Asian Cardiovasc Thorac Ann 1999;7:128-131
© 1999 Asia Publishing EXchange Pte Ltd
Aortobifemoral Bypass Surgery Using Mini-Laparotomy Technique
Ünal Açikel, MD,
Özalp Karabay, MD,
Erdem Silistreli, MD,
Akin Turan, MD,
Nejat Sariosmano
lu, MD,
Öztekin Oto, MD
Department of Thoracic and Cardiovascular Surgery
Dokuz Eylül University School of Medicine
 zmir, Turkey
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For reprint information contact: Erdem Silistreli, MD Tel: 90 232 277 5867 Fax: 90 232 277 2165 email: silistre{at}cs.med.deu.edu.tr Mithatpasa Cad. No. 257/5, Balcova, zmir 35340, Turkey.
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Abstract
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We describe 4 cases of aortobifemoral bypass performed using a mini-laparotomy incision (6 to 8 cm) between January 1997 and February 1998. Revascularization of the lower extremities was carried out successfully without the need to enlarge the incision. The mean aortic cross-clamp time was 12.7 ± 3.4 minutes and the mean duration of the operation was 93.7 ± 30.9 minutes. In all cases, bowel sounds appeared at 2 to 8 hours postoperatively and oral nutrition was started after 24 hours. The mean hospital stay was 4.7 days. With the advantages of short operation time, optimal aortic exposure, easy and safe aortic cross-clamping, limited postoperative pain and scar tissue, early mobilization and resumption of intestinal functions, and short hospitalization, we believe that the mini-laparotomy technique is safe and effective for aortobifemoral bypass operations.
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Introduction
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Recently, minimally invasive procedures have become widely used in almost every field of surgery and many classical operations, particularly in thoracic and cardiac surgery, are being performed routinely using these techniques. However, in spite of the reported faster recovery, better cosmetic results, less pain, and lower cost associated with such surgery, there has not been a significant parallel development in the field of vascular surgery. This study was carried out to compare a minimally invasive technique of aortofemoral bypass with the conventional surgical procedure.
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Patients and Methods
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We performed 4 aortobifemoral bypass operations using a mini-laparotomy incision between January 1997 and February 1998. Comparisons of the duration of the operation, the need for blood transfusion, time of starting oral nutrition, and length of hospital stay were made with a group of 12 patients undergoing the conventional surgical procedure in the same period. Data was compared by the unpaired Student t test and values of p less than 0.05 were considered significant.
Aortoiliac occlusive disease can be classified into 3 subgroups: type I is defined as atherosclerotic lesions confined to the abdominal aorta and common iliac arteries; more extensive disease is classified as type II; and extension beyond the inguinal ligament is a type III lesion.1 The 4 mini-laparotomy patients had type I or II aortoiliac lesions. Three had intermittent claudication and the 4th patient had undergone recent coronary revascularization in our department. The characteristics of these patients are given in Table 1
and the demographic data of both groups are listed in Table 2.
The mini-laparotomy operations were performed after endotracheal induction of general anesthesia with optimal muscle relaxation. The vertebral colon and abdominal aorta were brought closer to the anterior abdominal wall by extreme twisting of the waist at the level of the umbilicus. A left paramedian laparotomy incision of 6 to 8 cm in length was made with a midpoint that was level with the umbilicus. The intestines were pushed to the edge of the abdomen with the help of retractors and the retroperitoneum was opened. The abdominal aorta and both common iliac arteries were exposed. Both femoral arteries and where necessary, the popliteal arteries were prepared for anastomosis using standard methods. The patients were given 1 mg•kg–1 heparin intravenously. The aorta and iliac arteries were clamped with a Satinsky clamp, partially in one patient and separately in the other 3. After a 3-cm arteriotomy, a polytetrafluoroethylene bifurcated Gore-Tex graft (WL Gore, Naperville, IL, USA), 16 x 8 mm or 18 x 9 mm, was anastomosed with 3/0 polypropylene suture using the continuous technique. The limbs of the graft were brought into the femoral area through the retroperitoneal tunnels. Femoral anastomosis was performed; femoropopliteal bypass was also carried out in patient no. 4. Following hemostasis, the retro-peritoneum, abdominal, femoral, and popliteal incisions were closed in the anatomic position. All of the patients were extubated and nasogastric tubes that were placed in accordance with our department of anesthesia's protocol, were removed before leaving the operating room.
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Results
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In these cases of aortoiliac occlusive disease, aorto-bifemoral graft interposition and revascularization of the lower extremities were performed successfully without enlarging the incision. The mean aortic cross-clamp and operation times in these patients and in the control group are shown in Table 2
. Patient no. 4 stayed in the intensive care unit for one day because of his coronary bypass graft surgery performed one month previously. The mean units of blood transfused in the control and mini-laparotomy groups are shown in Table 2.
In the mini-laparotomy group, resumption of bowel sounds was noted in the 2nd hour postoperatively for patient no. 1 and between 6 and 8 hours postoperatively for the other patients. Oral nutrition was started after 24 hours. There were no incidences of aortic graft occlusion, acute renal insufficiency, acute mesenteric or spinal chord ischemia, lymphatic drainage, bleeding, or infectious complications. All of these patients were discharged from the hospital after 4 to 6 days with good graft function. The mini-laparotomy and femoral incisions in a typical patient are shown in Figure 1. A comparison of this group with the 12 patients who underwent the conventional procedure is given in Table 2. Follow-up of the mini-laparotomy group ranged from 2 to 14 months (mean, 9 ± 2.6 months). There were no problems during the follow-up period.
