Hand-assisted laparoscopic aorto-aortic bypass: initial experience in a porcine model

Videoscopic surgical techniques have been developed to reduce morbidity of open aortic reconstructions. The advantage of hand-assisted laparoscopic surgery (HALS) technique is the introduction of the surgeon's hand into the peritoneal cavity. The aims of this study were to assess the feasibility and to examine the learning curve, limitations, and pitfalls of the HALS technique to perform aortic reconstruction in a porcine model for training purposes. HALS aorto-aortic 8 mm polytetrafluoroethylene (PTFE) interposition grafts were placed in 12 pigs. Proficiency was judged by measuring operative time points, satisfactory completion of the operation, and the need to convert to open procedure. The strength of the relationship between order number in which a procedure was performed and the various surgical time point measures was described with the Spearman rank correlation. HALS aortic grafting was successful in the last 8 pigs. The first 2 pigs required conversion to open repair, and the graft of the third and fourth animals occluded early. Median operative time was 115 minutes (range: 75 to 205), median intestinal retraction time was 28 minutes (range: 10 to 40), median aortoiliac dissection time was 30 minutes (range: 20 to 60), and median aortic cross-clamp time was 48 minutes (range: 35 to 82). The Spearman rank correlations and p values between the order of the procedure and the intestinal retraction time, aortoiliac dissection time, clamping time, and total operative time were -0.62 (0.06), -0.47 (0.17), -0.69 (0.03), and -0.83 (0.03), respectively. HALS facilitates intestinal retraction and completion of laparoscopic aortoiliac dissection. It offers adequate exposure in pigs for aortic grafting and allows open sutured aortic anastomosis. The learning curve for HALS aortic surgery in a porcine model is short and within reach of surgeons with standard laparoscopic surgery skills, since no laparoscopic suturing is required. Training on this porcine model may be an efficient and safe way to introduce surgeons to HALS for aortoiliac reconstruction.