Minilaparotomy for Aortoiliac Occlusive Disease

Abstract

This prospective study was designed to establish the feasibility of minilaparotomy for aortobifemoral bypass, and its effect on intraoperative and postoperative variables. A minilaparotomy has potential benefits for the patient, including smaller size of the surgical wound, reduced risk of infection, shorter postoperative intubation, decreased postoperative pain, earlier discharge, and a smaller, aesthetically more acceptable postoperative scar. Moreover, reoperation is less hazardous, because the peritoneum is not completely dissected.

From the beginning of June 1999 through the end of September 2001, we used a minilaparotomy in 33 patients with aortoiliac occlusive disease. Obesity and prior abdominal surgery were regarded as contraindications to the operation. One patient required conversion to a full laparotomy because of intraoperative bleeding. Another patient developed wound infection. There were no deaths. The technique has proved safe, effective, and aesthetically acceptable to the patient.

To date, no study has compared a median laparotomy with a minimally invasive alternative for the surgical treatment of aortoiliac occlusive disease. Prospective randomized trials are needed to determine whether minilaparotomy is the superior technique for treatment of aorto-occlusive disease. (Tex Heart Inst J 2002;29:316–8)

Because of its long-term results, the aortofemoral bypass procedure remains the gold standard for the correction of aorto-occlusive disease. Endovascular treatment has begun to reveal its limitations, particularly in regard to the management of severe and extensive aorto-occlusive disease and abdominal aneurysms. ^1–3 A 3rd alternative, laparoscopic vascular surgery, is a technically challenging procedure that requires a special suturing technique and specialized instrumentation. ^4–6

This prospective study was undertaken to establish the feasibility of minilaparotomy for the management of aorto-occlusive disease and to determine its effects on intraoperative and postoperative variables. Minilaparotomy, which has been used to reduce surgical trauma, provides good exposure of the operating field, similar to that afforded by the conventional procedure.

Patients and Methods

Patients

From the beginning of June 1999 through the end of September 2001, 33 patients with aortoiliac occlusive disease were treated by aortobifemoral bypass through minilaparotomies. Five other patients were not considered for the procedure because of obesity and prior abdominal surgery. Patients in the study ranged in age from 51 to 74 years (mean, 63 yr). Preoperatively, one-third of the patients were evaluated by pelvic angiography, due to complaints of claudication.

Methods

The operation was performed under general anesthesia with endotracheal intubation. A 6- to 8-cm incision was made at the level of the umbilicus, and 2 infrainguinal incisions were made for access to the femoral arteries (Fig. 1). The bowel was retracted by means of an abdominal retractor and abdominal compresses, and an incision was made in the retroperitoneum above the aorta using standard open-surgery instruments. After completing the dissection, we placed 2 Cosgrove flex clamps percutaneously in the upper-left and lower-right quadrants through 1-cm incisions (Fig. 2). After the administration of 5,000 units of heparin, the aorta was cross-clamped proximally (immediately below the renal arteries) and distally (immediately above the bifurcation). The aorta was opened for end-to-side anastomosis, and the distal aorta was never oversewn. Patients received a 16- to 18-mm Vascute® bifurcated graft (Sulzer Vascutek Ltd.; Renfrewshire, Scotland, UK). Proximal anastomosis of the Dacron bifurcated graft was performed with continuous 3-0 Prolene suture (Fig. 3). Both limbs of the graft were pulled retroperitoneally to the femoral arteries and affixed with sutures. We used a curved, 8¼″ (210-mm) Aesculap® BF-27 dressing forceps to tunnel the graft. The retroperitoneum was closed with a continuous silk suture. No drainage tube was inserted into the wound. The wounds were closed in layers.

Fig. 1 Minilaparotomy was accomplished by means of a 6- to 8-cm paraumbilical incision.

Fig. 2 Two Cosgrove flex clamps were placed percutaneously through the left-upper and right-lower quadrants.

Fig. 3 An 18- × 9-mm bifurcated Dacron graft was secured in position with continuous 3-0 Prolene sutures.

After the operation, all patients were taken to the intensive care unit.

Results

Minilaparotomy for aortobifemoral bypass was used in 32 of the 33 patients. One patient required intraoperative conversion to a full median laparotomy because of bleeding from the proximal anastomosis. Another patient had a postoperative wound infection. The minimally invasive approach for aorto-occlusive disease was accomplished without difficulty. The mean aortic occlusion time was 17 ± 6 (SD) minutes (range, 11 to 23 min), and the mean stay in the intensive care unit was 32 ± 8 hours. The duration of nasogastric tube suction was 1.4 ± 1 days. Two of the 33 patients required blood transfusion. Six patients developed mild ileus. Twenty-seven patients resumed a normal diet 2 to 3 days after surgery. Less pain was reported with this technique, due to the smaller incision. Less pain medication was required for postoperative treatment. The mean length of hospital stay was 5 days (range, 4 to 7 days).

The average rehabilitation time was 2 weeks. At the 30-day postoperative follow-up, there was no morbidity or death. The patients were satisfied with the aesthetic results of surgery.

Discussion

Reconstructive surgery for treatment of aorto-occlusive disease has generated long-term patency. ⁷ The conventional median laparotomy, which consists of an incision of the abdominal wall approximately 30 cm long, causes significant trauma and is associated with pain and prolonged postoperative recovery, especially in older patients. Furthermore, the long incision in the abdominal wall increases the risk of wound infection. A majority of patients develop postoperative adynamic ileus as a result of intraoperative extracavitary small-bowel retraction. Therefore, the conventional median laparotomy prolongs the hospital stay and increases the cost of treatment. ⁷

Laparoscopic vascular surgery remains a technically challenging procedure with a steep learning curve. It requires a new suturing technique and specialized instruments. ^8–10 The operative time is longer than that of conventional laparotomy. ¹¹

The minimally invasive approach provides better results than those of conventional median laparotomy. It provides good visualization of the surgical field, but affords the surgeon slightly less maneuvering room. If necessary, a minilaparotomy can easily be extended to a median laparotomy. The small abdominal incision and subtle postoperative scar yields an aesthetically gratifying result that gives the appearance of a much less extensive surgical procedure. The minilaparotomy is technically feasible for aortobifemoral bypass, with an acceptable cross-clamp time, lower blood loss, and less morbidity.

We believe that our approach shortened the rehabilitation time of our patients. They began to take fluids orally on the day of the operation, and light foods on the 1st day after surgery. Ileus occurred less often than after conventional repair, was milder when it did occur, and resolved sooner, because the intestine stays inside the abdominal cavity.

The minimally invasive approach can be used for vascular surgical procedures other than aortobifemoral bypass, such as abdominal aortic aneurysm repair. ¹² We report our small series of patients to highlight the use of this new minimally invasive surgical approach for aortoiliac occlusive disease. To date, no study has compared a median laparotomy with a minimally invasive alternative for the surgical treatment of aortoiliac occlusive disease. Prospective randomized trials are needed to determine whether minilaparotomy is the superior technique for treatment of aorto-occlusive disease.