title: Total laparoscopic bypass for aortoiliac occlusive lesions: 93-case experience.
abstract: OBJECTIVE
  We describe our experience with a new technique of total laparoscopic bypass surgery to treat aortoiliac occlusive lesions.
  
  
  METHODS
  From November 2000 to December 2003, 93 total laparoscopic bypass procedures were performed to treat TASC (TransAtlantic Inter-Society Consensus document) grade C or D aortoiliac occlusive lesions. We also reimplanted 2 inferior mesenteric arteries, and performed 3 prosthesis-superior mesenteric bypasses and 2 suprarenal aorta endarterectomies. Our technique includes a sloping right lateral decubitus installation, which enables a simple transperitoneal left retrocolic or retrorenal approach to the infrarenal abdominal aorta. In patients with a hostile abdomen a retroperitoneal videoscopic approach was used. Aorta-prosthesis laparoscopic anastomoses are performed simply, which averts any trauma to the suture material.
  
  
  RESULTS
  Patients included 76 men and 17 women, with median patient age 61 years (range, 38-79 years). The approach to the aorta was always possible, in particular, in obese patients. It enabled stable aortic exposure during performance of the laparoscopic aorta-prosthesis anastomosis. Median operative time was 240 minutes (range, 150-450 minutes). Median aortic clamping time measured to unclamping of the first prosthetic limb was 67.5 minutes (range, 30-135 minutes). Median duration of aorta-prosthesis anastomosis was 30 minutes (range, 12-90 minutes). The longest durations were mainly observed during the learning curve. Thirty-day postoperative mortality was 4% (4 of 93 patients). Two patients died of myocardial infarction. One patient with American Society of Anesthesiologists grade 4 disease operated on to treat critical ischemia died of multiple organ system failure, and 1 patient died of colonic ischemia. Major nonlethal postoperative complications were observed in 4 patients, and included lung atelectasia in 2 patients, graft infection in 1 patient operated on emergently to treat aortic occlusion, and secondary spleen rupture at day 5 in 1 patient. Median hospital stay was 7 days (range, 2-57 days). With a mean follow-up of 19 months (range, 1-37 months), complete recovery was observed in 89 patients, and all grafts were patent. One patient had kinking of a prosthetic limb at the groin, and in 1 patient Staphylococcus epidermidis graft infection developed, which was treated with in situ replacement with a rifampin-bonded graft.
  
  
  CONCLUSIONS
  Total laparoscopic aortic bypass is feasible. In patients with TASC C and D aortoiliac occlusive lesions, short-term outcomes are comparable to those with conventional aortic bypass. After the initial learning curve, laparoscopic technique may reduce the operative trauma of aortic bypass.
authors.affiliation: Department of Vascular Surgery, Ambroise Paré University Hosital, 92104 Boulogne Cedexd, France. mpcoggia@aol.com
authors.forename: Marc
authors.initials: M
authors.lastname: Coggia
authors.forename: Isabelle
authors.initials: I
authors.lastname: Javerliat
authors.forename: Isabelle
authors.initials: I
authors.lastname: Di Centa
authors.forename: Giovanni
authors.initials: G
authors.lastname: Colacchio
authors.forename: Jean Pascal
authors.initials: JP
authors.lastname: Leschi
authors.forename: Michel
authors.initials: M
authors.lastname: Kitzis
authors.forename: Olivier A
authors.initials: OA
authors.lastname: Goëau-Brissonnière
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D001012:Aorta, Abdominal; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007083:Iliac Artery; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D012494:Sampling Studies; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods*