1Section oUniversity of C

2Section ofMedicine, Chic

CorrespondSurgery and ES. Marylandhbassiou@surg

Ann Vasc SurgDOI: 10.1016/� Annals of VPublished onli

Total Laparorobotic Repair of AbdominalAortic Aneurysm with Sac ExclusionObliteration and Aortobifemoral Bypass

Timothy Wu,1 Jateen Prema,1 Gregory Zagaja,2 Arieh Shalhav,2

and Hisham S. Bassiouny,1 Chicago, Illinois

A 65-year-old man with coronary artery disease, hypertension, and peripheral vascular diseasewas found to have an asymptomatic abdominal aortic aneurysm (AAA) of 5.5 cm on surveillancefor his peripheral vascular disease. Cardiac stress testing demonstrated no evidence of myocar-dial ischemia, and he opted to undergo open repair of his aneurysm. Laparorobotic repair of theinfrarenal AAA using the da Vinci� robotic system was performed with an aortobifemoralbypass. We describe a novel technique for AAA exclusion using a cerclage method, whichgreatly facilitates repair of infrarenal AAAs using laparorobotic techniques. Laparorobotic repairof infrarenal AAA can be greatly facilitated by AAA sac exclusion and obliteration without theneed to ligate all lumbar arteries or to open the aneurysm. This virtually avoids blood lossfrom the sac and minimizes the possibility for open conversion as a result of poor visualization.Minimally invasive aortic intervention for aneurysmal disease using laparascopic methods hasbeen reported in the literature. Problems associated with this technique include a prolongedlearning curve and difficulty completing intracorporeal anastomoses. Robotic surgery providesan advantage over laparoscopic surgery in its ability to provide greater degrees of freedom ina relatively small field of view along with superior high-definition, three-dimensional visualization.To date, there have been no known reports of using robotic surgery in the United States as a solemethod for repair of AAA. We report our technique of combining robotic surgery with a novelprocedure for sac exclusion and obliteration to successfully repair AAA without the need foropening the aneurysm sac and endoaneurysmorrhaphy.

CASE REPORT

A 65-year-old man with coronary artery disease,

hypertension, and peripheral vascular disease pre-

sented with an incidentally found asymptomatic

abdominal aortic aneurysm (AAA) measuring

5.5 cm. The patient had a history of prior coronary

artery bypass surgery as well as bilateral iliac stents

f Vascular Surgery and Endovascular Therapy, Thehicago Pritzker School of Medicine, Chicago, IL.

Urology, The University of Chicago Pritzker School ofago, IL.

ence to: Hisham S. Bassiouny, MD, Section of Vascularndovascular Therapy, The University of Chicago, 5841

Avenue, MC 5028, Chicago, IL 60637, USA, E mail:ery.bsd.uchicago.edu

2009; 23: 686.e11 686.e16j.avsg.2009.02.005ascular Surgery Inc.ne: July 24, 2009

for his peripheral arterial disease. On physical

exam he had a palpable AAA with pedal pulses bilat-

erally. Computed tomography angiography (CTA)

demonstrated an infrarenal aortic aneurysm with

a 2 cm neck and no involvement of the iliac arteries

(Fig. 1A, B). Cardiac stress testing demonstrated no

evidence of myocardial ischemia. After discussion of

the risks and benefits of endovascular versus open

repair of the aneurysm, the patient opted for the

latter. The patient agreed to a laparorobotic repair

because of the minimally invasive nature of the

procedure, markedly less incisional pain, and faster

postoperative recovery time. The patient consented

to the procedure while fully aware that the da

Vinci� robotic system was to be used off-label and

that open conversion may be necessary.

After induction, the patient was positioned

supine with a bump to raise the left flank and the

bed was rotated to the right lateral decubitus

686.e11

Fig. 1. Preoperative CTA (A) and reconstruction (B)

demonstrating 5.5 cm infrarenal AAA.