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Discussion
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Atherosclerosis is a generalized disease that often involves the aortoiliac segment with symptoms of arterial insufficiency in the lower extremities. Cramps, claudi-cation, sexual impotence, ischemic tissue necrosis, and pain at rest can be encountered.2 Aortoiliac occlusive lesions are seen 6 times more frequently in males.1 All of our patients were male and had suffered claudication. All of them had undergone coronary arteriography that revealed coronary artery lesions (necessitating coronary artery bypass grafting in one of them).
The concept of mini-laparotomy has been evolving since 1992 and the term is defined as an abdominal incision of between 3 and 10 cm. Terminology differs somewhat according to the size of the incision: an incision smaller than 2 cm has been termed a micro-laparotomy; an incision of 4 to 6 cm is referred to as a medium mini-laparotomy; and an incision of 6 to 10 cm is called a conventional mini-laparotomy.3,4 In our patients, we performed a 6-cm laparotomy in 2 cases, it was 7 cm in one case, and 8 cm in the other.
A few laparoscopic vascular surgical operations have been reported in recent years.5,6 When compared to conventional laparotomy, the advantages of this technique in which incisions of 1 to 3 cm are used, are similar to those of a mini-laparotomy. The chief advantages are minimal bleeding with reduced need for blood transfusion, early resumption of intestinal passage, shortened hospital and intensive care unit stays, and less abdominal scar formation. However, the duration of the operation is longer than the conventional laparotomy technique, taking an average 160 minutes (90 to 240 minutes). Resumption of intestinal passage on the second postoperative day and hospital stay of 4 to 7 days has been reported. Extensive aortic calcification, poor left ventricular function, previous abdominal surgery, and obesity were considered to be contraindications that necessitated open techniques in 22% of patients.5 As reported by Berens and Herde6, aortobifemoral bypass cross-clamping time was between 40 and 70 minutes and the mean operation time was 7 hours with laparoscopy. In our study using a mini-laparotomy, the mean aortic cross-clamping period was 12.7 ± 3.4 minutes and the mean duration of the operation was 93.7 ± 30.9 minutes (range, 50 to 120 minutes). There was no significant difference in aortic cross-clamp time or operative time when compared to our control group. Blood requirement was significantly lower in the mini-laparotomy patients who received 1 unit each during the operation and had no need of a transfusion in the postoperative period.
In a study by Perotti and colleagues7, a longer operation period and a 50% higher cost were reported for a laparoscopic intervention compared to the mini-laparotomy technique. Intensive care stay was short after either laparoscopic surgery or mini-laparotomy.5,7,8 There was no need for intensive care in 3 of our patients and the 4th was closely monitored for 12 hours because of his recent coronary bypass graft surgery. In laparoscopic operations, resumption of intestinal passage and start of oral nutrition are earlier compared with conventional laparotomy and hospital stay after laparoscopy is between 4 and 7 days.5–8 Similar findings were observed in our patients with a mini-laparotomy. Both laparoscopy and mini-laparotomy have the advantages of optimal aortic exposure and less blood loss, postoperative pain, and scar tissue. However, the length of the operation period, insufficient aortic exposure, difficulty of safe cross-clamping, and the need for expensive disposable instruments constitute major disadvantages of laparoscopy when compared to the mini-laparotomy technique. We believe that a mini-laparotomy is a feasible, safe, and reliable technique for aortobifemoral bypass operations.
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References
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Rutherford RB. Vascular surgery. 4th edition. Philadelphia: Saunders, 1995:767–8.
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Sobinsky KR, Borozan PG, Gray B, Schuler JJ, Flanigan DP. Is femoral pulse palpation accurate in assessing the hemodynamic significance of aortoiliac occlusive disease? Am J Surg 1984;148:214–6.[Medline]
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Nuefang T, Post S, Markus P, Becher H. Manually assisted laparoscopic surgery: realistic evolution of the minimally invasive therapy. Initial experiences with the "Endohand". Chirurg 1996;67:952–8.[Medline]
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Rozsos I. Micro and modern mini-laparotomy in biliary tract surgery. Kaposi Mor Megyei Korhaz, Kaposvar, I.sz. Sebeszeti Osztaly es Pecsi Orvostudomanyi Egyetem Egeszsegugyi Foiskola Kaposvari Kara. Orv-Hetil 1996;137:2243–8.
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Fabiani JN, Mercier F, Carpentier A, Le Bret E, Renaudin JM, Piere J. Video-assisted aortofemoral bypass: results in seven cases. Ann Vasc Surg 1997;11:273–7.[Medline]
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Berens ES, Herde JR. Laparoscopic vascular surgery: four reports. J Vasc Surg 1995;22:73–9.[Medline]
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Perrotti M, Gentle DL, Barada JH, Wilbur HJ, Kaufman RP. Mini-laparotomy pelvic lymph node dissection minimizes morbidity, hospitalization and cost of pelvic lymph node dissection. J Urol 1996;155:986–8.[Medline]
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Ou H. Laparoscopic–assisted mini-laparotomy with colectomy. Dis Colon Rectum 1995;38:324–6.[Medline]
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Abstract
Introduction
