Interactive Cardiovascular and Thoracic Surgery 2:186-189(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Sutureless thoracic aorta to femoral artery bypass with robotic videoendoscopic approach: a fast track procedure
Piergiorgio Tozzi*,
Antonio F. Corno and
Ludwig K. von Segesser
Department of Cardio-Vascular Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
* Corresponding author. Tel.: +41-21-314-22-80; fax: +41-21-314-22-78
tozzig{at}hotmail.com
Received September 16, 2002;
received in revised form January 27, 2003;
accepted February 3, 2003
 |
Abstract
|
|---|
This study was undertaken to determine the feasibility of robotic videoendoscopic thoracic aorta to femoral artery bypass. In six pigs, three ports were inserted in the fourth, eighth and tenth left intercostal spaces. Lung retraction was obtained by insufflating CO2. The ZEUS robotic surgical system and the AESOP system were used to perform aortic dissection and to position the camera via voice control. A length of 5cm of descending thoracic aorta was exposed. A 4mm polytetrafluoroethylene (PTFE) graft was used as conduit. The proximal anastomosis was constructed using a prototype of sutureless aortic connector. Left femoral artery was exposed and an endograsp was passed to create a retroperitoneal tunnel. The prosthesis was then anastomosed to the left femoral artery. CO2 insufflating pressure was 9±1mmHg. The operation was completed in three animals while the other three died. In two animals, the death was due to aortic injury during aortic exposure and in one complications of anesthesia. Total operative time was 48±15min. Robotic videoendoscopic descending thoracic aorta to femoral artery bypass is a technically feasible operation in a pig model. The use of the sutureless device to perform the proximal anastomosis dramatically reduces the technical demand of this procedure.
Key Words: Occlusive aortic disease; Sutureless anastomosis; Robotic surgery; Endoscopy
|
1. Introduction
|
|---|
The surgical approach to occlusive aorto-iliac disease requires transabdominal or retroperitoneal exposure of the abdominal aorta. These procedures have established efficacy and are associated with low mortality and morbidity in well-selected patients [1]. Recent reports describe the performance of ‘laparoscopic aorto-iliac’ or ‘aorto-femoral’ bypass, but the enthusiasm for these procedures has been limited by a number of technical difficulties. Both the transabdominal and the retroperitoneal approaches to laparoscopic vascular surgery present technical difficulties with bowel retraction, or by maintaining pneumoperitoneum while suctioning the operative field. Moreover, laparoscopic procedures are contraindicated in patients with multiple, previous abdominal operations [2–5]. Many of these technical limitations may be avoided if the aorto-femoral bypass originates from the descending thoracic aorta as demonstrated in two studies reported by Hill [6] and Noel [7]. The thoracoscopic approach to the aorta has the advantages of easy aortic dissection, excellent graft inflow and improved aortic exposure without need for insufflations [7]. The thoracoscopic approach presents some technical limitations, indeed. The need of aortic cross- or side clamp, the fact that constructing a vascular anastomosis with endoscopic technique is a technically highly demanding procedure and the duration of this procedure are all factors reducing the diffusion of this surgical technique. The introduction of robotic technology and the use of suturless anastomotic device could solve those problems and this experimental study has been designed to verify this hypothesis.
|
2. Methods
|
|---|
Six pigs underwent acute study on general anesthesia and mechanical ventilation through single lumen endotracheal tube. With the animals in ventral decubitus, two 5mm dissecting ports were inserted in the fourth and tenth left intercostal spaces 2cm posterior the scapula angle line. The 10mm camera port was placed in the eighth left intercostal space on the scapula angle line (Fig. 1). Lung retraction was obtained insufflating CO2 in the left chest with measurement of the insufflation pressure. The ZEUS robotic surgical system and the AESOP system (Computer Motion Inc., Goleta, California) were used to perform aortic dissection and to position the camera via voice control. The posterior parietal pleura was opened, hemyazygos vein divided and a length of 5cm of descending thoracic aorta were exposed with regard to seventh and eighth vertebral body (Fig. 2). A 4mm polytetrafluoroethylene (PTFE) graft was used as conduit. The proximal side-to-end anastomosis was constructed using a sutureless anastomotic device inserted through the camera port incision. We used a design iteration of the CorLink device (Cardiovation, Ethicon Inc.), an automated aortic connector [8]. The synthetic graft was mounted onto a nickel–titanium connector coupled with an aortic punch. The aortic punch made the aortotomy and sealed it while the pre-mounted graft was inserted in the descending thoracic aorta. The anastomosis was done in a few seconds, without clamping the aorta. Inflow was generically assessed removing the clamp on the conduit. A 5cm incision was done in the left groin to expose the femoral artery and an endograsp was passed behind the left kidney, into the posterior thoracic attachments of the diaphragm to create a retroperitoneal tunnel. The prosthesis was then end-to-side anastomosed to the left femoral artery with a running 5-0 polypropylene suture. An intravascular ultrasound (IVUS) was performed to evaluate the proximal anastomosis by inserting a probe Sonicath UltraTM 3.2 through the left femoral artery (Fig. 3). Values were expressed as mean±standard deviation.