686.e12 Case reports Annals of Vascular Surgery

position in reverse-Trendelenberg. Both common

femoral arteries were exposed and controlled

through longitudinal incisions over the groins. An

18-gauge Veress needle was inserted in the midline

midway between the umbilicus and the xiphoid for

transperitoneal insufflation. A 12 mm port was

placed in this position for camera-assisted place-

ment of two robotic arm ports along the left anterior

axillary line. The midline port was later used for

a fan retractor as the robot camera port was posi-

tioned lateral and midway between the arm ports

with a separation of no more than 8 cm between

the three ports. A fifth port was placed lateral and

posterosuperiorly to the camera for suction and irri-

gation (Fig. 2). The da Vinci robotic system (Intui-

tive Surgical, Sunnyvale, CA) was brought

adjacent to the patient, and the arms and camera

were attached. Using the robotic bipolar grasper

and monopolar scissors, the posterior parietal peri-

toneum was divided lateral to the aorta and medial

to the gonadal vein along the length of the aorta

from the left renal vein to a point beyond the left

common iliac artery. A posterior peritoneal apron

was developed by medial dissection above the

AAA sac and slung with two transcutaneous

4-0 monofilament sutures on Keith needles to

retract the small bowel (Fig. 3). The inferior mesen-

teric artery was double-clipped and divided, as were

the visualized left lumbar arteries. A sufficient retro-

aortic space was developed to introduce a 4.5 cm

adjustable vascular stapler (Ethicon, Somerville,

NJ) across the infrarenal aorta. A curved Scanlon

aortic clamp was introduced through a stab incision

1 cm below the xiphoid process and test-clamped

with success. A 16 x 8 mm Hemashield (Boston

Scientific, Natick, MA) graft was delivered into the

peritoneal cavity with a 4-0 Gore-Tex suture (W.

L. Gore and Associates, Flagstaff, AZ) pre-tied to

the heel of the hood of the main graft body. Prior

to clamping the infrarenal aorta, both limbs of the

graft were withdrawn to their respective groin inci-

sions using a tunneling clamp in the retroperitoneal

space. After systemic heparinization (100 units/kg),

the aorta was clamped and stapled at the distal

infrarenal neck and aneurysm junction. Another

vascular stapler was fired distal to the aneurysm

and proximal to the aortic bifurcation to completely

exclude the sac. The proximal aortic neck was

completely transected above the staple line, and

the proximal anastomosis was completed in

a running fashion, end-to-end on the aorta with

pledgeted reinforcement. There was pulsatile flow

in the graft limbs after unclamping. The distal limbs

were subsequently anastomosed to the common

femoral arteries in an end-to-side fashion, and

flow was restored to the lower extremities after

adequate flushing with heparinized saline. Finally,

a 1-0 Prolene suture on a large 7.5 cm CTX-B curved

cutting needle (Ethicon) was passed transcutane-

ously into the abdomen and the AAA sac was oblit-

erated (Fig. 4A, B). To perform the cerclage, the

needle was passed through the sac three times,

with a separation of 60 degrees between each pass

of the suture. This was repeated with two additional

sutures at equidistant points along the length of the

aneurysm (Fig. 5). The sutures were tied down over

pledgets sequentially to collapse the aneurysm sac

on itself (Fig. 4A). All ports were removed, and the

Fig. 2. Patient positioning and port placement.

Fig. 3. Intraoperative photograph of posterior peritoneal

apron technique of bowel retraction and isolation.

Fig. 4. A, B Intraoperative photographs of aortic exclu

sion by cerclage technique.

Vol. 23, No. 5, September 2009 Case reports 686.e13

groin incisions were closed. Total operative time was

approximately 6 hr, and cross-clamp time was

approximately 1 hr.

The patient was observed in the intensive care

unit overnight and subsequently discharged home

on the third postoperative day. At his 3-week post-

operative follow-up he had a minor wound infec-

tion of the left groin, which did not involve the

graft and healed with conservative management

and antibiotics. Subsequent follow-up with CTA

confirmed obliteration of the aneurysm sac with

no evidence of endoleak (Fig. 6A, B).

DISCUSSION

In the current era, AAAs with favorable infrarenal

aortic necks can be treated satisfactorily with

currently available endovascular stent-graft tech-

nology. With continued refinements in this tech-

nology, even AAAs with short, angulated, or

difficult necks may also be eligible for endovascular

aneurysm repair (EVAR). Though open aneurysm

repair has been practically supplanted by the signif-

icant growth of EVAR, there are specific limitations

to that approach that cannot be ignored. Endoleak,

migration, the need for reintervention, significant

device costs, and obligatory surveillance of the stent

graft and aneurysmal sac with serial, contrast-

enhanced CT imaging for the lifetime of the patient

all greatly add to the cumulative cost of the

procedure.

Direct open aneurysm repair retains its status as

the gold standard in the definitive treatment of

AAAs despite relatively higher 30-day morbidity

and mortality compared to EVAR.1 Recent work

toward the development of minimally invasive

Fig. 5. Postoperative CTA (A) and reconstruction (B)

demonstrating obliteration of aneurysm sac and no

evidence of endoleak.

