Total robotic iliac aneurysm repair with preservation of the internal iliac artery using sutureless vascular anastomosis

Abstract

Objective Internal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments. Methods Between June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft. Results The median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m 2 (range, 23-26.4 kg/m 2 ). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs. Conclusions Total robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.

Robotic-assisted abdominal aortic surgery: evidence and techniques

“…Compared to these development, robotic-assisted surgeries could not be established in the vascular field. Initial case series published in the 2000s reported comparatively long operation and cross-clamping times and included only small numbers of patients [ 10 , 22 , 23 ]. At least, based on laparoscopic vascular surgery, a reproducible concept for RAAS could be developed regarding positioning, trocar placement, and transperitoneal aortic access [ 11 ].…”

Robot-Assisted Surgery of an Iliac Artery Aneurysm: A Case Report

“…In addition, the growing number of hybrid suites and new stent and prosthesis designs (e.g., self-anchoring) offer optimal conditions for the development of innovative vascular procedures involving robotic platforms. 4 Finally, a shorter postoperative length of stay compared with open surgical procedures can be expected due to rapid wound healing and faster mobilization with reduced access trauma. However, the country-specific minimum lengths of stay specified by the health insurance companies must be taken into account here.…”