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG; EVAR trial participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364: 843–848. 8 Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R et al.; Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Eng J Med 2004; 351: 1607–1618. 9 Malas MB, Freischlag JA. Interpretation of the results of OVER in the context of EVAR trial, DREAM, and the EUROSTAR registry. Semin Vasc Surg 2010; 3: 165–169. 10 Luk TL, Shearman CP. Laparoscopic aortic surgery. Br J Surg 2010; 97: 1153–1154. 11 Monahan TS, Schneider DB. Fenestrated and branched stent grafts for repair of complex aortic aneurysms. Semin Vasc Surg 2009; 22: 132–139. 12 Brewster DC, Jones JE, Chung TK, Lamuraglia GM, Kwolek CJ, Watkins MT et al. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg 2006; 244: 426–438. 13 van Marrewijk C, Buth J, Harris PL, Norgren L, Nevelsteen A, Wyatt MG. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 2002; 35: 461–473. 14 Jones WB, Taylor SM, Kalbaugh CA, Joels CS, Blackhurst DW, Langan EM III et al. Lost to follow-up: a potential under-appreciated limitation of endovascular aneurysm repair. J Vasc Surg 2007; 46: 434–440. 15 Brown LC, Brown EA, Greenhalgh RM, Powell JT, Thompson SG. Renal function and abdominal aortic aneurysm (AAA): the impact of different management strategies on long-term renal function in the UK EndoVascular Aneurysm Repair (EVAR) Trials. Ann Surg 2010; 251: 966–975.
16 Wald R, Waikar SS, Liangos O, Pereira BJ, Chertow GM, Jaber BL. Acute renal failure after endovascular vs open repair of abdominal aortic aneurysm. J Vasc Surg 2006; 43: 460–466. 17 Prinssen M, Buskens E, de Jong SE, Buth J, Mackaay AJ, van Sambeek MR et al; DREAM trial participants. Cost-effectiveness of conventional and endovascular repair of abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg 2007; 46: 883–890. 18 Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health 1990; 13: 227–236. 19 Economopoulos KP, Martinou E, Hakimian S, Schiza D, Georgopoulos S, Tsigris C et al. An overview of laparoscopic techniques in abdominal aortic aneurysm surgery. J Vasc Surg 2013; 2: 512–520. 20 Ferrari M, Adami D, Del Corso A, Berchiolli R, Pietrabissa A, Romagnani F et al. Laparoscopy-assisted abdominal aortic aneurysm repair: early and middle-term results of a consecutive series of 122 cases. J Vasc Surg 2006; 43: 695–700. 21 Coggia M, Javerliat I, Di Centa I, Alfonsi P, Colacchio G, Cerceau G et al. Total laparoscopic infrarenal aortic aneurysm repair: preliminary results. J Vasc Surg 2004; 40: 448–454. 22 Javerliat I, Di Centa I, Cerceau P, Alfonsi P, Goëau-Brissonnière O, Coggia M. Totally laparoscopic tube graft bypass for infrarenal aortic aneurysm: a well-established surgical technique. Acta Chir Belg 2006; 106: 261–266. 23 Di Centa I, Coggia M, Cochennec F, Javerliat I, Alfonsi P, Goëau-Brissonniere O. Total laparoscopic repair of abdominal aortic aneurysm with short proximal necks. Ann Vasc Surg 2009; 23: 43–48. 24 Coscas R, Coggia M, Di Centa I, Javerliat I, Cochennec F, Goëau-Brissonniere O. Laparoscopic aortic surgery in obese patients. Ann Vasc Surg 2009; 23: 717–721. 25 Hopper AN, Jamison MH, Lewis WG. Learning curves in surgical practice. Postgrad Med J 2007; 83: 777–779. 26 Kolvenbach R, Ceshire N, Pinter L, Da Silva L, Deling O, Kasper AS. Laparoscopy-assisted aneurysm resection as a minimal invasive alternative in patients unsuitable for endovascular surgery. J Vasc Surg 2001; 34: 216–221.
