Laparoscopic aortorenal bypass in an acute porcine model under warm ischemia: feasibility study and resident training...

Laparoscopic aortorenal bypass (LARB) in a human being has never been reported. Both the skills required and the concern over preserving renal parenchyma by minimizing ischemia time has limited laparoscopic renal revascularization. The limit of safe renal warm ischemia is 30 minutes, which, it may be argued, is too short to permit laparoscopic anastomosis by those who have never performed the procedure. We sought to demonstrate the feasibility of LARB by determining whether it can be performed under warm ischemia and entirely by a resident after sufficient training. We describe our training program and experience with LARB.

An LARB was performed in four pigs. There were no practice pigs, as data were collected on the first pig, which was intentionally euthanized postoperatively, while the remaining three were allowed to survive for 24 hours. All procedures were performed by a resident with limited previous training after a regimented program in a "dry laboratory," beginning with basic skills and progressing to LARB modeling using cadaver pig kidneys.

The mean time needed for the graft-to-aorta anastomosis was 30.5 minutes (range 21-47 inutes). The renal arterial anastomosis was completed within 30 minutes in three of the four animals, including the first animal attempted (24, 32, 19, and 15 minutes, respectively). The mean total operative time was 3.1 hours.

With continuing refinements in technique, LARB under warm ischemia is feasible and not only for an elite few surgeons with advanced skills. We believe any surgeon can become capable of performing this procedure. In addition, LARB provides a porcine model for training that includes both advanced skill and time endpoints.