I am also trained in hybrid aorto iliac and peripheral procedures being experienced with the use of a hybrid theatre setting from since i was an endovascular fellow in UCLH.
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I am also trained in the treatment of venous disease and have great experience in minimally invasive endovenous techniques such as foam sclerotherapy and RF endovenous ablation. From the research point of view Dr Vlachakis holds a Master Degree in Medical research and Methodology and has several peer-reviewed publications. Effects of local oxygen delivery on the treatment of Diabetic Ulcers,. The trial compares the risks and benefits of treatment by modern optimal medical management alone versus the addition of immediate carotid surgery plus optimimal medical management.
Postgraduate Training in Medical Research and Methodology, School of Medicine, Aristotle University of Thessaloniki Thesis: Activation of the cholinergic anti-inflammatory pathway using Semapimod on acute intestinal ischemia-reperfusion injury experimental study in rabbits. In fact, hand instrumentation needed for laparoscopy is reusable and inexpensive.
In addition, length-of-stay seems to be shorter than for open surgery. The Dutch DREAM trial 48 addressed this issue and concluded that EVAR does not result in quality-adjusted life-year gain at 1 year, does provide only a marginal overall survival benefit, and is associated with a substantial, if not prohibitive, increase in costs. Hayter et al 49 also concluded that EVAR results in significantly greater hospital costs compared with open repair, despite reduced length-of-stay. As Noll et al 50 showed that efforts at minimizing cost should emphasize technical and device modifications aimed at reducing endoleaks and the need for secondary procedures.
Surgical Technique. Four laparoscopic techniques have been described to date. As previously mentioned, the totally laparoscopic procedure is the most demanding but remains our preferred method Figures 2 and 3. Most authors now use the transabdominal retrocolic approach to the aorto-iliac vessels similar to ours. The goal is to allow the surgeon to gain greater ease with laparoscopy to progress from a laparoscopic-assisted approach toward a totally laparoscopic approach. The 3 techniques now recognized are the totally laparoscopic approach, the laparoscopic-assisted approach, 52,53 and the hand-assisted laparoscopic approach.
Potential complications of laparoscopic surgery for aorto-iliac disease can be divided in 2 main categories. Complications related to access of the aorto-iliac vessels and complications related to surgery on the infrarenal aorta and iliac arteries. Complications Related to Access of the Aortoiliac Segment. Prior to surgery, careful evaluation of previous abdominal operations is done and scars looked at. As a rule, previous midline infraumbilical incisions are not contraindications to Veress needle use to create the pneumoperitoneum. For other more extensive or left-sided incisions, the aponeurosis should be opened and access to the abdominal cavity guaranteed before trocars are inserted.
Prior left hemicolectomy will render retrocolic access more difficult. Therefore, beginners should select their first patients. Once trocars have been inserted, care should be taken not to injure the small bowel when pushing it away from the operative field. Inadequate handling may cause enterotomies.
If this happens, we suggest proceeding to a small laparotomy for repair of the laceration. If there is no gross bile spillage, the aortic bypass can be performed. Every effort should be made to keep the left kidney in situ by not dissecting behind and lateral to it. The plane of dissection should be kept anterior where the left renal vein will be dissected.
The other reason to keep the kidney away from the aorta is to keep the ureter at a distance. In an early description of our technique, the kidney was mobilized cephalad and adopted a more medial location, bringing the ureter closer to the aorta. We have never injured the ureter, although others have reported this complication for both conventional surgery and laparoscopic surgery.
We have encountered 2 cases of early transient hydronephrosis of the left ureter that could be attributed to the second mechanism mentioned. Retroperitoneal bleeding is usually venous and related to trauma to the gonadal vein or a branch of this vein. These episodes of bleeding can rapidly be stopped using hemoclips. Once one learns to dissect and follow the gonadal vein from its distal location upward to the left renal vein, these minor complications should not occur. Another less frequent source of bleeding may be the presence of a retroaortic left renal vein.
Today, this complication is usually avoided with its identification on preoperative CT-scans. If such a vein is traumatized, laparoscopic control is obtained by first applying pressure with the instruments already present in the abdomen and carefully using the suction device. At this point, one has the choice of proceeding to a laparotomy to repair the laceration or to do it laparoscopically by applying hemoclips on the renal vein. One potentially lethal complication is trocar-site bleeding. Although a rare occurrence, this complication can easily be avoided by looking at the sites at the end of the procedure.
Heparinization during the procedure can be incriminated. The use of an endostitch will quickly resolve the matter. It must be emphasized that perfect hemostasis should always be obtained at the end of the procedure. When dissecting the aorta, one must be careful not to traumatize the lumbar veins, which could lead to major bleeding. When this occurs, tamponade should first be performed followed by clipping. Adequate visualization of the juxtarenal region will be obtained by clipping and incising the gonadal and lumbar veins at the level of the left renal vein.
During the arteriotomy, oozing may appear from the proximal stump. In that case, a second aortic clamp should be inserted at the level of the arteriotomy. One can reposition the first aortic clamp to take care of the bleeding lumbar artery at which point the second aortic clamp could be removed. During the performance of a laparoscopic anastomosis, the quality of the aortic stump must be inspected and endarterectomy performed when necessary. The running suture should always be followed up by the assistant holding and tightening it with a laparoscopic nerve hook.
Leaks can be corrected easily by using a variety of techniques in both end-to-end and end-to-side anastomoses. From our experience, the most difficult anastomoses are those made in calcified aortas. In such cases, one should consider a limited laparotomy, suprarenal clamping, or both of these.
In some cases, the laparoscopic gastrointestinal anastomotic GIA device cannot penetrate the calcified distal aorta to allow its occlusion, at which point intracorporeal suturing should be attempted laparoscopically or conversion to laparotomy should be considered. Over the past few years, numerous difficulties have been resolved. The totally retroperitoneal approach has virtually been abandoned, because of specific problems related to working in a small cavity.
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For the totally laparoscopic technique, most authors work through a transabdominal retrocolic approach. A direct transabdominal approach has been described for the robotic-assisted technique. Surgeons practicing hand-assisted laparoscopy will select 1 of the 2 mentioned approaches for a given patient. To make the less traumatic totally laparoscopic technique easier and more attractive to vascular surgeons, work is underway to evaluate the possibility of simplifying the anastomosis using automated devices.
This is the focus of the following section. Development of dedicated instrumentation has made possible the safe performance of laparoscopy for aorto-iliac disease. To prevent this problem, we used two cm sutures which, for end-to-end anastomoses, would begin posteriorly and run anteriorly on either side of the anastomosis.
Blocking the end of the running suture with a pledget leads to improvement in suturing time because only one knot is needed. To perform a faster anastomosis, many authors will transect the proximal aorta so that the proximal aortic stump can be mobilized, thus facilitating the procedure. Also, beginning the end-to-end anastomosis at 9 o'clock facilitates the technique. Alternatives to the "Handmade" Laparoscopic Anastomosis. In the s, Soviet surgeons already contemplated the possibility of using an automated suturing device.
He divided these various devices into 5 distinct groups: devices using rings, staples, adhesive glues, stents, and laser welding. All of these techniques offer the advantage of a significant reduction in anastomotic time and appear to offer the added benefit of less trauma to the arterial wall compared with the handmade suture. However, each of these devices has some drawbacks. Because of their rigidity, the rings could pose a difficulty when the diameters of tissues to be anastomosed are not equal.
Staples involve vessel wall eversion that in theory avoids creation of neointimal hyperplasia. In the early days, their use was hampered by the presence of atheromatous plaque in the human aorta, allowing for uneven coaptation of the staples around the anastomosis. In the case of glues, it appears they could be used on small vessels but would most likely lead to false aneurysms and anastomotic disruption in larger vessels. As for stents, permeability rates have been shown to be quite low. Laser welding has not been studied rigorously for large-caliber anastomoses.
It seems that these techniques would be difficult to introduce in the setting of large aortic anastomoses, considering that most of them have been designed for small-caliber anastomoses.
