Javerliat Isabelle, Capdevila Clément, Beauchet Alain, Di Centa Isabelle, Goëau-Brissonnière Olivier, Coggia Marc
Vascular Surgery Department, Hôpital Ambroise Paré, Boulogne-Billancourt, Cédex, France.
Ann Vasc Surg. 2013 May;27(4):412-7. doi: 10.1016/j.avsg.2012.07.006. Epub 2013 Feb 11.
The recent Anévrisme de l'aorte abdominale: Chirurgie versus Endoprothèse (ACE) study showed that open surgery of infrarenal abdominal aortic aneurysms (AAAs) provided very good results in patients with standard surgical risk, with good anatomic results for endovascular aneurysm repair (EVAR). The goal of the current study was to show that aortic laparoscopy is a minimally invasive alternative to open surgery while avoiding the complications associated with laparotomy.
From February 2002 to August 2010, the authors performed 239 laparoscopic AAA repairs. A subgroup of 99 patients with standard surgical risk presented with AAAs compatible with EVAR. The evaluation criteria of surgical risk and anatomic criteria compatible with EVAR corresponded to those edicted by the Agence Française de Sécurité Sanitaire des Produits de Santé and the Haute Autorité de Santé. The patients' database was prospective and the file analysis was retrospective. Digital data were given in median and extremes.
The patient age was 68 years (range, 53-79 years). The aneurysmal diameter was 51 mm (range, 45-69 mm). Surgery and clamping times were 210 min (range, 180-520 min) and 81 min (range, 35-140 min), respectively. There were 60 aortic tubes and 39 bifurcated prostheses. Five patients (5%) required conversion. No hospital mortality occurred. Three patients presented with severe systemic complications (3%): 1 perioperative cardiac arrest on atrioventricular block grade 3, 1 case of febrile hypoxic atelectasis, and 1 colonic ischemia with transient renal failure with transient dialysis. Ten patients had a moderate systemic complication (10%): 7 transitory elevations of creatinemia, 1 pneumonia, 1 prostatitis, 1 sigmoiditis, and 1 cardiac arrhythmia/atrial fibrillation (CA/AF). Intensive care stay and hospitalization durations were 24 hours (range, 12-768 hours) and 6 days (range, 4-39 days), respectively. Four local complications occurred: 1 limb thrombosis, 1 compartment syndrome, 1 spleen rupture, and 1 parietal hematoma. On multivariate analysis, the overall procedure time was a predictive factor of severe systemic complications (P=0.02). Follow-up was 42 months (range, 1-97 months). Two patients required late surgery (2%): 1 for limb thrombosis after neuroendovascular procedure and 1 for iliac thrombosis. Morphologic tests did not show any defects at the aortic prosthesis level. The only abdominal complication was a rupture at the level of a laparotomy conversion. The 6 late deaths (6%) were not related to the AAA.
This study shows that AAA laparoscopic surgery is a safe, long-lasting, minimally invasive technique in patients with standard surgical risk when EVAR can be considered.
最近的腹主动脉瘤：手术与腔内修复（ACE）研究表明，对于具有标准手术风险的患者，肾下腹主动脉瘤（AAA）的开放手术效果非常好，腔内动脉瘤修复术（EVAR）的解剖学效果也很好。本研究的目的是表明主动脉腹腔镜手术是开放手术的一种微创替代方法，同时避免与开腹手术相关的并发症。
从2002年2月至2010年8月，作者进行了239例腹腔镜AAA修复术。99例具有标准手术风险的患者亚组出现了与EVAR兼容的AAA。手术风险评估标准和与EVAR兼容的解剖学标准与法国卫生安全产品局和法国卫生高级管理局规定的标准一致。患者数据库是前瞻性的，文件分析是回顾性的。数字数据以中位数和极值给出。
患者年龄为68岁（范围53 - 79岁）。动脉瘤直径为51mm（范围45 - 69mm）。手术时间和夹闭时间分别为210分钟（范围180 - 520分钟）和81分钟（范围35 - 140分钟）。使用了60个主动脉管和39个分叉假体。5例患者（5%）需要转为开放手术。无医院死亡病例。3例患者出现严重全身并发症（3%）：1例围手术期因三度房室传导阻滞发生心脏骤停，1例发热性缺氧性肺不张，1例结肠缺血伴短暂性肾衰竭并进行了短暂透析。10例患者出现中度全身并发症（10%）：7例肌酐血症短暂升高，1例肺炎，1例前列腺炎，1例乙状结肠炎，1例心律失常/心房颤动（CA/AF）。重症监护停留时间和住院时间分别为24小时（范围12 - 768小时）和6天（范围4 - 39天）。发生了4例局部并发症：1例肢体血栓形成，1例骨筋膜室综合征，1例脾破裂，1例腹壁血肿。多因素分析显示，总手术时间是严重全身并发症的预测因素（P = 0.02）。随访时间为42个月（范围1 - 97个月）。2例患者需要二期手术（2%）：1例因神经血管内手术后肢体血栓形成，1例因髂静脉血栓形成。形态学检查未显示主动脉假体水平有任何缺陷。唯一的腹部并发症是在转为开腹手术部位发生破裂。6例晚期死亡（6%）与AAA无关。
本研究表明，对于具有标准手术风险且可考虑EVAR的患者，AAA腹腔镜手术是一种安全、持久的微创技术。
