Gefässchirurgie 2002 · 7: 143–147 DOI 10.1007/s00772-002-0223-x

Übersicht W. D.Turnipseed University of Wisconsin Medical School,Madison/WI

Minimal incision aortic surgery: a competitive alternative to endovascular and standard open aortic repair

Abstract Endovascular repair of aortic aneurysms (EVAR) has established an important role in the practice of vascular surgery.However, currently available devices have demonstrated unpredictable patterns of clinical and mechanical failure, raising valid concern about long-term durability.Alternative less invasive modifications of standard open repair,such as minimal incision aortic surgery (MIAS), provide important treatment alternatives for younger healthy patients and high-risk patients with aneurysms that do not qualify for EVAR because of anatomic limitations.MIAS is cost efficient, durable, requires no costly equipment, and can be performed by currently trained vascular surgeons. Keywords

Purpose With the emergence of endoaortic repair alternatives for the treatment of abdominal aneurysms, surgeons have had to determine whether outcome quality (see 1) and cost efficiency (see 2) can be improved by making open aortic procedures less invasive. The major arguments for expansion and development of catheter-based aneurysm repair have been phase I and II clinical trials performed in the United States and Europe, which demonstrate morbidity and mortality outcomes that rival those accepted for standard open aortic surgery [1, 2]. Of concern, however, is the fact that midterm performance analysis of endoaortic surgery suggests that there are predictable patterns of device failure, which may not become apparent for years after implantation [3, 4, 5, 6, 7].

Even the most enthusiastic proponents of endovascular therapy have had to emphasize the need for life-long CAT scan surveillance, and to suggest that patients currently treated with endografts should be more judiciously selected. Uncertainty regarding the durability of currently available aortic devices and concern regarding clinical access to devices which periodically are pulled from the shelf because of structural failures have encouraged some surgeons to look at alternative approaches to aortic exposure and repair, and to determine whether

© Springer-Verlag 2002 William D.Turnipseed M.D., University of Wisconsin Medical School, 600 Highland Avenue, STE.G5/327, Madison/WI 53792 e-mail: [email protected]

Minimal incision aortic surgery (MIAS) · Abdominal aortic aneurysm · Endovascular repair of aortic aneurysms (EVAR) · Standard open aortic repair · Aortoiliac occlusive disease

Fig.1  Equipment required for MIAS: Fish closure pad, long needle holder and knot cincher, Cosgrove vascular clamps Gefässchirurgie 3•2002

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Gefässchirurgie 2002 · 7: 143–147 DOI 10.1007/s00772-002-0223-x

Übersicht

W. D.Turnipseed

die Aorta.Die Freilegung der Aorta und ihrer Seitenäste geschieht durch langstieliges Instrumentarium und Einsatz des Elektrokauters.Zur Darstellung weiterer Abschnitte der Aorta bewegt man die Bauchwand mit dem Bauchdeckenhalter nach proximal oder distal. Zur Kompression der Aorta werden die großen Cosgrove-Gefäßklemmen benutzt, die kleinen setzt man für die Iliakalarterien ein.Damit die Klemmen nicht abrutschen, müssen die Gefäße in einem Winkel von 300° freigelegt sein.Nach Antikoagulanzienbehandlung werden die Aorta und ihre Seitenäste abgeklemmt,das Aneurysma eröffnet und die Thromben darin entfernt.Nach Entlastung des Aneurysmas ist genügend Platz zur Arterienrekonstruktion vorhanden. Ein kleiner Schmetterlingshaken wird in den Aneurysmasack gebracht, um dorsal abgehende Lumbalarterien darzustellen.Diese können einfach mit einem Castro-Viejo-Nadelhalter ligiert werden, der dem Chirurgen bei eingeengten Verhältnissen eine einfache Nadelführung ohne extreme Handgelenkbewegungen erlaubt.Wenn Anastomosen distal der Aa.iliacae communes notwendig sind, werden Gefäßprothesen durch einen Tunnel in die Leiste geführt und die distalen Anastomosen auf der Höhe der A.femoralis communis angelegt. Es wird nicht routinemäßig eine Epiduralanästhesie durchgeführt, da dadurch die Frühmobilisierung des Patienten und die Entfernung von Foley-Kathetern verzögert würden.Gegen Ende des Eingriffs wird 0,5%iges Marcaine in den Inzisionsbereich injiziert und zur Schmerzlinderung postoperativ über 24–48 h eine i.v.-PCA-Anästhesie („patient controlled anesthesia“, PCA) eingesetzt.Die Patienten werdem im OP extubiert, die Nasensonde wird im Aufwachraum entfernt, und einen Tag nach der Operation dürfen die Patienten trinken.Am 2.oder 3.Tag wird auf normale Kost umgestellt.Durchschnittlich dauert der Krankenhausaufenthalt in einem unkomplizierten Fall bei Anwendung der genannten Technik 3 Tage. Seit 5 Jahren wird die MIAS-Technik als Standardverfahren für die elektive Operation von Patienten mit infrarenalem Aortenaneurysma und/oder aortoiliakaler Verschlusskrankheit eingesetzt.Bei den meisten jüngeren Patienten (<65 Jahre) und bei Patienten mit hohem Risiko aufgrund ihres Krankheitsbilds oder ihrer Gefäßmorphologie wird der Methode der Vorzug vor der endoaortalen Behandlung gegeben.Zu den Hochrisikopatienten gehören auch Patienten mit schwerer Pulmonalinsuffizienz, instabiler Herzerkrankung oder einem schwierig zu operierenden

