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Recent studies have shown that fasting during the preoperative period for elective surgery induces a metabolic state that seems unfavorable for patients. Results from animal studies indicate that rapid depletion of liver glycogen before surgery leads to mobilization of muscle glycogen after surgery, in turn leading to reduced muscle strength. Depletion of liver glycogen also influences the function of the mononuclear phagocytic system (MPS), which is located predominantly in the liver. The MPS is essential in restricting endotoxin, which may translocate from the gut. In addition, surgery per se puts a substantial physical strain on the patient, and fasting may adversely affect the metabolic response to surgery. This paper presents experimental and clinical data that, when combined together, prove that fasting before surgery has adverse consequences for the patient.

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Objective The objective of this systematic review is to evaluate the results of clinical studies on laparoscopic surgery for aorto-iliac disease.Methods A systematic review of the literature from 1966 to September 2006 on laparoscopic and robotic vascular surgery was performed. Only patient series containing more than 5 cases were included. Operative, clamping and anastomosis times, conversion, mortality and morbidity and hospital stay were evaluated.Results Thirty studies were identified. These were all descriptive and included 9 comparative studies. Operative times varied widely, the shortest being for hand-assisted procedures (2.5-4 hours) and the longest for totally laparoscopic procedures (4 -6.5 hours). Clamping times were allϽ1 hour in hand-assisted procedures while in other techniques clamping times from 1-2.5 hours were seen. The conversion rate varied from Ͻ5% up to 16% in smaller series. The mortality rate was approximately 5% and frequently caused by cardiac ischemia. A variety of problems ranging from minor local wound problems to cardiopulmonary-and renal insufficiency, bleeding, ureter lesions and graft thrombosis were described. Mean hospital stay for nearly all procedures was Ͻ1 week.Conclusions Experience of laparoscopic surgery for aorto-iliac disease is still limited. Most study results are biased by patient selection. Only a few surgeons have mastered the required surgical technique and more data are needed to asses the clinical potential of this type of surgery, in comparison with the endovascular alternative. For wider implementation simplification of the surgical procedure seems necessary.

The following changes need to be implemented: On 2nd page, 3 rd paragraph, 3 rd sentence, add: ''and had preoperatively been diagnosed with either TASC (Trans-Atlantic Inter-society Consensus) type C or D lesions (Table 2)'' On same page and paragraph, after 4 th sentence insert: ''Pre-operative clinical condition was described using the American Society of Anesthesiologists classification (ASA-classification, Table 2).'' On same page 4th paragraph should read: ''Details of different surgical techniques have been described elsewhere [1, 3, 5, 8, 10, 11, 18]. We initially used a transabdominal approach with the ''apron technique'' as described by Dion et al. [10]. In this approach, a peritoneal ''flap'' is dissected laparoscopically and subsequently used to ''suspend'' the intestines onto the abdominal wall from inside the abdominal cavity with stitches, in order to keep a clear operative field. We also have used a retroperitoneal The online version of the original article can be found under

ePTFE sutures are least susceptible to robotic manipulations and are, therefore, to be considered as a material of first choice.

Experience of laparoscopic surgery for aorto-iliac disease is still limited. Most study results are biased by patient selection. Only a few surgeons have mastered the required surgical technique and more data are needed to asses the clinical potential of this type of surgery, in comparison with the endovascular alternative. For wider implementation simplification of the surgical procedure seems necessary.

Our initial experience with robotic assisted laparoscopic surgery (RALS) shows it is a feasible technique for aortoiliac bypass surgery. However, laparoscopic aortoiliac surgery demands considerable experience and operative times need to be reduced before this technique can be widely implemented.