Yves-Marie Dion

Current modifications to totally laparoscopic “apron technique”

Since our original description in 1997 of a totally laparoscopic technique for treatment of aortoiliac disease, this type of minimally invasive procedure has been used both in the United States and abroad. We describe improvements that should make this technique more easily reproducible. This modified procedure was offered to six patients, one of whom received a tube graft for treatment of aneurysm disease.

Laparoscopic Aortic Surgery

Vascular surgeons have been attracted to the ideas of minimally invasive surgery and of the resulting benefits in terms of immediate survival and quality of life. This probably resulted in the initial popularity of extra-anatomical bypasses in the aorto-iliac occlusive disease [1] and the enthusiastic support for the endovascular interventions. Overall, extra-anatomic bypass for aorto-iliac occlusive disease rarely performs as well as aorto-bifemoral bypass and therefore is seldom recommended for claudication [2]. On the other hand, despite their usefulness, endovascular interventions cannot be offered to treat all vascular lesions. One cannot put aside the proven value of laparoscopy extensively studied by general surgeons who made it the procedure of choice for treatment of most intra-abdominal and intrathoracic diseases. Vascular surgeons, having to deal with lower extremity disease, who did not have much exposure to general laparoscopic surgery found the advancements of endovascular technology more appealing.

Totally laparoscopic juxtarenal aortic anastomosis: an experimental study.

The surgical management of juxtarenal aneurysms necessitates suprarenal aortic clamping and control of the renal arteries. We attempted to reproduce this procedure laparoscopically. Five female piglets were submitted to a totally laparoscopic approach of the aortoiliac segment. After laparoscopic control of the renal arteries and suprarenal clamping, a 6-mm Dacron tube graft was anastomosed to the juxtarenal aorta. After the procedure, a midline laparotomy allowed verification of the patency of the renal arteries and the quality of the anastomosis. Mean operative time was 198 minutes (range, 170–240 minutes). The dissection took an average of 92 minutes (range, 75–110 minutes). The mean suprarenal aortic cross-clamp time was 46.3 minutes (range, 29.1–81.5 minutes), and the mean anastomotic time was 28.9 minutes (range, 16.5–68.1 minutes). This study demonstrates in this animal model the feasibility of juxtarenal aortic anastomosis using a laparoscopic technique. Newly designed instruments should allow a shorter clamping time in the future.

Mechanical characterization of endoscopic surgical staples during an experimental Hernia repair

Recent developments in laparoscopic hernia repair techniques have led to the design of titanium staples. In a laparoscopic hernia repair, a polypropylene mesh is stapled over the direct and indirect hernia sites in the inguinal region. The effectiveness of these staples in holding the prosthetic mesh, and therefore providing adequate strength to the abdominal wall, has not been yet investigated. We have characterized the bursting strength (BS) of an experimental hernia mesh repair fixed with Prolene suture, which is used extensively for this procedure, and the BS of repairs fixed with two currently available staplers, the Endopath EMS endoscopic multifeed stapler and the Endo Hernia stapler. We first simulated abdominal wall hernias in 16 piglets by creating incisions on both sides of the abdomen of each animal. Each defect was then covered with a polypropylene mesh, which was fixed on one side with Prolene sutures and on the other side using either the Endopath EMS (Group 1) or the Endo Hernia stapler (Group 2). The abdominal tissue with the mesh covering the defect was then excised and the BS evaluated using an Instron machine. Since many mechanical characteristics contribute to the BS of a repair, we investigated these characteristics in vitro, including tensile properties of the staples and the prosthetic mesh as well as the suture-tearing resistance of the mesh. Polypropylene mesh exhibits the same elongation in the three directions, i.e. 0 degrees , 45 degrees and 90 degrees . This elongation was estimated at 136% (SD = 130).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of a plasma-based composite biologic sealant with fibrin glue (Tisseel) for vascular anastomoses.

Biologic sealants are needed in numerous, more and more demanding, procedures-especially with developments occurring in endovascular and laparoscopic vascular techniques. An initial pilot study in dogs showed that a 4-cm aortotomy closed with a polyester patch sutured in place by a 4-mm-spaced running suture consistently led to massive hemorrhage. We then designed a study using five dogs where two aortotomies were done to compare the effect of Tisseel® to that of an autologous sealant prepared in our laboratory. Arterial pressures and heparinization were maintained throughout the surgical procedure. Both biologic sealants prevented hemorrhage from the arteriotomy at unclamping. Macroscopic and histologic assessments were performed. At killing, one week later, the autologous sealant exhibited less blood saturation of the collagen sponge compared with Tisseel®. The use of autologous plasma combined with other adhesive components could be an efficient alternative to allogenic fibrin glue. Further studies are needed to confirm these observations.

Advanced laparoscopic surgery

Since its introduction to the United States in 1991, laparoscopic antireflux surgery (LARS) has created renewed interest in the surgical treatment of gastroesophageal reflux disease (GERD). Acceptance of the reliability of the laparoscopic procedure combined with the attraction to both patients and physicians of shorter recovery and hospital stay and decreased pain has led to a dramatic increase in the numbers of these procedures being performed. We will discuss controversies in indications for surgery, necessary preoperative work-up and technical aspects of antireflux surgery.

Thoracoscopic Transpleural Azygos Vein Cannulation as Vascular Access for Hemodialysis: Experimental Study in a Porcine Model

Temporary hemodialysis is conventionally performed by accessing either the jugular, the femoral, or the subclavian veins. Repetitive or chronic use of these venous sites may lead to complications such as thrombosis of the superior vena cava. Alternative venous accesses have been described. The purpose of this acute experiment is to evaluate in 8 female pigs the feasibility and immediate complications associated with the transpleural cannulation of the azygos vein performed under thoracoscopy. All animals survived the experiment. There were 5 successful cannulations. There was one termination of the procedure and 2 conversions to thoracotomy because of bleeding which, even if minor, hindered the view of the operation field. There was one lung injury caused by a retractor. In conclusion, the thoracoscopic technique was found to be feasible and could become an alternative access in patients with unsuitable conventional central venous access. Further investigation could validate our findings.

Early transient hydronephrosis after laparoscopic aortobifemoral bypass grafting

Hydronephrosis early after aorto-bifemoral bypass grafting is probably an underestimated complication. We describe early and transient hydronephrosis that developed in two patients after totally laparoscopic aorto-bifemoral bypass surgery to treat aortoiliac occlusive disease. A conservative approach to treatment was adopted, and both patients recovered. We review the literature and discuss the pathophysiology, diagnosis, and treatment of this unusual form of hydronephrosis.

Minimally invasive interventions in aorto-iliac occlusive disease.

Introduction Aorto-iliac occlusive disease can cause disabling symptoms and Trans-Atlantic Inter-Society Consensus (TASC II) has recommended the treatment options for varying severity of the disease. In the TASC II article, an increasing interest for laparoscopic aorto-ilio-femoral surgery was noted. Aim To review the literature on the minimally invasive interventions currently used in aorto-iliac occlusive disease with a focus on laparoscopic aortic surgery. Methods Medline search and hand search of references from relevant articles to describe the current management options for aorto-iliac occlusive disease. Conclusion Laparoscopic aorto-femoral surgery is a therapeutic option for most TASC C and D lesions.