Minimal-invasive Aortenchirurgie – eine konkurrenzfähige Alternative zur endovaskulären und konventionellen offenen Chirurgie der Aorta Zusammenfassung Ziel. Ziel des Beitrags ist die Vorstellung eines chirurgischen Verfahrens zur Behandlung der Aorta abdominalis mittels einer minimalen abdominellen Inzision („minimal incision aortic surgery“,MIAS).Dabei sind die erforderlichen technischen Fähigkeiten und Ausstattung sowie die Dauer geringer als bei der laparoskopischen Chirurgie.Das Hauptproblem bei der minimalen abdominellen Inzision besteht in der Freihaltung des Operationsgebiets.Dazu sind nur wenige einfache chirurgische Instrumente erforderlich. ◗ Der Bookwalter-Bauchdeckenhalter

ermöglicht die erforderliche Spreizung der Bauchdecke. ◗ Durch Cosgrove-Gefäßklemmen mit ihrem anpassungsfähigen Stiel können die Aorta und ihre Seitenäste atraumatisch komprimiert werden, ohne im Operationsgebiet zu stören. ◗ Mit dem Fish-Wundverschlussbauchtuch, einem halbstarren Gummituch, als Rückhaltewand kann der Dünndarm aus dem Operationsgebiet gehalten werden. ◗ Langstielige Instrumente einschließlich eines Castro-Viejo-Nadelhalters und einer Knüpfzange ermöglichen das Operieren auf der Ebene der Bauchdecke oder darüber. Methode. Wir setzen in unserer Praxis eine kleine mediane periumbilikale Inzision (<10 cm lang).So können die Aorta infrarenalis und die proximalen Aa.iliacae communes dargestellt werden.Die mediane Schnittführung erlaubt bei Bedarf eine einfache Erweiterung des Operationsgebiets. Die linke Hand wird in die Bauchhöhle eingeführt und der Dünndarmanteil auf die rechte Seite der Aorta gebracht.Das FishWundverschlussbauchtuch wird aufgerollt und rechts neben die Aorta in die Bauchhöhle eingebracht.Dort lässt man es sich senkrecht entrollen, wodurch es wie eine halbstarre Rückhaltewand fungiert. Der Bookwalter-Bauchdeckenhalter wird dann in seiner Position mithilfe des kleinen flachen Metallrings und der bei 2,5,8 und 11 Uhr gesetzten Valven fixiert.So erhält man freie Sicht auf den Retroperitonealraum und

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Turnipseed · Minimal incision aortic surgery: a competitive alternative to endovascular and standard open aortic repair

