The classic procedure for aortobifemoral bypass is open surgery. Laparoscopy has been accepted by several authors as a minimal invasive alternative for aortoiliac occlusive disease. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. Whatever the approach, the aortoprosthetic anastomosis is a major difficulty making those techniques unpopular despite obvious advantages for the patients. We report a clampless and sutureless approach for the proximal anastomosis of a totally retroperitoneal laparoscopic aortobifemoral bypass using an EndoVascular REtroperitoneoScopic Technique (EVREST). This approach was proposed to a 56-year-old man with severe aortoiliac occlusive disease. There was no indication for endovascular re-vascularization. The patient was placed in a 30 degrees right lateral decubitus position. The dissection of the retroperitoneal space was performed and the infrarenal aorta was exposed. A bifurcated graft was inserted into the retroperitoneal space. Under videoscopic control the prosthetic limbs were brought to the groins. The main body of the graft was connected on the left side of the aorta by an intra and extra aortic covered stent-graft. This connection was performed without the use of an aortic clamp and without suture. The femoral anastomoses were performed by classic open surgery.

The classic procedure for aortobifemoral bypass is open surgery. Since the first totally laparoscopic aortobifemoral bypass reported in 1997 by Yves-Marie Dion, laparoscopy has been accepted by several authors as a possible minimally invasive alternative for aorto-iliac occlusive disease. The transperitoneal left retrocolic and retrorenal ways are generally used. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. We report here a totally laparoscopic retroperitoneal approach to performing aortobifemoral bypass. This approach was proposed to a 51-year-old man with aorto-iliac occlusive disease. There was no indication for endovascular revascularization. The patient suffered from 10 metres of bilateral intermittent claudication and lower limb ulcers. During the surgical procedure our patient was placed in a 30-degree right lateral decubitus position. The optical system was first placed in an intra-abdominal position to check the positioning of the trocars in the left retroperitoneal space. The dissection of the retroperitoneal space was performed by CO2 insufflation and by blunt dissection using laparoscopic forceps. The infrarenal aorta was exposed and clamped by laparoscopic clamps. A bifurcated graft was sutured on the left-hand side of the aorta by a running suture. Both prosthetic limbs were tunnelized retroperitoneally to the groin under optical control. The femoral anastomoses were performed by classic open surgery.

A 21-year-old male patient presented with a typical middle aortic syndrome. Echography disclosed a severe narrowing of the lower thoracic aorta with parietal thickening. The isolated character of the lesion was confirmed by magnetic resonance imaging and aortography. The surgical cure was realized by a Dacron bypass between the upper thoracic descending aorta and the juxta-diaphragmatic thoracic aorta. Aortic biopsy confirmed Takayasu's disease. Postoperative course was uneventful with normalized blood pressure. The therapeutic options, surgery versus percutaneous dilatation and stent, are discussed.

EDITOR:Patients who have been treated with bleomycin should not receive high concentrations of oxygen during subsequent general anaesthesia as this can lead to respiratory failure [1,2]. Marzetti and colleagues described the conduct of general anaesthesia in two cases of testicular germ cell tumour following recent chemotherapy and highlighted the risk of neural injury related to cisplatin exposure [3]. Their patients also had received bleomycin as part of the chemotherapy but their general anaesthetic technique involved the use of 50% inspired oxygen. The risk of respiratory failure with general anaesthesia and high inspired oxygen in patients who have received bleomycin is not well known amongst anaesthetists; hence this communication which we hope will increase awareness of this hazard.Two major risk factors for the development of bleomycin-induced pulmonary damage related to hyperoxia exposure are evidence of pre-existing pulmonary damage from bleomycin and prior exposure to bleomycin within a 1-2-month period. Other risk factors for bleomycin-induced pulmonary damage are total dose of bleomycin Ͼ450 mg and a creatinine clearance Ͻ35 mL min Ϫ1 . Cisplatin, when used with bleomycin can increase the lung toxicity of bleomycin because it is nephrotoxic and can delay renal clearance of bleomycin [4]. The current recommendations are that patients with one or both major risk factors present should be maintained on the lowest F i O 2 to maintain S P O 2 Ͼ 90% [4,5].