Operative Technique

A pneumoperitoneum is established and the abdomen is inspected. A transperitoneal retrocolic access combined with medial mobilization of the left kidney is preferred (Figure 1). Alternatively, the left kidney can be left in situ. For more complex total laparoscopic operations like conversion after EVAR, up to eight trocars are required.

The retrorenal access described permits complete transperitoneal exposure of the abdominal aorta and, when necessary, suprarenal clamping. When an endograft has been in place for several months, there is quite often a dense inflammatory retroperitoneal reaction. In very rare cases under these circumstances a transperitoneal approach must be chosen.

The origin of the IMA is identified and the artery is divided between clips. When clips are too small to safely occlude the IMA, a vascular stapler is used. This facilitates further mobilization of the aorta. The aneurysm and the aortic neck are identified. As many lumbar arteries as are accessible are clipped on the left side of the aorta. Because access to the right-sided lumbar arteries is often very difficult because of the inflammatory changes, we now prefer a more direct approach, stitching lumbar arteries from inside as is done during open surgery.

Laparoscopic Remodelling of the Aorta After Endovascular Aneurysm Repair

The principal laparoscopic steps are performed without clamping the aorta because this would damage the endograft. Instead, transfemorally under fluoroscopic guidance, an aortic balloon occlusion catheter is introduced from the groin through a hemostatic sheath. This balloon is inflated before the sac of the aneurysm is incised to stabilize the graft inside the aorta. The balloon is inflated to prevent dislodging the endograft when taking out the thrombus.

The sac of the aneurysm is incised and opened with laparoscopic scissors in an H-shaped configuration (Figure 2). The graft is inspected using the magnification of the 30-degree endoscope to exclude any damage of the fabric or stents. Laparoscopic graspers and a 10-mm suction–irrigation device are used to remove the thrombus material. Patent lumbar arteries are stitched from within using Vicryl sutures. The surgeon is standing on the right side of the patient. In addition to these steps, bioglues can be injected into the sac of the aneurysm to accelerate graft incorporation and to prevent any backbleeding from the lumbar arteries (Figure 3). With a laparoscopic running suture (2–0 Prolene), the sac of the aneurysm is closed, wrapping the aorta tightly around the endograft.

Exclusion Criteria for Laparoscopic Remodeling After Endovascular Aneurysm Repair

Laparoscopic remodeling should not be used in cases with extensive graft migration, even with the balloon catheter in place. However, this technique has been used in combination with endovascular repair, like the placement of extension cuffs or angioplasty as well as graft limb thrombectomy. Another contraindication are patients with a hostile abdomen, in whom laparoscopic exposure of the retroperitoneum cannot be accomplished.

Hybrid techniques can facilitate complex total laparoscopic procedures. Total laparoscopic techniques can be used to perform more complex operations like conversion after failed stent graft exclusion, using balloon catheters to prevent back bleeding from iliac arteries. If necessary, transfemorally placed balloons can be inserted through hemostatic 11-Fr sheaths that are placed percutaneously over the wire through the abdominal wall into the peritoneal cavity. This technique avoids gas loss and permits direct and rapid access to the iliac arteries.

Laparoscopic conversion after stent graft placement is facilitated by leaving part of the iliac extensions in place and by suturing the Dacron graft to the remnants of the stent graft.