Abdomen.Ausschlusskriterien liegen vor bei rupturierten oder pararenalen Aneurysmen und Patienten, bei denen gleichzeitig eine Nieren- oder Mesenterialarterienrekonstruktion in Betracht kommt. Ergebnisse. Die letzten 100 in unserem Krankenhaus mit MIAS behandelten Patienten wurden mit den Ergebnissen von Patienten nach konventioneller offener oder endovaskulärer Aortenchirurgie („endovascular repair of aortic aneurysms“,EVAR) in der gleichen Zeit verglichen. Im MIAS-Kollektiv wurden Rekonstruktionen mit Rohrprothesen in 65% der Fälle durchgeführt, im konventionellen Kollektiv in 70%.Bei endovaskulärem Vorgehen wurden immer Bifurkationsprothesen eingesetzt. Beim MIAS-Verfahren wurden Bifurkationsprothesen routinemäßig mit den Aa.femorales communes anastomosiert, dagegen nur in 14% der Fälle konventioneller offener Chirurgie. Die OP-Zeit war nicht signifikant unterschiedlich bei bei MIAS, konventioneller offener Chirurgie und EVAR (157±37 vs.190±64 vs.257±50).Die Gesamtkosten pro Patient lagen bei MIAS niedriger als bei den Vergleichsmethoden. Schlussfolgerungen. Bis zum eindeutigen Nachweis der Dauerhaftigkeit endoaortaler Rekonstruktionsverfahren ist es im Interesse des Patienten, dass alternative weniger invasive Verfahren zur Behandlung des Bauchaortenaneurysmas und der aortalen Verschlusskrankheit zur Verfügung stehen.Vorteil des MIAS-Verfahrens sind der Verzicht auf laparoskopische Ausstattung und Erfahrung, das leichtere Anlegen von Anastomosen und die kürzere OP-Zeit im Vergleich zu videoassistierten Techniken. Gegenüber der endovaskulären Gefäßrekonstruktion liegt der Vorteil darin, dass weniger Patienten aufgrund ihrer Gefäßmorphologie oder der begrenzten Apparateverfügbarkeit abgelehnt werden sowie weder aufwendige Katheter- noch teure bildgebende Verfahren erforderlich sind.Im Vergleich zur konventionellen Aortenrekonstruktion werden zwar die Morbidität und die Dauer des Krankenhausaufenthalts durch weniger invasive Verfahren verringert, nicht jedoch die postoperative Mortalitätsrate. Schlüsselwörter Minimale abdominelle Inzision Bauchaortenaneurysma · Endovaskuläre Aortenchirurgie ·Konventionelle offene Aortenchirurgie · Aortoiliakale Verschlusskrankheit

Übersicht Turnipseed · Minimal incision aortic surgery: a competitive alternative to endovascular and standard open aortic repair

Methods

Table 1

Clinical outcome: MIAS vs standard open and endovascular aortic repair (University of Wisconsin)

Intraoperative O.R. time (min) I.V. fluid (cc) Transfusion (units) Postoperative ICU stay (days) Gen. diet (days)a Total loss (days)a Morbidity (%) Mortality (%)

MIAS

Standard open repair

EVAR

157±37 4375±1583 1.1±1.3

200±44 5304±2433 1.7±2.0

257±50 No data 1. 1.5

1.5±1.2 3.4±1.2 (2.0) 4.8±1.4 (3.0) 15 1.3b

1.8±1.5 5.4±4.7 (4.0) 7.7±3.4 (5.8) 26 2.5b

1.0±1.0 2.0±1.5 3.0±1.3 (2.0) 16 3.0

ap<0.001. bMyocardial infarct. ()Uncomplicated recovery.

clinical and economic benefit can be achieved with such techniques. One innovative concept has been laparoscopically assisted aortic surgery [8, 9, 10, 11, 12].Video-assisted techniques in general surgery have rapidly developed because of electrocautery and autosuture devices, which have enabled effective hemostasis and the ability to perform gastrointestinal anastomoses. Unfortunately, laparoscopic techniques applied to abdominal vascular surgery have been less effective because dependable autosuture devices for performing aortic vascular anastomoses have not yet been developed. This means that intraperitoneal hand-sewn anastomoses performed through laparoscopes require the highest level of technical skills to complete. The purpose of this article is to suggest that small abdominal incisions can be used for direct repair of the abdominal aorta, eliminating the technical skills, equipment, and the amount of time required for laparoscopically assisted surgery [13, 14]. The major problem with a small abdominal incision is maintaining an uncluttered surgical field within which to work. A very simple collection of surgical tools makes the minimal incision aortic approach possible. ◗ The Bookwalter retractor allows for adequate retraction of the abdominal wall without vertical clutter at the wound margins.

◗ Cosgrove vascular clamps, which have a malleable stem, allow for atraumatic compression of the aorta and its branch vessels without vertical clutter in the surgical wound. ◗ The Fish abdominal closure pad is a semirigid rubber sheet which can be used as a retaining wall to keep small bowel from entering the surgical field (Fig. 1). ◗ Long instrumentation including a Castro Viejo needle holder and knot cincher allows the surgeon to work at or above the level of the abdominal wall.