Editor’s comments
This is a small but creditable series from enthusiasts. Yet the role of this technology a decade after its introduction remains unclear. Laparoscopic aortic surgery is not so much a failed experiment, but not really an experiment at all yet. Time for a controlled trial. J. J. Earnshaw Joint Chief Editor, BJS
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BJS 2015; 102: 368–374
Introduction of laparoscopic abdominal aortic aneurysm repair A. Q. Howard1,2 , P. C. Bennett1 , I. Ahmad1 , S. A. Choksy1 , S. I. P. Mackenzie3 and C. M. Backhouse1 1 Department of Vascular Surgery, 2 Iceni Centre, and 3 Department of Anaesthetics, Colchester Hospital University NHS Foundation Trust, Colchester, UK Correspondence to: Mr A. Q. Howard, Colchester Hospital University NHS Foundation Trust, Turner Road, Colchester CO4 5JL, UK (e-mail: [email protected])
Background: The aim was to review a consecutive series of patients treated with laparoscopic abdominal
aortic aneurysm (AAA) repair. These patients were compared with patients having elective open AAA repair. Methods: Demographic and operative details were collected prospectively and outcomes recorded for all patients undergoing laparoscopic or open AAA repair. Results: A total of 316 patients underwent laparoscopic (51), open (53) or endovascular (EVAR; 212) AAA repair between 2007 and 2013. The median age of patients who had laparoscopic or open repair was 72 (i.q.r. 66–75) years, and 92⋅3 per cent were men. There was no significant difference in sex distribution, age or V-POSSUM physiology score between laparoscopic and open repair. Of the 51 laparoscopic procedures, six were totally laparoscopic, 43 were laparoscopically assisted and two were converted to open repair. Pain scores were similar on days 1 and 3 after laparoscopic and open repair, even though epidurals were used in the open group, and were lower on days 5 and 7 after laparoscopic procedures. Patients who had laparoscopic repair had significantly fewer postoperative cardiorespiratory and renal complications (P = 0⋅017), and were discharged from hospital sooner (median 5 (i.q.r. 3–7) versus 8 (6–11) days; P = 0 ⋅001). Conclusion: Laparoscopic AAA repair was performed safely, and with at least equivalent outcomes to open repair, in patients unfavourable for EVAR.
Paper accepted 20 October 2014 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9714
Introduction
Laparoscopic aortic aneurysm repair (LR) has been pioneered in North America and Europe over the past two decades1 – 4 , but has only recently been developed in the UK. It gained approval from the National Institute for Health and Care Excellence5 in 2007, with special arrangements for consent, and for audit or research. LR has been slow to develop in the UK6 . There are no large randomized clinical trials to support LR over open abdominal aortic aneurysm (AAA) repair (OR). The lack of trained surgeons with the skills to perform laparoscopic dissection and repair, and the improved outcomes after endovascular aneurysm repair (EVAR)7 – 9 led others to question the need for laparoscopic repair10 . The availability of fenestrated and branched stent-graft devices, broadening the scope of EVAR to treat aneurysms with complex anatomy11 , may further reduce the number © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
of aneurysms needing an alternative method of repair. However, a significant proportion of patients (approximately 20–40 per cent) continue to undergo OR because of unsuitable anatomy for EVAR or patient choice12 – 17 . Laparoscopic aortic surgery may offer a minimally invasive alternative to OR for infrarenal and juxtarenal AAAs when EVAR is not in the best interests of the patient, that is in young, medically fit people seeking definitive repair, without the need for lifelong surveillance. Laparoscopic aortic surgery may also be a cost-effective option owing to a reduced need for level 2 and 3 critical care, and shorter hospital stay than after OR. The aim of this single-centre case series was to demonstrate that a laparoscopic aortic programme can be introduced safely into the National Health Service, with comparable outcomes to OR in patients in whom EVAR is unfavourable. BJS 2015; 102: 368–374
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Methods
Development of the laparoscopic aortic programme The laparoscopic aortic programme was started after the lead clinician had completed 2 years of laparoscopic vascular training. Mentorship during the first ten laparoscopically assisted procedures was provided by experienced laparoscopic colorectal surgeons from the institution. Subsequent mentorship was provided by Professor Marc Coggia (Ambroise Paré University Hospital, Paris, France) for four totally laparoscopic procedures. Laparoscopic vascular training continued during this 3-year interval under the auspices of the newly formed Laparoscopic Aortic Surgery Steering Group, UK (GLASS). This training included porcine laparoscopic vascular surgery (Covidien, Elancourt, Paris), regular GLASS training days with live surgery and self-directed simulator sessions.
