European Journal of Vascular & Endovascular Surgery
Volume 32, Issue 3 , Pages 270-272, September 2006

Total Laparoscopic Iliac Artery Aneurysm Repair Using Endoscopic Techniques and Endovascular Balloon Occlusion

  • S. Wassiljew
    • ,
  • R. Kolvenbach

      Affiliations

    • Corresponding Author InformationCorresponding author. Prof. Ralf Kolvenbach, MD, PhD, Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Clinics Duesseldorf, Amalien Str. 9, 40472 Duesseldorf FRG, Germany.
    • ,
  • A. Puerschel
    • ,
  • E. Schwierz

Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital Duesseldorf FRG, Germany

Accepted 11 April 2006. published online 06 June 2006.

Article Outline

We present a novel total laparoscopic technique to treat patients with iliac and aorto iliac aneurysms. The laparoscopic procedure does not require clamping of the iliac arteries because of a hybrid approach.

Report

Laparoscopic exposure of the aorta is performed using transperitoneal left retrorenal access. A transfemorally placed balloon catheter blocks the external iliac artery. Two haemostatic sheaths are inserted directly through the skin into the abdominal cavity. Balloons are passed through these sheaths to block the common iliac artery and the hypogastric artery, allowing bypass grafting to be performed with appropriate haemostatic control.

Discussion

The technique described preserves inflow into the hypogastric arteries . This is accomplished by a combination of laparoscopic and endovascular techniques reducing the problems that can be caused by clamping diseased arteries.

Keywords: Total laparoscopic, Hybrid, Iliac aneurysm

 

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Introduction 

Aorto iliac and large iliac artery aneurysms can present quite a technical challenge when trying to perform a total laparoscopic repair. A combination of laparoscopic and endovascular techniques can facilitate these complex operations. In the following report we describe a simple hybrid technique for total laparoscopic repair of iliac and aorto iliac aneurysms preserving inflow into at least one hypogastric artery.

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Report and Technical Details 

The technique described was used in patients with iliac or aorto iliac aneurysms.

Laparoscopic access was gained by a transperitoneal left retrorenal approach after mobilization of the left hemicolon in all cases.1 If necessary to obtain better exposure the left hemicolon was suspended with two stay sutures.2 This permitted rapid exchange of the instruments in the lower abdomen without the risk of bowel injury by scissors or laparoscopic dissectors and without small bowel obstructing the view.

The hybrid laparoscopic technique used depended mainly on the morphology and anatomic distribution of one or more iliac artery aneurysms:

1.Left common iliac artery aneurysm:
Aneurysm resection and aorto – iliac bypass with a laparoscopic anastomosis with the left iliac bifurcation was performed. Balloon occlusion from within the abdomen of the left external iliac and hypogastric arteries was used. The right common iliac artery was clamped with a regular laparoscopic aortic clamp. The laparoscopic anastomosis of the bifurcated Dacron graft is performed with the infrarenal aorta, the right common iliac artery and the left iliac bifurcation after balloon occlusion.


2.Common iliac and hypogastric artery aneurysm on the left or right side with no residual flow in the internal iliac artery:
Laparoscopic staple exclusion of the common iliac and the external iliac artery and if necessary coil embolization of the hypogastric artery aneurysm is carried out. This approach can be combined with thrombin injection. Anastomosis of the bypass is performed with the external iliac or the common femoral arteries to assure adequate peripheral blood flow.


3.Right iliac artery aneurysm extending to the iliac bifurcation:
On the right side we always use a transfemoral balloon catheter in these cases. Exact transabdominal placement of a balloon catheter into the right external iliac artery can be difficult because of the right decubitus position of the patient. Backflow from the right hypogastric artery is controlled with a second catheter inserted through a transabdominal haemostatic sheath.


Technique of balloon placement 

The hybrid procedure includes percutaneous transfemoral balloon insertion over the wire in patients with right common iliac artery aneurysms. A 9 F haemostatic sheath is inserted into the right common iliac artery. Intraoperative fluoroscopy is only required in cases where the Terumo wire cannot be advanced expeditiously from the groin into the aorta. For occlusion of the right external iliac artery we prefer a 8 or 9mm angioplasty balloon catheter. Alternatively a Fogarty embolectomy catheter with an extra lumen for the guide wire can be employed. The percutaneous access of the right common femoral artery is sealed postoperativey with an occlusion device.

