Technique

All patients receive the standard preoperative examination required for major aortic surgery. If necessary, coronary angiography and pulmonary function tests are performed. A laxative is given 1 day before the procedure like in bowel surgery. The patient is placed on the operating table on a vacuum bag. When tilting the table to the right, the patient can be positioned almost 70 degrees on the right side (Figure 42-1A). The left hemicolon and the splenic flexure are mobilized medially.

FIGURE 42-1 A, Right decubital position of the patient. B, Retrorenal exposure of the aorta.

The line of Told is used for orientation to incise the lateral attachments of the sigmoid colon. In many patients, there are adhesions that should be taken down to avoid a postoperative ileus. Incomplete mobilization of the splenic flexure can cause lacerations of the spleen particularly in cases with adhesions after previous surgery. When conversion to a minilaparotomy is required, conventional retractors can cause severe damage of the spleen, necessitating a splenectomy. It is best to avoid any dissection of the ureter, which is only placed laterally when necessary. In most cases, any mobilization of the ureter can be avoided.

The technique of medial mobilization was originally described by Dion and colleagues ^3,⁴ to separate the abdominal contents from the retroperitoneal space. One laparoscopic retractor is required in obese patients. A left hemicolon retrorenal approach with medial mobilization of the left kidney and the ureter is usually preferred (see Figure 42-1B); this permits expeditious exposure of the aorta even in obese patients. This approach can also be used for medial viscero rotation to obtain access to the suprarenal aorta. All three surgeons are standing on the right side of the patient during the entire procedure.

Laparoscopic exposure of the aorta is initiated at the level of the neck of the aneurysm.³ The left renal vein is one of the first structures we see when dissection is started. The laparoscopic camera stays in port 2 most of the time during exposure of the aorta (Figure 42-2). Especially in patients with occlusive disease, only the site for the anastomosis proximal to the origin of the inferior mesenteric artery is dissected. This exposure technique avoids damage of the lumbosacral nerves adjacent to the aortic bifurcation. During retroperitoneal dissection, the first assistant holds the camera and helps to put the tissue on attention with a grasping clamp (see Figure 42-2).

FIGURE 42-2 Placement of trocars.

Lumbar arteries are controlled extra luminally from the left side. When the left-sided lumbar arteries are divided after clipping, the adjacent right-sided lumbar artery can be clipped. Lumbar arteries that are still bleeding after incision of the sac of the aneurysm are stitched with laparoscopic sutures and secured with a titanium clip to save time.⁵

When the sac of the aneurysm is incised and collapsed, most lumbar arteries can expeditiously be identified medially and laterally of the aorta and occluded with a clip. Hernia staplers have also been used to stop bleeding from lumbar arteries.

Aortoiliac Aneurysms

In large iliac or aortoiliac aneurysms, a hybrid procedure is used combining endovascular and laparoscopic techniques.

The hybrid procedure consists of transfemoral balloon occlusion of the right common iliac artery after insertion of an 8-French hemostatic sheath. The left common iliac artery is occluded from within the aneurysm. A balloon catheter is introduced intraabdominally through an 8-French hemostatic sheath inserted directly through the abdominal wall. An average of three endovascular balloons is used in each case. One endovascular balloon is used for occlusion of the hypogastric artery from within.

If possible, at least one distal anastomosis is performed with the iliac bifurcation; this anastomosis is sutured also laparoscopically. In cases with hypogastric artery aneurysms, coil embolization is performed followed by staple occlusion of the common iliac and the proximal external iliac artery and a distal anastomosis with the external iliac artery.

No distal clamps are required when using this technique. Only the infrarenal aorta is clamped using a laparoscopic aortic clamp (Storz Endoscopic Manufacturer, Tuttlingen FRG).

Laparoscopic Anastomosis

Laparoscopic dissection and suturing is performed with the surgeon standing on the right side of the patient ⁵ (Figure 42-3). The transperitoneal left retrorenal exposure of the aorta permits access to the entire suprarenal aorta, permitting subdiaphragmatic cross-clamping (Figure 42-4). In patients with an end–end anastomosis with the proximal aorta, the posterior wall of the aorta is left intact as in open surgery.