Transabdominal approach with laparoscopic ports inserted into the left side of the abdomen in cephalocaudal ‘rectangular grid’ format. Surgeons and scrub nurse are positioned on the left side of the patient with laparoscopic camera held by robotic camera assistant (FreeHand 2; Freehand 2010, Cardiff, UK)
Fig. 1
Laparoscopic surgical technique
a
Under general anaesthesia (without nitrous oxide) and after establishing a pneumoperitoneum, the patients were positioned in right lateral tilt at 45–80∘ from horizontal depending on the chosen approach (80∘ for retrocolic, retrorenal; 45∘ for anterior transperitoneal). After establishing a pneumoperitoneum with a disposable 12-mm laparoscopic port in the umbilicus, six laparoscopic reusable trocars (Karl Storz Endoscopy (UK), Slough, UK) were inserted into the left side of the abdomen in cephalocaudal ‘rectangular grid’ format (Fig. 1 and 2).
Transabdominal approach In the transabdominal approach, the lead surgeon and assistant were on the left side of the patient (Fig. 1 and 2). This approach exposed the infrarenal aorta in a similar fashion to open surgery. The periaortic peritoneum was incised along the left side of the aneurysm to create a barrier suspended on sutures through the anterior abdominal wall, used to hold the small bowel to the right side of the abdominal cavity. Retroperitoneal approach For the retroperitoneal approach, the lead surgeon and assistant were on the right side of the patient (Fig. 3). Retroperitoneal dissection for the left retrocolic or left retrocolic, retrorenal approach was commenced 2 cm lateral and parallel to the white line of Toldt, and followed the avascular surgical planes adjacent to the left psoas muscle, ureter and the retrorenal Zuckerkandl’s fascia to the aortoiliac arteries. Once adequate exposure of the aortic aneurysm, aortic neck and iliac arteries had been achieved, © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
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Positioning of laparoscopic ports and theatre staff for the transabdominal approach. Port 1 is made with a peritoneal incision under direct vision using a Hasson port (12 mm); subsequent ports (10 mm) are inserted under camera vision in the numerical order shown. The lead consultant (A) and assistant surgeon (B) carry out laparoscopic dissection from the patient’s left. Screens (a and b) are positioned on the right of the patient and a robotic camera holder (FreeHand 2; Freehand 2010, Cardiff, UK) is used with camera ports, which are mainly on the left side of the abdomen. A scrub nurse (C) and assistant scrub nurse (D) stand on the right of the patient
Fig. 2
laparoscopic clamps (Karl Storz Endoscopy (UK); B. Braun Medical, Sheffield, UK) were positioned but not deployed. The inferior mesenteric artery and easily accessible lumbar arteries were controlled with laparoscopic clips (Challenger Ti/ Ti-P®; B. Braun Medical). www.bjs.co.uk
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Positioning of laparoscopic ports and theatre staff for the retroperitoneal approach. Port 1 is made with a peritoneal incision under direct vision using a Hasson port (12 mm); subsequent ports (10 mm) are inserted under camera vision in the numerical order shown. The lead consultant (A) and assistant surgeon (B) carry out laparoscopic dissection from the patient’s right. Screens (a and b) are positioned on the left of the patient and a robotic camera holder (FreeHand 2; Freehand 2010, Cardiff, UK) is used with camera ports, which are mainly on the left side of the abdomen. Scrub nurse (C) and assistant scrub nurse (D) stand on the left of the patient
Fig. 3