View larger version (100K):
[in this window]
[in a new window]
|
Fig. 1 Animal in ventral position. Ports are inserted in the fourth, eighth and tenth intercostals spaces. Note the robot's arms position with respect to the animal: the camera arm is on the right animal side while both the instrument arms are on the left in order to reduce the risk of arms conflict.
|
|
View larger version (132K):
[in this window]
[in a new window]
|
Fig. 2 A length of 5cm of descending thoracic aorta were exposed using robotic assisted videoendoscopic technique.
|
|
View larger version (116K):
[in this window]
[in a new window]
|
Fig. 3 IVUS of the descending thoracic aorta at the suturless anastomosis level. Metallic struts and the prosthetic conduit appear on the left side.
|
|
|
3. Results
|
|---|
CO2 insufflating mean pressure was 9±1mmHg. Mean total operative duration was 48±15min. The operation was successfully completed in 3/6 animals. Three animals died before the end of the surgical procedure (mortality=50%). In two animals, the death was due to aortic injury during aortic exposure and in one, complications of anesthesia. There were no bleeding complications associated with the construction of the sutureless anastomosis.
|
4. Discussion
|
|---|
Other authors have already reported the advantages of the thoracoscopic approach to the aorta as an alternative way to solve the occlusive aorto-iliac disease [6,7]. In this study, we have introduced two new concepts that could potentially improve the surgical technique: the use of robotic instrumentation and voice-controlled camera guidance to prepare the descending thoracic aorta and the use of a sutureless device to construct a vascular anastomosis.
One of the main problems of the endoscopic procedures resides in the limitation of vertical, horizontal, rotational and grasping movements. Many studies in the domain of minimal invasive cardiac surgery have demonstrated that computer-assisted systems like ‘ZEUS’ [9] and ‘Da Vinci’ [10] can duplicate the degrees of freedom obtained with the use of a standard endoscopic instruments controlled by the surgeon's hands. In addition, natural tremor is completely filtered and the instrument movements are scaled for a better surgeon ergonomics. As all new surgical procedures, this technique requires a learning curve. We lost two animals (33%) due to aortic injury during the aortic preparation before learning how to safely handle the instruments. On completion of the learning curve, robotic control of endoscopic instruments really improves the surgical dexterity.
The second limiting factor of the videoendoscopic thoracic aorta to femoral artery bypass is the proximal anastomosis construction. The construction of a vascular anastomosis using endoscopic technique is highly technically demanding and limited to a few skilled surgeons. The difficulty results in long operative duration and occasionally significant blood loss as reported by several authors: Noel had a mean anastomotic duration of 57min and mean operative duration of 310min; Hill reported a mean anastomotic duration of 80min and a mean operative duration of 280min. Moreover, this technique requires aortic cross-clamp which could cause paraplegia, renal failure, mesenteric ischemia and the possibility of distal emboli [8].
Sutureless anastomosis is an old concept. Payr and other authors have described several non-suture techniques to construct a vascular anastomosis since 1900 [11]. Those techniques have not reached clinical success mostly because of technical and engineering limitations. In the last 5 years, the use of metal alloys with thermal memory, coupled with new construction technologies, led to the development of suturless devices mostly used in cardiac surgery [12–14]. The ideal anastomotic device has to provide minimal graft manipulation, optimal intima-to-intima apposition, minimal amount of prosthetic material in the vessel lumen, optimal anastomotic angle and, above all, evidence of long-term effectiveness. In this study, we used a prototype of an automated anastomotic device. The synthetic graft is mounted onto a nickel–titanium connector coupled with the aortic punch. The anastomosis is performed in a few seconds, without clamping the aorta. We believe that this way of constructing the aortic anastomosis has several advantages: it reduces the technical demand and the individual surgical dexterity as determinant factor for anastomosis outcome; it avoids aortic cross-clamp and it makes the procedure quicker than standard endoscopic techniques. Even if the duration of a surgical procedure is not of primary importance, a mean operative time of 48min to treat the abdominal aorta occlusive disease could represent an important step forward in the development of a fast track vascular procedure.