The minimal incision or minilaparotomy technique employed in our practice utilizes a small midline, periumbilical incision (<10 cm in length) (Fig. 2). This small incision is adequate for exposure of the infrarenal aorta and proximal common iliac arteries. Use of the midline incision offers the surgeon flexibility to easily expand the surgical field should greater exposure be required. After making the small midline incision, the procedure is done in the following manner. The left hand is inserted into the abdominal cavity and the small bowel finger manipulated to the right of the abdominal aorta. The Fish abdominal closure pad is then scrolled and inserted into the abdomen to the right of the aorta, then allowed to expand vertically acting as a semirigid retaining wall (Fig. 3). The Bookwalter retractor is then fixed into place using the small, flat, metal ring and speculum retractors are placed at 2, 5, 8, and 11 o'clock positions. This provides an unobstructed view of the retroperitoneum and underlying aorta (Fig. 4). Long instrumentation and electrocautery is used for dissection of retroperitoneal tissues from the aorta and its branch vessels. The abdominal incision can be moved cephalad and distally to facilitate exposure of the aortic neck and bifurcation, respectively, by moving the abdominal wall with the retractor. The Cos-

Fig.2  Inverted question mark incision is preferred for infrarenal aneurysm repair when aneurysm is limited to the abdominal aorta. Upright question mark incision is preferred when aneurysm or occlusive disease involves the iliac arteries Gefässchirurgie 3•2002

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Übersicht Turnipseed · Minimal incision aortic surgery: a competitive alternative to endovascular and standard open aortic repair

Table 2

Fiscal analysis (University of Wisconsin)

O.R. cost I.C.U. cost Total hospital cost Total reimbursement Net revenue

MIAS [US-$]

Standard open repair [US-$]

EVAR [US-$]

3,068 3,134 12,585 21,030 +8,445

3,805 3,132 18,445 23,434 +4,989

24,563 1,256 32,040 24,777 –7,263

grove vascular clamps come in two sizes, the larger of which is designed for compression of the aortic neck, while the smaller clamps are very useful in controlling the iliac arteries. It is important to dissect approximately 300° of circumference of the aorta and the iliac arteries in order to prevent these clamps from slipping. Once the patient has been anticoagulated, the aorta and its branch vessels are cross-clamped, the aneurysm is opened, and its clotted content removed. After the aneurysm is decompressed, there is plenty of room in which to work and complete the arterial reconstruction. A small butterfly retractor placed in the aneurysm sac will expose back bleeding lumbar vessels on the posterior wall of the artery.These can be simply ligated using a long Castro Viejo needle holder. This needle holder is preferred because it allows for easy manipulation of needle angles in a small space without the surgeon needing to use exaggerated wrist motions. When complex iliac disease in the pelvis is encountered requiring anastomoses below the common iliac arteries, graft limbs are tunneled into the groin and distal anastomoses performed at the common femoral level. Epidural anesthesia is not routinely used because it restricts early patient mobility and prolongs removal of Foley catheters. At the end of the case, 0.5% Marcaine is injected into the abdominal incision and intravenous PCA anesthesia is used for 24–48 h postoperatively for pain control. Patients are extubated in the operating room, nasogastric tubes removed in the recovery room, and patients are started on PO fluids the 1st day after surgery. Regular diets are started on the 2nd or 3rd day. The average hospital length of stay for uncomplicated patients using this technique is 3 days.

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Over the past 5 years, the MIAS technique has been used as the standard procedure for elective treatment of patients with infrarenal aortic aneurysms and/or aortoiliac occlusive disease. This approach is preferred over endoaortic repair for most younger patients (<65 years) and for high-risk patients who are poor candidates for endograft repair because of disease configuration or vessel morphology. The definition of high risk includes patients with severe pulmonary insufficiency, unstable car-

Fig.3  Fish closure pad reinforced by speculum retractors keeps small bowel out of the surgical field

Fig.4  Surgical setup demonstrating MIAS aneurysm repair

diac disease, or a surgically hostile abdomen. Exclusion criteria include ruptured aneurysms, pararenal aneurysms, and patients who might require concomitant renal or mesenteric artery reconstruction. This technique is not very practical in the very obese patient.

Results The outcomes of the last 100 patients treated with minimal incision aortic surgery (MIAS) were compared with outcomes for patients treated by standard open and endovascular aortic repair (EVAR) during the same time period at our hospital. Males were prevalent in all groups (72% vs 66% vs 68%). Tube graft reconstructions were performed in 65% of the MIAS group and in 70% of the standard open repair group. Bifurcated grafts were used in all endovascular cases. When bifurcated grafts were required for open repairs, the common femoral arteries were targeted for distal anastomoses routinely in the MIAS procedure, but in only 14% of the standard open repairs. Distal anas-

