Said S, Mall J, Peter F, Müller J M
Department of General, Thoracic, and Vascular Surgery, University Hospital-Charité, Berlin, Germany.
J Vasc Surg. 1999 Apr;29(4):639-48. doi: 10.1016/s0741-5214(99)70309-5.
Postoperative complications are mainly related to the surgical trauma derived from the extensive abdominal incision and dissection after a conventional aortofemoral bypass grafting procedure. In an attempt to reduce postoperative complications, a concept of video-endoscopic vascular surgery on the infrarenal aortoiliac artery has been developed. On the basis of our experience with the practicability of video-endoscopic vascular surgery in the pelvic region in an animal study and in a pilot study of human cadavers, the purpose of this report was to describe three different methods that we evaluated on human cadavers and that we partly applied to patients.
In this experimental study, three different approaches were used to perform video-endoscopic aortofemoral bypass grafting. We performed an observational trial on human corpses (n = 24) with the transabdominal-retroperitoneal approach (TARA), the extraperitoneal approach (EPA), and the transabdominal left paracolic approach (TAPA). The EPA also was applied to patients with aortoiliac occlusive diseases.
The TARA on cadavers (n = 4) soon was abandoned because it caused a burdensome sliding of the intestine into the operative field adjacent to the renal vessels, particularly in cases with obese subjects. In comparison, the TAPA (n = 6) with right-sided positioning of the patient retained the intestine in the right upper abdomen throughout the procedure. Until a surgeon actually is acquainted with the anatomic landmarks and the laparoscopic preparation technique, the EPA (n = 14) is a challenging procedure that necessitates thorough training. As with the TAPA, the EPA represents a procedure that reveals constant exposure of the operating field, even in cases with obese subjects. In the clinical observational study (n = 7), aortobifemoral bypass grafting was achieved totally laparoscopically with the EPA. The mean operating time was 6.5 hours and ranged from 3 to 10 hours. Blood transfusions were necessary after surgery in three patients (range, 1 to 3 red packed blood cells). One patient, who had had occlusion of the inferior mesenteric artery, died of ischemic colitis at postoperative day 10. The other patients had uneventful postoperative courses with minor wound discomfort.
Laparoscopic vascular surgery seems to be a promising procedure to minimize postoperative complications. On the basis of our experience, we do not favor the TARA. Because it necessitates steep Trendelenburg positioning to displace intra-abdominal organs, the TARA is not an appropriate approach, particularly in obese and cardiopulmonary frail cases. Contrarily, the TAPA and the EPA deliver potentially better results in terms of exposing the operative field and thus reducing operating time and perioperative morbidity rates. A prospective cadaveric and clinical trial may be justified to further evaluate the use of these surgical techniques.
术后并发症主要与传统主-股动脉旁路移植术后广泛的腹部切口和解剖所导致的手术创伤有关。为了减少术后并发症，已经提出了针对肾下腹主动脉-髂动脉的视频内镜血管手术的概念。基于我们在动物研究和人体尸体初步研究中对盆腔视频内镜血管手术实用性的经验，本报告的目的是描述我们在人体尸体上评估并部分应用于患者的三种不同方法。
在本实验研究中，采用三种不同方法进行视频内镜主-股动脉旁路移植术。我们对24具人体尸体采用经腹-腹膜后入路（TARA）、腹膜外入路（EPA）和经腹左结肠旁沟入路（TAPA）进行了观察性试验。EPA也应用于患有腹主动脉-髂动脉闭塞性疾病的患者。
尸体上的TARA（n = 4）很快被放弃，因为它会导致肠道沉重地滑入肾血管附近的手术区域，特别是在肥胖受试者中。相比之下，患者右侧卧位的TAPA（n = 6）在整个手术过程中可使肠道保留在上腹部右侧。在外科医生实际熟悉解剖标志和腹腔镜准备技术之前，EPA（n = 14）是一项具有挑战性的手术，需要进行全面培训。与TAPA一样，EPA即使在肥胖受试者中也能持续暴露手术视野。在临床观察研究（n = 7）中，采用EPA完全在腹腔镜下完成了主-双股动脉旁路移植术。平均手术时间为6.5小时，范围为3至10小时。三名患者术后需要输血（范围为1至3个红细胞单位）。一名患有肠系膜下动脉闭塞的患者在术后第10天死于缺血性结肠炎。其他患者术后过程顺利，伤口仅有轻微不适。
腹腔镜血管手术似乎是一种有望将术后并发症降至最低的手术方法。基于我们的经验，我们不支持TARA。由于它需要采用陡峭的头低脚高位来移位腹内器官，TARA不是一种合适的入路，特别是在肥胖和心肺功能较弱的病例中。相反，就暴露手术视野从而减少手术时间和围手术期发病率而言，TAPA和EPA可能会带来更好的结果。进行前瞻性尸体和临床试验以进一步评估这些手术技术的应用可能是合理的。