However, this is a preliminary study and we are still far from the clinical application of this technique. There are at least two limitations: there is still no evidence of long-term effectiveness of the suturless anastomosis device and the reproducibility in patients of this surgical technique has to be proved. Moreover, a femoro-femoral cross-over graft, necessary to provide a complete revascularization of the lower limbs, has to be added and the costs of all new technologies, we used to achieve these results, could affect the wide acceptance of this fast track procedure.
|
5. Conclusions
|
|---|
Robotic videoendoscopic descending thoracic aorta to femoral artery bypass is a technically feasible operation in a pig model. Robotic control of endoscopic instruments can enhance the surgical dexterity and allow quick and excellent exposure of the entire descending thoracic aorta. The use of the sutureless device, to perform the proximal anastomosis, allows avoidance of aortic clamp, to reduce the technical demand and the duration of this procedure. Cost and absence of long-term effectiveness of sutureless anastomotic device could be the limiting factors for its clinical application.
doi:10.1016/S1569-9293(03)00031-8
|
References
|
|---|
- Rutherfort RB. Options in the management of aortoiliac occlusive disease. Semin Vasc Surg. 1994;7:11–16[Medline]
- Criado E, Johnson GJ, Burnham SJ, Buehrer J, Keagy BA. Descending thoracic aorta to iliofemoral artery bypass as an alternative to aortoiliac reconstruction. J Vasc Surg. 1992;15:550–556[CrossRef][Medline]
- Berens ES, Herd JR. Laparoscopic vascular surgery: four case reports. J Vasc Surg. 1995;22:73–79[CrossRef][Medline]
- Dion YM, Katkouda N, Rouleau C, Aucoin A. Laparoscopy assisted aortofemoral bypass. Surg Laparosc Endosc Percutan Tech. 1993;3:425–429
- Jones DB, Thompson RW, Soper NJ, Olin JN, Rubin BG. Development and comparison of transperitoneal and retroperitoneal approaches to laparoscopic assisted aortofemoral bypass in a porcine model. J Vasc Surg. 1996;23:466–471[Medline]
- Hill AB, MacKenzie KS, Steinmetz OK, Fried GM. Videoendoscopic thoracic aorta to femoral artery bypass. A feasibility study in a canine model. J Vasc Surg. 1998;27:948–954[Medline]
- Noel AA, Gloviczki P, Young MM, Karnicki K, Deschamps C, Moir C. Videoendoscopic thoracic aorta to femoral artery bypass in the pig. J Surg Res. 2000;93:70–74[Medline]
- Riess F-C, Helmold H, Hilfer I, Bader R, Stripling J, Loewer F, Bleese N. Clinical experience with the CorLink device for proximal anastomosis of the saphenous vein to the aorta: a clinical, prospective and randomized study. Heart Surg Forum. 2002;5(4):345–353[Medline]
- Reichenspurner H, Damiano RJ, Mack M, Boehm DH, Gulbins H, Detter C, Meiser B, Ellgass R, Reichart B. Use of the voice-controlled and computer-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1999;118:11–16[Abstract/Free Full Text]
- Loulmet D, Carpentier A, D'Attellis N, Berrebi A, Cardon C, Ponzio O, Aupécle B, Relland J. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg. 1999;180:4–10
- Payr E. Beitrage zur technique der Blutgefass-und Nervennaht nebst Mittheilungen uber die Verwendung eines resorbirbaren Metalles in de Chirurgie. Arch Klein Chir. 1900;62:67–93
- Calafiore AM, Bar-El Y, Vitolla G, Di Giammarco G, Teodori G, Iaco AL, D'Alessandro S, Di Mauro M. Early clinical experience with a new sutureless anastomotic device for proximal anastomosis of the saphenous vein to the aorta. J Thorac Cardiovasc Surg. 2001;121:854–858[Abstract/Free Full Text]
- Tozzi P, Solem JO, Boumzebra D, Mucciolo A, Genton CY, Chaubert P, von Segesser LK. Is the GraftConnector a valid alternative to running suture in end-to-side coronary arteries anastomoses? Ann Thorac Surg. 2001;72(3):S999–S1003[Abstract/Free Full Text]
- Tozzi P, Corno AF, von Segesser LK. Sutureless coronary anastomoses: revival of old concepts. Eur J Cardiothorac Surg. 2002;22:565–570[Abstract/Free Full Text]
|
|
Top
Abstract
1. Introduction