Gasless videoendoscopic implantation of aortobifemoral vascular prostheses via a transperitoneal approach–an animal experiment

BACKGROUND Standard approach for aortobifemoral vascular approach prostheses is the transperitoneal approach, following median laparotomy and bilateral inguinal incision. The goal of this animal experiment was the development of a new minimal-invasive surgical technique utilizing a less-traumatic approach for aortobifemoral bypass. METHODS The gasless videoendoscopic implantation of 6 x 6 mm diameter aortobifemoral-bifurcation prostheses in transperitoneal approach was tested at the Surgical Department of the University of Cologne in 10 domestic pigs. Gasless videoendoscopic surgery is performed with a laparolift-laparfan-system. After videoendoscopic implantation of aortobifemoral prostheses, all 9 animals underwent laparotomy and resection of the aortobifemoral prosthetic segment. The quality of the endoscopically sutured aortic end-to-side anastomoses was examined under artificial in-vitro circulation of glycerol/ringer-lactate solution for evaluation of possible leakage and bursting pressures. Moreover, the anastomoses were compared to conventionally sutured end-to-side anastomoses of six-hour old porcine abdominal aortas and 6 mm diameter prostheses. The maximum bursting pressure of all endoscopically sutured anastomoses averaged 450 mmHg, whereby the minimum bursting pressure amounted to 100 mmHg mean pressure. RESULTS Aortobifemoral prostheses were successfully implanted in 9 out of 10 animals, one animal dying during preparation for the surgery, succumbing to massive coronary infarctions. Surgical durations for the transperitoneal approach averaged four hours, whereby surgical durations were reduced with increasing experience to a minimum of 3 hours 30 minutes. Dissection of the infrarenal aorta until occlusion required 35 minutes. Average aortic occlusion duration amounted to 1 hour; iliacofemoral occlusion duration amounted to 1 hour for each side. The leakage per minute at the beginning achieved a maximum of 80 ml/min and systolic pressure values of 350 mmHg in consideration of all flow levels, 60 ml/min for systolic pressure values of 200 mmHg and 20 ml/min for systolic pressure values of 120 mmHg. The minimum level leakage per minute was less than 10 ml/min for systolic pressure values between 120-350 mmHg. CONCLUSION Gasless videoendoscopic implantation of aortobifemoral vascular prostheses in transperitoneal approach is practicable in animal experiments. All endoscopically sutured aortic endo-side anastomoses were comparable to conventionally sutured anastomoses in in-vitro evaluation of bursting pressure and leakage per minute.