For over 50 years Abdominal Aortic Aneurysms (AAA) have been treated successfully by elective open surgical replacement with a synthetic graft (endoaneurysmorrhaphy) using either a transperitoneal or retroperitoneal approach to the aorta.

Due to the large incision and the interruption of blood flow during surgery, there is a significant risk of complications as well as a considerable recovery period. (Table 1)

Table 1

In 1991, the use of an endovascular stent-graft exclusion technique was reported for the first time. However, the risk of migration, persistent endoleak, proximal and distal attachment failure, aneurysm expansion and subsequent rupture make the long term outcome of stent-graft procedures uncertain. (Table 2)

Table 2

Advanced laparoscopic aortic surgery addresses the needs for a safe minimally invasive repair of the abdominal aorta for a secure and permanent attachment of the graft. The laparoscopic aneurysm repair technique using the GelPort^® system avoids many of the issues identified with open AAA and stent-graft repair.

GelPort Laparoscpic System
The Applied GelPort system is the only device currently available that combines the patient benefits of laparoscopy with the advantages of open surgery by allowing the surgeon to use the hand. The GelSeal^® cap can be removed from the Alexis^® O™ retractor and self-retaining retractors can be applied in order to continue the anastomosis through the mini-incision of the GelPort laparoscopic system.

Positioning of the patient and laparoscopic exposure
For the laparoscopic-assisted surgery the modified transperitoneal left retrocolic approach is used (Fig. 1). The operating table may be tilted to a 40 degree right lateral Trendelenburg position. The table is then tilted to a 5 to 10 degree right rotation.  The right arm is placed alongside the body, the left arm at a right angle or overhead. The operating team consists of the surgeon and two assistants; often a laparoscopic specialist and a vascular specialist team up with an assistant and an experienced scrub nurse.

Fig 1. Patient positioning 

Planning of the ports and laparoscopic dissection
The planning of the ports involves an 11 mm trocar for the introduction of the laparoscope that is placed above the umbilicus. Pneumoperitoneum is established at a pressure limit of 12 mmHg. The abdomen is inspected and two 11 mm trocars are placed in the midline below and above the umbilicus. Incisions are best placed in the lower abdomen to minimize the side effects of access in the upper abdomen (Fig. 2).

Figure 2. Trocar and GelPort Device Placement

The cosmetic results are excellent when compared to conventional aortic surgery. Exposure of the aorta begins with the mobilization of the left hemi colon. After identification of the left renal vein the neck of the aneurysm can be exposed. The surgeon creates the opening of the peritoneum as proximal as possible to facilitate deep dissection towards the neck of the aneurysm. The right common iliac artery is then partially dissected.

The hand of the surgeon assists in the careful identification and dissection of critical structures. The left lumbar arteries can be freed and occluded using clips. The hand assists in the dissection of the fatty and lymphatic tissue that surrounds these vessels. After achieving the aortic-iliac dissection, the aortic neck can be reached more easily.

After dissection of the aneurysm and the aortic bifurcation, a laparoscopic cross clamp is introduced. (Fig. 3) If the iliac arteries are too calcified to permit safe occlusion with laparoscopic clamps, balloon catheters are inserted and the iliac arteries are occluded.

Figure 3. Clamping the infrarenal aorta

GelSeal cap is removed
At this point the insufflation is stopped and the GelSeal cap is removed and the operation continues through the mini incision in a conventional way. A table mounted, self-retaining retractor is applied and the operation continues through the mini-incision of the GelPort Laparoscopic system. A normal dose of an intravenous bolus injection of heparin is administered by the anesthesiologist. The proximal laparoscopic aortic clamp is closed. The clamps are applied on the common iliac arteries. The aneurysm is opened longitudinally, followed by an opening on the right and left lateral surfaces on both sides of the incision. The mural thrombus is removed. The lumbar arteries are stitched inside with a short 2-0 vicryl suture having a pledget at the end of the thread.

The appropriate polyester or polyetrafluoroethylen graft is inserted (aortic tube or bifurcated graft). The proximal end-to-end anastomosis is performed through the mini-incision with two 3-0 monofilament sutures. Conventional anastomosis of the graft to the aorta is performed with 3-0 monofilament sutures. In a case where the aneurysm involves the bifurcation, the origin of each iliac artery is opened longitudinally and transversally. The branches of the bifurcated graft are cut with a slant to the appropriate length. Using a 4-0 or 5-0 vicryl suture, a conventional end-to-end anastomosis on the graft to the common iliac arteries is performed on each side.

After placement of the graft and checking hemostasis, the graft is covered by the left hemicolon and peritoneum by turning the operating table to the left. A retroperitoneal closure can be performed through the mini-incision using slowly absorbable suture. The self-retaining retractor is then disassembled. The mini-incision and the trocar incisions are closed in 2 or 3 planes in the conventional way without drainage.

Indications for GelPort laparoscopic aortic surgery
GelPort laparoscopic aortic surgery can be offered to most patients presented with aorto iliac occlusive disease or abdominal aneurysms. GelPort laparoscopic aortic surgery can be used in morbidly obese patients. The feasibility and advantages of hand-assisted laparoscopic aortic surgery has been demonstrated by a number of opinion leaders and early adaptors.¹

How to start a laparosopic aortic program
GelPort laparoscopic aortic surgery should be performed only after acquiring laparoscopic skills. A specific vascular laparoscopy course should be part of the initial laparoscopic aortic surgery training program. There is a substantial learning curve when starting laparoscopic aortic surgery but the technique can be mastered by vascular surgeons the same way complex GelPort laparoscopic operations are now routinely performed by colorectal surgeons.

The importance of proctoring by experienced laparoscopic vascular specialists should not be underestimated. Applied Medical is committed to support the development of Minimally Invasive Endo Aortic surgery is seeing an increasing demand for training courses and proctorships in this new frontier of advanced laparoscopic vascular surgery.