Laparoscopic aortoiliac surgery for aneurysm and occlusive disease: when should a minilaparotomy be performed?

The purpose of this study was to determine the benefits and the indications of performing a minilaparotomy during laparoscopic abdominal aortoiliac reconstructions.

This prospective study was approved by the Commission Consultative de Protection des Personnes dans la Recherche Biomédicale of the University of Marseilles, and all patients gave their informed consent. Between January 1998 and March 2000, 27 patients (23 men; 4 women) with a mean age of 58.2 years (range, 42-76 years) underwent aortoaortic (n = 3), aortounifemoral (n = 4), or aortobifemoral (n = 20) bypass graft for aortoiliac occlusive disease (n = 20), emboligenic aortitis (n = 1), or abdominal aortic aneurysm (AAA) (n = 6). At the beginning of the trial, the decision was made to perform an intraoperative conversion to open surgery in case of bleeding (group 0), when a totally laparoscopic procedure was possible (group I), or when a 6- to 8-cm supraumbilical minilaparotomy was needed in case of technical difficulty (group II). In each case of AAA, the remaining lumbar arteries were controlled (group III); and for the last six patients of this series (group IV), a minilaparotomy was systematically performed.

One patient was admitted with multiple organ failure and died on day 12 (3.7%) with a patent graft. One intraoperative conversion to open surgery (3.7%, group 0) was performed for bleeding; recovery was uneventful. Seven postoperative surgical procedures (26%) were necessary, including two cases of aortic bleeding because of hypertensive access. Seven procedures were totally laparoscopic (group I), and a minilaparotomy was performed in the other 19 cases, including seven cases of technical difficulty (group II). The mean operative and clamping times and the mean postoperative hospital stay were globally (P =.021) and individually (P < or =.016) significantly shorter in group IV when compared with those of the other three groups. Twenty patients (74%) had a postoperative hospital stay of 6 days or less (3-6 days), with minimal complaints of pain, tolerance of oral feeding on day 2, and mobilization on day 2 or 3. All bypass grafts remained patent after a mean follow-up of 11 months (1-26 months).

With regard to the instrumentation presently available, this study shows the benefit of a minilaparotomy when performing a laparoscopic aortoaortic or aortofemoral bypass graft for the treatment of aortoiliac occlusive disease and AAA.