Contribution of professor V.A. Kornilov () to vascular surgery
Over the past 5 years, with increasing developments in vascular laparoscopy, a number of devices have been tested. Below, the most promising devices available are presented. The device holds the graft in place by a series of hooks penetrating the aortic wall Figure 4. The previous 3 devices are not in contact with blood flow, thus limiting neointimal hyperplasia. He conducted his study in sheep. Following these experiments, Kolvenbach 70 presented a human case series utilizing this stapler. The results seem satisfying although some issues have to be resolved with this type of instrumentation before it becomes available for laparoscopic use.
However, it seems unlikely that it will be used in aorto-iliac surgery, because of concerns linked to its configuration made to avoid contact with blood flow by clips that do not penetrate the arterial wall. Such a configuration may contribute to weaken the anastomosis. One may speculate that one or more devices mentioned previously will eventually permit automated, easier, and faster laparoscopic anastomoses.
Two minimally invasive vascular techniques have been under scrutiny for almost 20 years. Both have their own advantages and potential disadvantages as discussed in this chapter. Much more has been studied on endovascular therapy and endografting for aorto-iliac disease compared with laparoscopy. Immeasurable investments have been made to develop endovascular therapy. However, laparoscopy reproduces the advantages recognized for open surgery without its disadvantages.
As discussed earlier, less postoperative pain, decreased mortality, decreased hospital stay and return to work, better cosmesis and decreased incisional hernia rates have been reported compared with open surgery. As previously stated, studies have demonstrated a significantly decreased day mortality rate for EVAR compared with open surgery. Therefore, the 2 minimally invasive techniques discussed in this chapter must be thought of as complementary to each other in both occlusive and aneurysmal aorto-iliac disease.
This problem will be supplanted by the development of well-designed laparoscopic anastomotic devices. Minimally invasive techniques will play an increasing role in the treatment of patients with aorto-iliac disease. Figure 1. Figure 2. Patient position and trocar sites for a totally laparoscopic technique.
Note that the table can be rotated toward the left to allow femoral dissection when necessary. It is usually rotated toward the right to ensure that intraperitoneal organs will not interfere with adequate visualization of the operative field. The location of the seven mm trocars is shown: 4 are located in the midline 1 infraumbilical, 1 umbilical, and 2 supraumbilical and 3 laterally on a line slightly medial to the anterosuperior iliac spine. Figure 3.
Aorto-aortic bypass shown in a totally laparoscopic repair of an abdominal aortic aneurysm. Figure 4. Oudot J. Mem Acad Chir Paris.
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The use of tubes constructed from vinyon "N" cloth in bridging arterial defects. Ann Surg. Self-fixing prosthesis for remote endoprosthetics of aorta and large artery. In: Moscow, ed. Device for insertion of a prosthesis in a vessel. USSR Patent. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa Suppl. Endovascular stented grafts for thoracic, abdominal aortic, and iliac arterial disease: clinical experience in the Ukraine from Seminars in Interventional Radiology.
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A case of remote transfemoral endoprosthetics of the thoracic aorta with a synthetic self-fixing prosthesis for traumatic aneurysm. Grudnaya Khirurgia Russia. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. Laparoscopy-assisted aortobifemoral bypass.
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Hand-assisted laparoscopy versus conventional median laparotomy for aortobifemoral bypass for severe aorto-iliac occlusive disease: a prospective randomised study. Eur J Vasc Endovasc Surg. Total laparoscopically and robotically assisted aortic aneurysm surgery: a critical evaluation. Total laparoscopic aortic surgery versus minimal access techniques: review of more than patients.
Early and mid-term results of totally laparoscopic surgery for aortoiliac disease: lessons learned. Surg Laparosc Endosc Percutan Tech. The learning curve of totally laparoscopic aortobifemoral bypass for occlusive disease. How many cases and how safe? Laparoscopic vascular surgery: a systematic review. Total laparoscopic aortobifemoral bypass: short- and middle-term results.
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