Killewich Lois A, Cindrick-Pounds Lori L, Gomez Guillermo
Section of Vascular Surgery, Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555, USA.
Vasc Endovascular Surg. 2004 Jan-Feb;38(1):83-7. doi: 10.1177/153857440403800111.
Aortobifemoral bypass is the standard method for revascularization of aortoiliac occlusive disease but is associated with significant morbidity and mortality. Laparoscopic aortic reconstruction eliminates the large incision but is limited by the cumbersome nature of laparoscopic instrumentation. A robotic system (da Vinci Computer-Enhanced Robotic Surgical System, Intuitive Surgical, Mountain View, CA) has been developed that allows the surgeon to suture in the same manner as in open procedures. The authors report the first case of an aortic reconstruction for occlusive disease performed using the da Vinci system. A 53-year-old woman presented with gangrene of the left great toe. Angiography revealed distal aortic occlusive disease and occlusion of the common iliac arteries bilaterally. Dissection of the aorta was performed by a transabdominal-retroperitoneal approach modified from Dion (J Vasc Surg 26:128-132, 1997). With use of laparoscopic techniques, the abdominal contents were retracted to the patient's right side while the kidney and ureter remained in the retroperitoneum. The aorta was isolated from the bifurcation proximally to the left renal vein. The patient was anticoagulated, and the aorta was clamped below the left renal artery and proximal to the bifurcation. The da Vinci robotic system was placed on the patient's right side, and an extruded polytetrafluoroethylene (ePTFE) graft was passed into the retroperitoneum. While seated at a computer console viewing the operative field on a screen, the surgeon used robotic instruments to fashion an arteriotomy and complete an end-to-side aortic anastomosis using ePTFE suture. The left groin was opened and the aortic graft passed down to the groin. The reconstruction was completed by performing a left-to-right femoro-femoral bypass in standard, open fashion. The procedure was completed in 8 hours with an aortic clamp time of 65 minutes and a 500 cc blood loss. The patient was extubated in the operating room, ate a regular diet on postoperative day 2, and was discharged on postoperative day 4 without complications. Return to normal activities occurred 2.5 weeks postoperatively. The da Vinci robotic system facilitated creation of the aortic anastomosis and shortened aortic clamp time over that achieved with laparoscopic techniques. Robot-assisted laparoscopic aortofemoral bypass should decrease the morbidity and mortality of aortic reconstruction, while providing a durable solution to aortoiliac occlusive disease.
主动脉双股动脉搭桥术是治疗主髂动脉闭塞性疾病血运重建的标准方法，但会伴随较高的发病率和死亡率。腹腔镜主动脉重建术避免了大切口，但受限于腹腔镜器械操作的复杂性。一种机器人系统（达芬奇计算机增强机器人手术系统，直观外科公司，加利福尼亚州山景城）已被研发出来，它能让外科医生以与开放手术相同的方式进行缝合。作者报道了首例使用达芬奇系统进行的闭塞性疾病主动脉重建手术。一名53岁女性因左大足趾坏疽前来就诊。血管造影显示远端主动脉闭塞性疾病以及双侧髂总动脉闭塞。采用经腹 - 腹膜后入路（改良自迪翁的方法，《血管外科杂志》26:128 - 132, 1997）进行主动脉解剖。运用腹腔镜技术，将腹腔内容物牵至患者右侧，同时肾脏和输尿管保留在腹膜后。从主动脉分叉处至左肾静脉近端游离主动脉。对患者进行抗凝处理，在左肾动脉下方、分叉近端夹闭主动脉。将达芬奇机器人系统置于患者右侧，把一段膨体聚四氟乙烯（ePTFE）人工血管置入腹膜后。外科医生坐在计算机控制台，通过屏幕观察手术视野，使用机器人器械制作动脉切口，并使用ePTFE缝线完成端侧主动脉吻合。切开左腹股沟，将主动脉人工血管引至腹股沟。通过标准的开放方式进行左至右股 - 股动脉搭桥完成重建。手术历时8小时，主动脉阻断时间65分钟，失血500毫升。患者在手术室拔管，术后第2天进普通饮食，术后第4天出院，无并发症。术后2.5周恢复正常活动。与腹腔镜技术相比，达芬奇机器人系统有助于进行主动脉吻合，并缩短了主动脉阻断时间。机器人辅助腹腔镜主动脉股动脉搭桥术应能降低主动脉重建的发病率和死亡率，同时为主髂动脉闭塞性疾病提供持久的解决方案。