Laparoscopically assisted procedures In laparoscopically assisted procedures, access for graft suturing was via a minilaparotomy (transverse or left transrectus longitudinal incision) made between two port incisions. Warm moist packs and a Norfolk and Norwich retractor were inserted; after injection of intravenous heparin (3000–5000 units) the aneurysm was repaired in an identical fashion to OR. During laparoscopically assisted repair, the lateral ports were kept in situ for use of the laparoscopic suction/irrigation cannula (Porges SAS, Centre d’Affaires, La Boursidière, France), and the 45∘ laparoscope (Karl Storz Endoscopy (UK)) was used to provide illumination and additional monitor view. The aneurysm sac and peritoneum were closed in standard fashion, as for OR. The minilaparotomy was closed with nylon sutures. Since 2013, closure of the left transrectus incision incorporated a 5–8-cm wide mesh placed behind the rectus muscle within the rectus sheath. Totally laparoscopic procedures In totally laparoscopic procedures (without minilaparotomy), the remaining lumbar arteries were controlled after intravenous injection of heparin, and the proximal aortic © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
Laparoscopic monitor image showing the aortic clamp (Karl Storz Endoscopy UK, Slough, UK) positioned around the proximal aorta neck. The infrarenal aortic aneurysm can be seen clearly on the left side of the monitor screen
Fig. 4
clamp was deployed (Fig. 4). This was followed by iliac artery clamping, incising the aneurysm, removing thrombus, preparing anastomotic sites, and flushing the iliac arteries with heparinized saline. The graft (Gelsoft™; Vascutek, Inchinnan, UK) was inserted via a laparoscopic port and the anastomoses were performed intracorporally with reinforced sutures (Gore-Tex®; W. L. Gore and Associates, Livingston, UK). Complete haemostasis was attained before the prophylactic application of Tisseal® sealant (Baxter Healthcare, Thetford, UK) to the anastomoses and dissection planes. The left colon and kidney were held in the left paracolic gutter while the patient was rotated back to the supine position. Port sites were closed with polydioxanone sutures.
Patient recruitment All patients with an AAA were discussed at a vascular multidisciplinary meeting to check their suitability for EVAR, OR and LR. Suitability criteria for each method of aneurysm repair included: aneurysm morphology and anatomy of access vessels, patient age, co-morbidity, and predicted mortality with OR based on cardiopulmonary exercise testing (CPEX) results. Subjects deemed suitable for all procedures were given written information and counselled on the potential benefits and risk of complications with each procedure. The practice was to favour EVAR if the patient was aged 75 years or more, and/or predicted mortality based on CPEX was greater than 5 per cent. In patients aged less than 75 years, with a predicted risk of death below 5 per cent, open surgery was favoured if aneurysm morphology was suitable for all methods of treatment. Although patients were counselled on all procedures, this had the potential to include selection bias. www.bjs.co.uk
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Patients deemed anatomically unsuitable for EVAR were counselled on the risks of OR and LR only. Following counselling, patients were given time to consider the different treatment options before giving written consent for treatment. All patients having open or laparoscopic procedures since commencement of the laparoscopic aortic programme in 2007 were included in this study. Demographic details and vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (V-POSSUM) physiology scores were collected for patients having OR and LR. The presence of diabetes mellitus and hypertension was established from the medical history, and review of medication. The diagnosis of ischaemic heart disease was made if there was radiological or electrocardiographic evidence in the hospital notes at the time of admission for surgery. Peripheral arterial disease was diagnosed if there was radiological evidence in the hospital notes or documented evidence of an ankle : brachial pressure index below 0⋅9. The diagnosis of chronic kidney disease was made on the basis of serum creatinine level performed as part of the preoperative assessment. Cardiorespiratory and renal postoperative complications were recorded prospectively, and were based on a combination of clinical, biochemical and radiological evidence.
