Laproscopic AAA repair

[johnny_blaze]

I’ve read about this recently and I’m a bit curious about it. Have any of you that have operative experience on a vascular service actually seen a AAA being repaired Laparoscopically? How practical would it really be? Those of you that have operative vascular experience know how unpredictable the specialty can be intraoperatively. I’d love to know what the rate is for reverting to open repair.

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[Zoom-Zoom]

I've read about this recently and I'm a bit curious about it. Have any of you that have operative experience on a vascular service actually seen a AAA being repaired Laparoscopically? How practical would it really be? Those of you that have operative vascular experience know how unpredictable the specialty can be intraoperatively. I'd love to know what the rate is for reverting to open repair.

I think it's becoming a fairy successful procdure without much need for open repair. There are a lot of videos on OR-live showcasing new types of endoprosthetic devices that you might like to watch. It looks like the biggest problems occur when the shunt slides out of alignment, which requires a second procedure to go back in and anchor it again.

 

[njbmd]

I've read about this recently and I'm a bit curious about it. Have any of you that have operative experience on a vascular service actually seen a AAA being repaired Laparoscopically? How practical would it really be? Those of you that have operative vascular experience know how unpredictable the specialty can be intraoperatively. I'd love to know what the rate is for reverting to open repair.

I have repaired about 3/4s to 4/5ths of my AAAs via endovascular means (minimally invasive technique). If the anatomy is not correct, then the only repair is open. Since I already know the anatomy before going in, there is no revert to open. If there is a tear in a vessel from placing the sheaths etc., we just repair it. The trickiest part is deplying the stent. You have to know this technique and you have to make sure that the stent is in proper position. No hospital stocks the stents and thus patients undergoing endovascular repair of a AAA have to be measured and the stent brought to the OR on the day of surgery by the company rep.

In terms of repairing a AAA via a laproscope, no one at my hospital is doing such a procedure. Getting exposure via a laproscope and then doing a repair similiar to the hand-assised sigmoid colon resection might eliminate the long abdominal scar but the patient has the same problems with cross clamping the aorta as with the open procedure where exposure is not obtained via laparoscope. As I said above, most of my AAAs are repaired endovascularly which requires no abdominal incisions but incisions only in the groins. If the patient comes in with and manages to survive a leaking/ruptured AAA, then they are going to be done open anyway.

 

[Mr. McDuck]

How many of your patients present with endoleaks? It seems to be a surgeon/team-dependant thing. I've read a couple studies with 19-21% leak rates (back in 2001) and some with ~1-2% leak rates (2005 or later). We don't have the kind of volume to really say, but the ones we've done have hardly had any problems.

 

[droliver]

This is a discussion that was being had when I started residency in the late 1990's and laparoscopy was exploding in new procedures. While hard to imagine now, in 1997-8 the only routine laparoscopy surgery were appendectomies & cholecystectomies. Europe & Australia were close to a decade ahead of the U.S. at the time.

Papers from the E.U. were describing total lap. vascular procedures as the successor to traditional abdominal vascular techniques rather then endovascular techniques (which at the time was still, and continues to be in some ways, an immature technology). For a variety of reasons, but mostly due to the relative technical ease of endovascular surgery and the serious laparoscopic chops required for vascular surgery (which most general, let alone vascular surgeons do not have), this area died on the vine with no real serious investigation stateside although you can google it and find some mention of it from a few vascular centers.

The only thing I could see to make this area take off is going to be some long term problems with the endo-grafts that emerge beyond what we already have been seeing (endo-leaks, etc..)

A good descriptor of the technique can be found here