title: Laparoscopic-assisted treatment of abdominal aortic aneurysm requiring suprarenal cross-clamping.
abstract: OBJECTIVE
  Hand-assisted laparoscopic surgery (HALS) was previously employed to treat patients with infrarenal abdominal aortic aneurysm (IAAA). The use of HALS for juxtarenal abdominal aortic aneurysm (JAAA) has never been validated. In this study, we report our experience with this technique to demonstrate its feasibility and prove its safety in dealing with JAAA.
  
  
  METHODS
  From October 2000 to October 2008, we have selectively treated 271 patients with abdominal aortic aneurysm with the HALS technique. Of these, 83 were JAAAs which required a suprarenal aortic clamping (group A), and 188 were IAAA (group B). General data of the two groups were analyzed for comparability purposes and operative and postoperative data were prospectively collected. Additionally, patients in group A were stratified in three classes according to their pre-existing degree of renal function impairment. Statistical significance was defined at the P < .05 level.
  
  
  RESULTS
  Mean operative time was 220 minutes +/- 66 in group A and 231 minutes +/- 64 in group B (P > .05). The mean duration of suprarenal clamping was 28 minutes +/- 6; whereas infrarenal clamping lasted an average of 25 minutes +/- 5 (P > .05). Mean intraoperative blood loss was 1023 +/- 584 mL for group A and 961 +/- 633 mL for group B (P > .05). No conversion or 30-day postoperative mortality was recorded in either group. Sixteen percent of the patients in group A developed a postoperative complication, vs 11% in group B (P > .05). Mean postoperative stay for group A and B was 4.2 +/- 1.5 and 4.2 +/- 1.9 days, respectively (P > .05). Postoperative kidney function significantly worsened in 5 patients in group A (6%). A prolonged warm ischemia time (>40), pre-existing renal dysfunction, and diabetes, correlated to the development of postoperative renal insufficiency. Follow-up of patients averaged 37.9 +/- 20 months. The incidence of incisional hernias in group A and B was 15.5% vs 11.1%, respectively (P > .05).
  
  
  CONCLUSIONS
  The HALS technique proved to be feasible and safe not only for patients with IAAA, but also for the management of patients with JAAA. No significant difference could be shown in the comparison between the two groups, apart from the expected higher rate of postoperative renal dysfunction after suprarenal clamping. In view of the demonstrated benefit of this minimally invasive approach, we believe that it should be included among the alternative options of treatment for these patients.
authors.affiliation: Divisione di Chirurgia Vascolare, Dipartimento di Oncologia, dei Trapianti e delle Nuove Tecnologie in Medicina - Università di Pisa, Pisa, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Ferrari
authors.forename: Daniele
authors.initials: D
authors.lastname: Adami
authors.forename: Raffaella
authors.initials: R
authors.lastname: Berchiolli
authors.forename: Andrea
authors.initials: A
authors.lastname: Del Corso
authors.forename: Andrea
authors.initials: A
authors.lastname: Pietrabissa
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000503:physiopathology / Q000601:surgery*; D016063:Blood Loss, Surgical / Q000517:prevention & control; D003250:Constriction; D048909:Diabetes Complications / Q000209:etiology / Q000503:physiopathology; D005240:Feasibility Studies; D005260:Female; D006547:Hernia / Q000209:etiology; D006801:Humans; D007668:Kidney / Q000503:physiopathology; D010535:Laparoscopy / Q000009:adverse effects; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011446:Prospective Studies; D051437:Renal Insufficiency / Q000209:etiology / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects; D052096:Warm Ischemia / Q000009:adverse effects