Pain scoring A visual analogue scale (VAS, maximum score 10) was used to measure postoperative pain on days 1, 3, 5 and 7 after surgery18 .
Statistical analysis Data were summarized using mean(s.d.) or median (i.q.r.) values for continuous variables, with analysis using Student’s t test and the Mann–Whitney U test respectively. The χ2 test was used for analysis of categorical data. P < 0⋅050 was deemed significant. Data were analysed using Minitab® 16 (Minitab, State College, Pennsylvania, USA) Results
Between 2007 and 2013, 316 patients underwent elective AAA repair; 212 (67⋅1 per cent) underwent EVAR, 51 (16⋅1 per cent) had LR (6 totally laparoscopic, 43 laparoscopically assisted, 2 converted to open surgery) and 53 (16⋅8 per cent) had OR. All LRs were done by the same surgeon. For the purpose of quality assurance and patient safety after introduction of the laparoscopic aortic programme, comparison of patient demographics, aneurysm morphology, operative characteristics and postoperative recovery © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
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Demographic comparisons of patients undergoing laparoscopic or open abdominal aortic aneurysm repair
Table 1
Age (years)* Sex ratio (M : F) Hypertension Diabetes mellitus Current smoker Ever smoker Ischaemic heart disease Chronic kidney disease 3‡ COPD Peripheral arterial disease V-POSSUM physiology score†
Laparoscopic repair (n = 51)
Open repair (n = 53)
P§
72 (66–75) 48 : 3 28 (58) 1 (2) 15 (31) 20 (42) 16 (33) 3 (6) 9 (19) 4 (8) 16⋅2(2⋅7)
72 (66–76) 48 : 5 30 (63) 5 (10) 4 (8) 7 (15) 12 (25) 6 (13) 6 (13) 9 (19) 16⋅6(2⋅7)
0⋅708¶ 0⋅467 0⋅676 0⋅092 0⋅005 0⋅003 0⋅369 0⋅294 0⋅399 0⋅136 0⋅549#
Values in parentheses are percentages (n = 48) unless indicated otherwise; values are *median (i.q.r.) and †mean(s.d.). ‡Moderately reduced kidney function. COPD, chronic obstructive pulmonary disease; V-POSSUM, vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. §χ2 test, except ¶Mann–Whitney U test and #Student’s t test.
was made between the LR and OR groups. No statistically significant difference was found in age, sex distribution or V-POSSUM score between the two groups (Table 1).
Aneurysm characteristics Among the 104 laparoscopic and open AAA repairs, 29 aneurysms (27⋅9 per cent) were morphologically suitable for EVAR; patients aged below 75 years with a predicted mortality risk of less than 5 per cent were advised against EVAR. There were similar proportions of juxtarenal and infrarenal aneurysms in LR and OR. LR procedures had longer aortic clamp times and operating times than OR, with no difference in the proportion of bifurcated and tube grafts (Table 2).
Laparoscopic repair The LR group included 43 laparoscopically assisted and six totally laparoscopic repairs. Following proctorship of four totally laparoscopic procedures, two more were performed. It became apparent that these procedures had a steeper learning curve and the operations took much longer (median 450 (375–660) min versus 325 (270–383) min for laparoscopically assisted repairs; P = 0⋅016), exposing patients to the additional risk of perioperative complications. The decision was made to concentrate on developing experience with laparoscopically assisted repair. The laparoscopic approaches used were: retrocolic (5, 10 per cent), retrocolic, retrorenal (17, 33 per cent) and anterior (29, 57 per cent). The minilaparotomy incisions used for the laparoscopically assisted procedures (including www.bjs.co.uk
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Aneurysm and operative characteristics of laparoscopic or open abdominal aortic aneurysm repair
Table 2
Laparoscopic repair (n = 51) Aneurysm characteristics AAA diameter (cm)* Aneurysm neck size (mm)† Juxtarenal Infrarenal Pararenal Suitable for EVAR‡ Operative data Aortic clamp time (min)† Total duration of operation (min)† Graft type Bifurcated Tube Blood loss (ml)† Scar length (cm)†
Open repair (n = 53)
Comparison of postoperative pain and duration of hospital stay after laparoscopic or open abdominal aortic aneurysm repair
Table 3
P§
6⋅0(0⋅8)
6⋅8(1⋅4)
0⋅001¶
20 (10–30)
13 (8–25)
0⋅109#
8 (16) 42 (82) 1 (2) 19 (37)
12 (23) 41 (77) 0 (0) 10 (19)
0⋅368 0⋅872
90 (63–120)
76 (57–105)
0⋅048#
330 (270–390)
240 (180–300)
15 (29) 36 (71) 1400 (700–1900) 14 (12–16)
17 of 49 (35) 32 of 49 (65) 1120 (738–2300) 30 (25–35)
0⋅037
< 0⋅001#
Laparoscopic repair (n = 51)
Open repair (n = 53)
10 (20)
42 of 51 (82)
< 0⋅001‡
3 (2–5) 3 (1–3) 1 (0–2) 0 (0–1⋅5) 1 (1–2⋅5)
4 (2–7) 4 (2–5) 3 (1–5) 1⋅5 (0–4⋅25) 2 (1–3)
0⋅256 0⋅061 < 0⋅001 0⋅013 0⋅027
5 (3–7)
8 (6–11)
Epidural use* Pain score (maximum 10) Day 1 Day 3 Day 5 Day 7 Duration of critical care stay (days) Duration of hospital stay (days)
P†
0⋅001
Values are median (i.q.r.) unless indicated otherwise; *values in parentheses are percentages. †Mann–Whitney U test, except ‡χ2 test.
0⋅571
Cardiorespiratory and renal complications after laparoscopic or open abdominal aortic aneurysm repair
Table 4 0⋅752# < 0⋅001#
Values in parentheses are percentages unless indicated otherwise; values are *mean(s.d.) and †median (i.q.r.). ‡Patients aged less than 75 years, medically fit and with a predicted mortality risk of less than 5 per cent on cardiopulmonary exercise testing were considered unfavourable for endovascular aneurysm repair (EVAR). AAA, abdminal aortic aneurysm. §χ2 test, except ¶Student’s t test and #Mann–Whitney U test.
Laparoscopic repair (n = 51)
Open repair (n = 53)
Cardiac Respiratory Renal
3 (6) 5 (10) 2 (4)
9 (17) 9 (17) 4 (8)
Overall
10 (20)
Values in parentheses are percentages.
22 (42)
*χ2
P*
0⋅017
test.