Übersicht Turnipseed · Minimal incision aortic surgery: a competitive alternative to endovascular and standard open aortic repair

tomoses beyond the level of the common iliac artery origin are difficult to perform using the minilaparotomy technique. Minor groin wound complications developed in two MIAS, two standard aortofemoral bypass grafts, and three patients with EVAR. There was no significant difference in operating room time (min) for MIAS, standard open repair, or EVAR (157±37 vs 190±64 vs 257±50). Furthermore, there was no significant difference in intraoperative fluid use or transfusion requirements between MIAS and standard open repair. Autotransfusion was used in MIAS and standard aortic surgery. Intraoperative fluid administration varied considerably according to anesthesia staff and did not necessarily reflect physiologic need.When MIAS and EVAR were compared against standard open repair, ICU stay, return to general dietary feeding, hospital length of stay, and postoperative morbidity were significantly lower for MIAS and EVAR. In contrast, mortality rates were comparable for all three procedures. Total cost per patient was lower for MIAS than for standard aortic repair or EVAR.When compared to standard open repair, MIAS achieved cost efficiency because of reduced ICU and hospital length of stay.More dramatic cost savings were achieved with MIAS when compared to EVAR despite comparable reductions in ICU stay and hospital length of stay. These differences are explained on the basis of the endograft and device delivery systems costs inherent with catheter-based procedures.

Conclusion Although there is little question that endovascular stent grafts will prevail as an option for repair of aortic aneurysms, midterm performance standards have not met expectation and give rise to concern about the durability of currently available device technology. Until longterm efficiency and durability of endoaortic repair techniques can be clearly established, it would seem logical that an array of alternative less invasive procedures for treatment of abdominal aneurysm and aortic occlusive disease would be in the patient's best interest. Currently the major advantages MIAS has over video-assisted techniques are that laparoscopic skills and equipment are not required, anastomoses are easier to perform, and surgical times are significantly shorter. The major advantages of MIAS procedures over endovascular stent graft repair are that fewer patients are rejected because of vessel morphology or limited device availability, that advanced catheter management skills as well as expensive imaging and device delivery accessories are not required, and that less economic stress is exerted on hospital resources. Furthermore, longterm postoperative CAT surveillance for MIAS repairs is not indicated. When compared to standard aortic repair, it appears that less invasive alternatives including laparoscopically assisted techniques, stent endografts, and minimal abdominal exposure procedures reduce morbidity and shorten hospital stay, but ironically none of them have successfully reduced postoperative mortality rates.

3. Bush RL, Lumsden AB, Dodson TF (2001) Midterm results after endovascular repair of the abdominal aortic aneurysm.J Vasc Surg 33/2: 70–76 4. Holzenbein TJ, Kretschmer G,Thurnher S (2001) Midterm durability of abdominal aortic aneurysm endograft repair: A word of caution. J Vasc Surg 33/2: 46–54 5. Beebe HG, Cronenwett JL, Katzen BT (2001) Results of an aortic endograft trial: Impact of device failure beyond 12 months.J Vasc Surg 33/2: 55–63 6. Moore WS, Brewster DC, Bernhard VM (2001) Aorto-uni-iliac endograft for complex aortoiliac aneueyrms compared with tube-bifurcation endografts: Results of the EVT/Guidant trails. J Vasc Surg 33/2: 11–20 7. Makaroun MS (2001) The Ancure endografting system: An update.J Vasc Surg 33/2: 129–134 8. Kline RG, D'Angelo AJ, Chen MH, Halpern VJ, Cohen JR (1998) Laparoscopically assisted abdominal aortic aneurysm repair: first 20 cases.J Vasc Surg 27: 81–7 9. Castronuovo JJ, James KV, Resnikoff M, McLean ER, Edoga JK (2000) Laparoscopicassisted abdominal aortic aneurysmectomy. J Vasc Surg 32: 224–33 10. Edoga JK, Asgarian K, Singh D et al.(1998) Laparoscopic surgery for abdominal aortic aneurysms.Surg Endosc 12: 1064–1072 11. Dion YM, Gracia CR (1997) A new technique for laparoscopic aortobifemoral grafting in occlusive aortoiliac disease.J Vasc Surg 26: 685–692 12. Alimi YS, Hartung O,Valerio N (2001) Laparoscopic aortoiliac surgery for aneurysm and occlusive disease: When should a minilaparotomy be performed? J Vasc Surg 33/3: 469–480

Bibliography 1. Zarins CK,White RA, Schwarten D et al.(1999) AneuRx stent graft vs.open surgical repair of abdominal aortic aneurysms: multicenter prospective clinical trial (see comments). J Vasc Surg 29: 292–305 2. Moore WS, Rutherford RB (1996) Transfemoral endovascular repair of abdominal aortic aneurysm: results of the North American EVT phase 1 trial.EVT Investigators.J Vasc Surg 23: 543–53

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