For transabdominal balloon catheter insertion a 9 F haemostatic sheath is inserted over the wire directly through the abdominal wall. In patients with left sided common iliac artery aneurysms two balloons are required, one to block backflow from the left external iliac artery and the second one for the left hypogastric artery. We do not use a transfemorally placed balloon catheter on the left side (Fig. 1).

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  • Fig. 1. 

    Placement of trocars: A camera, B aortic clamp, C and D needle holders, E retractor lower abdomen, F and G instruments first assistant, H retractor, interrupted lines haemostatic sheaths.

If possible at least one distal anastomosis is performed laparoscopically with the iliac bifurcation (Fig. 2). In cases with hypogastric artery aneurysms coil embolization is performed transfemorally first, followed by staple occlusion of the common iliac and the proximal external iliac artery and a distal anastomosis with the external iliac artery or with the femoral artery. In cases with severe calcifications it can be easier to staple or to oversaw the aortic bifurcation minimizing the risk of venous injury.3 In calcified vessels there can be severe suture hole bleeding from the staples which can be avoided when the line of staples is reinforced with a PTFE sleeve.

  • View full-size image.
  • Fig. 2. 

    Schematic drawing: A transfemoral balloon in right external iliac artery, B balloon in right hypogastric artery, C balloon in left common iliac artery. Intraoperative Photo: Interrupted arrow pointing at balloon catheter in right hypogastric artery before completion of the anastomosis with the right iliac arterial bifurcation.

In patients with bilateral aorto iliac artery aneurysms after completion of the aortic anastomosis we first perform an anastomosis with the left common iliac artery or the left iliac bifurcation because access is easier and perfusion of the limb and the pelvic circulation can be restored more rapidly.

In obese patients exposure of the right common iliac artery and the iliac bifurcation requires an additional retractor in the right lower abdomen and a more neutral rotation of the operating table (30°).

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Discussion 

In our experience the use of the hybrid balloon occlusion technique was associated with less incidence of iliac artery dissection and thrombosis compared to iliac artery clamping with laparoscopic instruments. Balloon occlusion and total laparoscopic resection of iliac artery aneurysms has been performed in 19 patients. In four patients either due to adhesions in the right lower abdomen or to acute small bowel distension we had to use a small extraperitoneal suprainguinal incision to perform the anastomosis with the right iliac bifurcation. In one case we converted to a retroperitoneal incision because of bleeding from the right common iliac vein. The operating time is longer compared to a total laparoscopic tube graft repair mainly due to the complexity of the laparoscopic anastomosis with the right iliac bifurcation.

The essential operative steps can be summarized as followed: Left iliac aneurysms require a laparoscopic anastomosis with the iliac bifurcation. Right common iliac aneurysms require transabdominal and transfemoral balloon occlusion before the anastomosis with the right iliac bifurcation can be performed. In cases where the ipsilateral hypogastric artery is occluded staple occlusion of the aneurismal segment and an anastomosis with the femoral artery facilitates the procedure.

The technique described permits a total laparoscopic operation in patients with aorto iliac artery aneurysms. An anastomosis with the iliac bifurcation reduces the incidence of gluteal ischemia and buttock claudication. Endovascular repair in these cases would have required covering the origin of at least one hypogastric artery increasing the risk of bowl ischemia.4

In conclusion combining endovascular and laparoscopic techniques permits total laparoscopic aorto iliac aneurysm resection in cases which are otherwise very difficult or impossible to treat laparoscopically.

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References 

  1. Coggia M, DiCenta I, Javerliat I, Colacchio G, Goeau-Brissonniere O. Total laparoscopic aortic surgery: transperitoneal left retrorenal approach. Eur J Vasc Endovasc Surg. 2004;28:619–622
  2. Dion YM, Thaveau F, Fearn S. Current modifications to totally laparoscopic “apron technique”. J Vasc Surg. 2003;38:403–406
  3. Kolvenbach R, Schwierz E, Wasilljew S, Miloud A, Puerschel A, Pinter L. Total laparoscopically and robotically assisted aortic aneurysm surgery: a critical evaluation. J Vasc Surg. 2004;39:771–776
  4. Kolvenbach R, Pinter L, Raghunandan M, et al. Laparoscopic remodeling of abdominal aortic aneurysms after endovascular exclusion: a technical description. J Vasc Surg. 2002;36:1267–1270

PII: S1078-5884(06)00222-X

doi:10.1016/j.ejvs.2006.04.020

European Journal of Vascular & Endovascular Surgery
Volume 32, Issue 3 , Pages 270-272, September 2006

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