Original article
initial step toward totally laparoscopic techniques in patients with aorto-iliac occlusion in critical limb ischaemia

Introduction: Continuous progress in minimally invasive techniques forces on vascular surgeons the introduction of laparoscopic aortic procedures. Implementation of laparoscopic procedures should reduce invasiveness of procedures while providing comparable outcome with an open procedure.
Aim: Assessment of feasibility and of early and mid-term results in patients operated on with hand-assisted laparoscopic technique for aorto-iliac occlusion before introduction of totally laparoscopic aortic repair in everyday practice.
Material and methods: Fifteen patients with aorto-iliac occlusion resulting in critical limb ischaemia were qualified randomly for the laparoscopic procedure (median age 53 years, range: 41-64 years). Another 15 patients with comparable disease stage and risk factors and operated on with open procedure were chosen as a control group (median age 58 years, range: 40-73 years). The following parameters were assessed: duration of surgery, aortic clamping time, blood loss, amount of iv fluids administered, time of ICU stay, total postoperative stay, postoperative abdominal pain, 30-day mortality and morbidity, as well as 1-year mortality and morbidity.
Results: All patients survived the 30-day postoperative period. No difference in complication rate was observed. Median time of the open procedure (136 minutes) was significantly shorter (p < 0.01) than the laparoscopic one (median 190 minutes). No difference in aortic clamping time was observed. Perioperative blood loss between the groups was comparable with median of 350 ml (130-600 ml). Median ICU stay after laparoscopy was 21 hours (range: 16-48 hours) and was significantly shorter (p < 0.01) than after an open procedure – median 70 hours (range: 24-56 hours). Patients needed 1500 ml less i.v. fluids during the laparoscopic procedure, but the difference was not statistically significant. Total postoperative hospital stay was 2 days shorter in laparoscopy patients, but the difference was not statistically significant. All patients survived 1-year mid-term follow-up with no difference in outcome among the groups.
Conclusions: Hand-assisted procedures give comparable efficacy and safety as open surgery in patients with critical limb ischaemia and aorto-iliac occlusion. Only after sufficient training of aortic dissection in mixed technique can totally laparoscopic aortic procedures be introduced into clinical practice. Shorter stay on ICU and overall shorter hospital stay should stimulate the introduction of vascular aortic laparoscopy. A real benefit can be proven only after introduction of totally laparoscopic procedures.