686.e14 Case reports Annals of Vascular Surgery

direct repair utilizing laparoscopic instrumentation

has been pursued to render this an attractive

modality to surgeons.2-5 Ostensibly these authors

aimed to achieve advantages in both durability of

direct aneurysm repair and reduced morbidity and

mortality in utilizing a minimally invasive

approach. Development of laparoscopic techniques

in direct AAA repair has been slow, however, owing

to the steep learning curve and relative difficulty

compared to EVAR. To facilitate some of the difficul-

ties with laparoscopic AAA repair, some authors

have utilized hand-assisted laparoscopic surgery

(HALS) techniques to perform the operation. With

HALS, improved efficiency and expediency in

creating the aortic anastomoses were demonstrated

compared to an entirely laparoscopic approach.6

The assistance of robotic technology has proved

invaluable in a variety of surgical disciplines, most

notably in cardiac and urological surgery, offering

improved visual acuity through high-definition,

three-dimensional video monitoring of the opera-

tive field as well as allowing all possible degrees of

freedom in the robotic arms during dissection and

sewing. Robotically assisted vascular anastomoses

have been previously shown to be performed faster

than with a totally laparoscopic approach in reports

of robotically assisted and totally robotic surgical

treatment of aortoiliac occlusive disease and AAA

repair.4,7 Our group has also previously reported

success with the laparorobotic approach for visceral

debranching followed by endovascular stent-graft

placement to treat a symptomatic thoracoabdominal

aneurysm in a medically high-risk patient.8

The potential benefits of robotic surgery include

its minimally invasive nature and direct device

cost savings in comparison to EVAR as well as the

cost of surveillance imaging and reinterventions.

Perhaps most importantly, however, is that this lap-

arorobotic approach to AAA repair will ultimately

achieve the gold standard of sutured graft replace-

ment rather than mere exclusion of the aneurysmal

aorta with a covered stent graft.

Direct access to the abdominal aorta through

a transperitoneal approach and development of

a peritoneal apron, as originally described by Dion

and Garcia9 and espoused by Stadler et al.,3 appears

to be most effective for this laparorobotic approach.

In this case report a transperitoneal approach with

the da Vinci robotic system was employed to develop

a posterior parietal peritoneal apron to isolate the

small bowel in the right paracolic gutter and facilitate

aortic exposure. An anatomically favorable infrare-

nal aortic neck (�2 cm) is recommended to facilitate

transcutaneous aortic cross-clamping and the aortic

anastomosis. We also recommend an end-to-side

(functional end-to-end) proximal aortic anasto-

mosis after stapling the aortic neck to the superior

aneurysm junction as this is technically easier and

avoids potential catastrophic slippage of a bare

infrarenal aortic stump. Appropriate selection of

a transcutaneous aortic clamp is necessary to prevent

infrarenal clamp migration from respiratory excur-

sion and consequent loss of proximal control. Suture

lines, facilitated with an adequate length of strong

suture material and assisted by extracorporeal

tension maintenance, should allow for tight apposi-

tion of the graft to the aortic wall and avoid laxity and

traumatic handling of the suture material by the

robotic instruments. It is our strategy in this initial

phase of our experience to limit the robotic vascular

anastomosis to only the proximal infrarenal aorta to

Fig. 6. Schema of aneurysm exclusion in robotic AAA

repair. This diagram shows a modified approach to

robotic AAA repair. Endovascular placement of bilateral

iliac occluders or the cerclage technique can function to

exclude the aneurysm completely.

Vol. 23, No. 5, September 2009 Case reports 686.e15

minimize operative and limb ischemia time and

potentially risky dissection of the iliac vessels. Hence,

the rationale for aortobifemoral reconstruction in

this case is to quickly restore lower extremity perfu-

sion. As with any operative technique in its relative

infancy, development and advancement of this

approach must be made with the safety of the patient

of ultimate concern. Conversion to an open direct

repair is mandatory for excessive blood loss or oper-

ative time over a predetermined threshold.

In our approach the lumbar arteries are not

ligated within the sac as this is left intact to maintain

operative exposure and to minimize blood loss. We

instead clip the left lumbar arteries with titanium

surgical clips. While there may be a theoretical risk

of continued pressurization of the aneurysm sac by

the remaining, patent lumbar arteries and, with

that, a risk of expansion of the sac and subsequent

rupture, this risk has been reported to be 4 7%

with EVAR.10 The cerclage approach to aneurysm

exclusion obliterates the sac lumen, which theoret-

ically promotes sac thrombosis and any significant

endoleak from residual lumbar arteries. The patient

described in this case has undergone several surveil-

lance CT scans postoperatively, and at 1 year there is

evidence of complete obliteration of the aneurysm

sac, with no evidence of endoleak. We describe

distal exclusion of the aneurysm sac in this case by

use of a vascular stapler; however, additional

adjuncts for iliac occlusion can be used, such as

intravascular occlusion devices introduced in

a retrograde fashion from the femoral anastomosis

and stapling of the inferior mesenteric artery if

necessary.

CONCLUSION

The described technique for repair of an infrarenal

AAA with the da Vinci robotic system offers the

possibility of aortic repair without violating the

aneurysm sac. The aneurysm sac is obliterated by

a cerclage technique which, though previously

unpublished, has proven effective, as evidenced by

complete AAA sac obliteration at 1 year on CT

imaging. This case was performed using the da Vinci

robotic system as an off-label device as it is currently

not approved by the Food and Drug Administration

(FDA) for aortic reconstruction. An investigational

device exemption for peripheral and aortic recon-

struction is currently under review by the FDA. Lap-

arorobotic AAA repair by exclusion and

aortobifemoral bypass has the potential to evolve

into a viable, minimally invasive alternative to

open repair which offers a durable reconstruction

for infrarenal AAA.

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