Laparoscopic assisted aortic surgery. A review

We give an overview of different laparoscopic assisted techniques to perform aortic surgery. In a meta-analysis the paper describes the combined experience of two vascular surgical centers who together have performed more than 524 laparoscopic assisted aortic procedures. Basically the following techniques can be used to perform a laparoscopic assisted procedure: 1) transperitoneal approach (the Alimi procedure); 2) hand assisted laparoscopy (the Ferrari technique); 3) left retrocolic laparoscopic assisted; 4) combining laparoscopic assisted and total laparoscopy techniques. In all cases a transperitoneal approach was chosen to dissect the aorta. This was either accomplished directly or using a left retrocolic access originally described by Dion as the apron technique. In some cases a hand assist device was used, which permits the surgeon to introduce the non dominant hand while maintaining the pneumoperitoneum. The mortality in abdominal aortic aneurysm (AAA) patients in either center did not exceed 1.8%. ICU stay, postoperative ileus and length of stay were significantly shorter compared to patients with a full length incision. The Pisa group showed that there is still a significant reduction of operating time as well as aortic cross clamping time beyond the learning curve of the first 30 patients. The analysis of the pooled data shows that even in AAA patients the laparoscopic assisted procedure can be performed with operating times of less than 3 h and hospital stays up to 4 days, which we only know from endovascular aneurysm exclusion. This is the first publication of hand assisted laparoscopic endoaneurysm repair involving a large number of patients. The operations can be performed with expediency and safety. We can use these laparoscopic procedures to perform even complex aortic operations including suprarenal aneurysms with revascularization of the renal and visceral arteries. An outlook of future developments including stapling technology is given.