conversions) were: transverse (13), midline (5) and transrectus (27). Median scar length, regardless of incision, was 14 (12–16) cm. All recent patients had an anterior laparoscopic approach and a transrectus minilaparotomy incision was performed through the aortic anastomoses. This approach offered a view of the anatomy similar to that in OR and allowed surgeons in training to develop their competence in aortic dissection and open anastomoses. Thirty-six patients received straight grafts and 15 had bifurcated grafts. Operations with a straight graft took less time (median 300 (270–360) versus 390 (345–510) min; P = 0⋅001), with similar aortic clamp times and blood loss. The first ten patients having LR were treated similarly to those undergoing OR, and all had epidurals inserted during induction of anaesthesia for postoperative analgesia. Similarly, the introduction of oral fluids and diet followed the path of OR procedures initially. After analysis of the first ten patients, epidurals were no longer inserted, and eating and drinking was commenced on day 1. Comparing postoperative pain scores among the first ten patients, who had epidural analgesia, with the remaining 41 patients who had LR without epidurals, there were no significant differences in VAS pain scores on day 1 (median
2 versus 3), day 3 (3 versus 2), day 5 (1 versus 1) or day 7 (0 versus 0). Pain scores were similar after LR and OR on days 1 and 3, despite epidural use in the OR group, but on days 5 and 7, patients reported significantly less pain after LR than OR (P < 0⋅001 and P = 0⋅013 respectively) (Table 3). Patients who had LR were also discharged from hospital sooner (median length of hospital stay 5 (3–7) versus 8 (6–11) days for OR; P = 0⋅001). The duration of postoperative stay after LR was shorter for the last 17 patients than for the first 17 in the series (3⋅5 (3–6) versus 7 (5⋅5–9) days; P = 0⋅005). One patient in each group died during the first 30 days after operation. The death after LR occurred on day 5 following the development of acute atrial fibrillation, pulmonary embolus and ischaemic bowel that necessitated colectomy. The death after OR was a consequence of acute pulmonary oedema following a cardiac event. One patient in each group developed limb ischaemia requiring thromboembolectomy, and one in each group developed compartment syndrome that required fasciotomy. There were significantly fewer cardiorespiratory and renal complications after LR than OR: ten (20 per cent) versus 22 (42 per cent) respectively (P = 0⋅017).
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Discussion
Preliminary results from this laparoscopic aortic aneurysm programme suggest that the procedure can be done safely with at least equivalent outcomes to OR. There remains a lack of controlled data comparing outcomes following LR and OR for AAA, and prospective series of consecutive cases cannot be used to conclude whether or not there is any benefit to patients who have LR. However, in the present series patients who had LR had less postoperative pain, fewer cardiorespiratory and renal complications, and a shorter hospital stay, commensurate with other reports19 . Commencing any new surgical procedure potentially exposes patients and surgeons to the consequences of unforeseen error. It is vital that introduction of a new operative technique is conducted with approval, mentorship, prospective audit, governance, and procedure planning directed at patient safety. A decision was made to focus on laparoscopically assisted rather than totally laparoscopic repair, in order to keep operating times and difficulty to a minimum. With experience, the proportion of totally laparoscopic repairs will increase, with a reciprocal reduction in the time required for laparoscopic aortic dissection, similar to reports from other laparoscopic vascular surgeons1 – 4,20 – 24 . The decision to adopt the current standard surgical approach was made after the first 33 LRs. Following this, all subsequent LR procedures used the anterior approach with a transrectus incision. The anterior approach is very similar to that used in open surgery, which could decrease the learning curve and increase training opportunities for specialist registrars. The present experience is similar to the early series published by Coggia and colleagues3,4,21,22 , who demonstrated an initial learning curve with subsequently improved laparoscopic AAA repair outcomes. Once technical competence in a procedure has been reached, there may be a temporary deterioration in performance25 . This could be because the surgeon might undertake more difficult procedures, or may suffer from overconfidence resulting in lapses in technique or judgement25 . In the present consecutive series of laparoscopic aortic surgery, both conversions from LR to OR for uncontrollable lumbar artery bleeding, along with the only death, occurred between patients 20 and 27 in the series, which supports this possible occurrence25 . A number of authors2 – 4,20 – 24,26 from mainland Europe and North America have reported outcomes of LR comparable to those of OR. Without a large randomized trial, it is difficult to compare LR and OR directly. Sufficient expertise must be gained in the laparoscopic procedure before controlled testing can occur. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
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The main limitations of this study are the small sample size, and lack of randomization into LR and OR cohorts. The relatively small proportion of open and laparoscopic procedures performed since 2007 (32⋅9 per cent of all AAA repairs) is comparable to other reports12 – 17 and reflects the fact that the majority of patients have EVAR. Since the beginning of 2013, fenestrated procedures done in the hospital may have led to fewer aneurysms being anatomically unsuitable for EVAR. The authors’ laparoscopic aortic programme is in development, which is why patients were not randomized to LR or OR. The purpose of the present study was to demonstrate that LR can be introduced safely with outcomes at least as good as those of OR. An element of selection bias for inclusion in this study was likely as the policy was to counsel against EVAR if the patient was aged under 75 years with a predicted mortality rate of less than 5 per cent, even if anatomically suitable. However, this policy affected both the LR and OR groups. It is possible that larger aneurysms in the OR group were also the result of selection bias. Acknowledgements
The authors are grateful for the mentorship and support given by M. Coggia (Ambroise Paré University Hospital, Paris, France) and K. Poskitt (Cheltenham General Hospital, Cheltenham, UK). Disclosure: The authors declare no conflict of interest. References 1 Kolvenbach R, Puerschei A, Fajer S, Lin J, Wassiljew S, Schwierz E et al. Total laparoscopic aortic surgery versus minimal access techniques: review of more than 600 patients. Vascular 2006; 14: 186–192. 2 Nio D, Diks J, Bemelman WA, Wisselink W, Legemate DA. Laparoscopic vascular surgery: a systematic review. Eur J Vasc Endovasc Surg 2007; 33: 263–271. 3 Coggia M, Cerceau G, Di Centa I, Javerliat I, Colacchio G, Goeau-Brissonniere OA. Total laparoscopic juxta-renal abdominal aortic aneurysm repair. J Vasc Surg 2008; 48: 37–42. 4 Coggia M, Javerliat I, Di Centa I, Alfonsi P, Colacchio G, Kitzis M et al. Total laparoscopic versus conventional abdominal aortic aneurysm: a case–control study. J Vasc Surg 2005; 42: 906–911. 5 National Institute for Health and Clinical Excellence. Interventional Procedures Programme. Interventional Procedure Overview of Laparoscopic Repair of Abdominal Aortic Aneurysm. IP382. https://www.nice.org.uk/guidance/ipg229/resources/ laparoscopic-repair-of-abdominal-aortic-aneurysm-interven tional-procedures-overview2 [accessed 6 November 2014].
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6 Nott DM, Crinnion J, Benson J, Carne A, Gunning P. Laparoscopically assisted abdominal aortic aneurysm repair. Lancet 1999; 22: 1765–1766. 7 Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG; EVAR trial participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364: 843–848. 8 Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R et al.; Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Eng J Med 2004; 351: 1607–1618. 9 Malas MB, Freischlag JA. Interpretation of the results of OVER in the context of EVAR trial, DREAM, and the EUROSTAR registry. Semin Vasc Surg 2010; 3: 165–169. 10 Luk TL, Shearman CP. Laparoscopic aortic surgery. Br J Surg 2010; 97: 1153–1154. 11 Monahan TS, Schneider DB. Fenestrated and branched stent grafts for repair of complex aortic aneurysms. Semin Vasc Surg 2009; 22: 132–139. 12 Brewster DC, Jones JE, Chung TK, Lamuraglia GM, Kwolek CJ, Watkins MT et al. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg 2006; 244: 426–438. 13 van Marrewijk C, Buth J, Harris PL, Norgren L, Nevelsteen A, Wyatt MG. Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 2002; 35: 461–473. 14 Jones WB, Taylor SM, Kalbaugh CA, Joels CS, Blackhurst DW, Langan EM III et al. Lost to follow-up: a potential under-appreciated limitation of endovascular aneurysm repair. J Vasc Surg 2007; 46: 434–440. 15 Brown LC, Brown EA, Greenhalgh RM, Powell JT, Thompson SG. Renal function and abdominal aortic aneurysm (AAA): the impact of different management strategies on long-term renal function in the UK EndoVascular Aneurysm Repair (EVAR) Trials. Ann Surg 2010; 251: 966–975.
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Editor’s comments
This is a small but creditable series from enthusiasts. Yet the role of this technology a decade after its introduction remains unclear. Laparoscopic aortic surgery is not so much a failed experiment, but not really an experiment at all yet. Time for a controlled trial. J. J. Earnshaw Joint Chief Editor, BJS
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