Annals of Vascular Surgery
Volume 23, Issue 6 , Pages 717-721, November 2009

Laparoscopic Aortic Surgery in Obese Patients

Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, and Faculté de Médecine Paris-Ouest, René Descartes University, Paris, France

Article Outline

Background

Our objective was to demonstrate the feasibility of laparoscopic abdominal aortic aneurysm (AAA) repair in obese patients and to confirm advantages observed with laparoscopic techniques in other surgical specialties regarding pulmonary and parietal complications in this population.

Methods

Between November 2000 and December 2007 we performed 37 laparoscopic aortic reconstructions in obese patients (body mass index [BMI] > 30 kg/m2). Median BMI was 31.9 kg/m2 (range 30.1-40). Twenty-seven patients (73%) were operated for AAA and 10 (27%) for TASC C or D aortoiliac occlusive disease. Data were gathered prospectively and analyzed retrospectively.

Results

Aortic exposure was totally laparoscopic in 36 patients (97.3%). Median operative time was 290 min (range 160-480). Median duration of clamping was 77.5 min (range 40-105). Orotracheal extubation was possible before H24 for 35 patients (95%). Median lengths of intensive care unit stay and hospital stay were, respectively, 48 hr (range 12-624) and 8 days (range 4-35). One patient (2.7%) died postoperatively because of colonic ischemia. Five systemic postoperative complications were observed in 36 patients who survived (13.5%) including major nonlethal postoperative complications in two patients (pneumopathy and acute hemodynamic lung edema). All other patients had a fast recovery, with minimal wound discomfort and rapid return to general diet and ambulation, with a median follow-up of 21.5 months (range 1-78). One patient was lost. Complete recovery was observed in 35 other patients, and all grafts were patent at last follow-up. No graft infection was observed, and none of our patients presented incisional hernia.

Conclusion

Obesity is not an operative risk factor for laparoscopic aortic surgery. Our results confirm its feasibility and durability for this high-risk population. Laparoscopy should be considered as the technique of choice whenever direct AAA repair is planned in obese patients.

 

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Introduction 

Laparoscopic aortic surgery (LAS) is widely used in selected centers1, 2, 3, 4, 5, 6, 7 for both aortoiliac occlusive disease (AIOD)2, 3, 5, 6, 7 and abdominal aortic aneurysms (AAAs).1, 4, 5 Short- and mid-term results of LAS appear to be at least similar to those observed with conventional surgery.6, 8 The purpose of laparoscopy is to avoid large abdominal approaches with subsequent reduced operative trauma.

Obesity (body mass index [BMI] >30 kg/m2) is considered an operative risk factor in open general and/or aortic surgery. It is associated with major comorbidities such as coronaropathy9, 10 and severe respiratory insufficiency.11, 12 Intervention is technically challenging because of difficulties for exposition and access to abdominal organs.13 Early and late postoperative courses are worsened by pulmonary14, 15 and parietal16, 17 complications.

The aim of our study was to demonstrate the feasibility of LAS in obese patients and to discuss the advantages of laparoscopy in this subset of patients.

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Materials and Methods 

Surgical Technique 

Surgical techniques for LAS have been previously described.18, 19, 20 In obese patients, LAS involves the same principles as in other patients, with technical tricks to facilitate the procedures. Briefly, after insufflating a pneumoperitoneum through a Veress needle, the patient is placed in a right rotation of 70-80 degrees using an inflatable pillow (Pelvic-Tilt; O.R. Comfort, Glen Ridge, NJ) and rotation of the operative table. Three different approaches to the abdominal aorta were used: transperitoneal left retrocolic (TPRC),18 transperitoneal left retrorenal (TPRR),19 and retroperitoneoscopic (RP).20 Technical tricks used in obese patients were (1) the choice of TPRC if perirenal fat was thick, (2) the positioning of operating trocars more laterally with TPRR and TPRC, and (3) use of longer instruments.

Clinical Experience 

Between November 2000 and December 2007 we performed 37 total laparoscopic aortic reconstructions in obese patients. This represents 10.5% of the 354 laparoscopic reconstructions performed during the same period in our institution. All patients gave informed consent before the procedures. Data were collected prospectively and analyzed retrospectively.

Our study included 33 men and four women, who ranged in age from 46 to 82 years (median 69). Median BMI was 31.9 kg/m2 (range 30.1-40). Twenty-seven patients (73%) had an AAA repair and 10 (27%) were operated for Trans-Atlantic Inter-Society Consensus (TASC) C or D AIOD.

Sixteen (43%) patients had previous history of abdominal surgery including left colectomy (n = 3), cholecystectomy (n = 2), and appendectomy (n = 2). Preoperatively, all patients underwent computed tomography (CT) to assess the extent of aortic or iliac calcifications and the presence of possible venous anomalies. In addition, all patients underwent preoperative stress echocardiography and pulmonary, hepatic, and renal function tests. Median forced expiratory volume in 1 sec (FEV1) and left ventricular ejection fraction (LVEF) were, respectively, 2.70 L (range 1.23-3.66) and 60% (range 47-75%). Eleven patients (30%) with abnormal stress echocardiograms underwent coronarography, leading to one (2.7%) preoperative revascularization by coronary angioplasty. Other patients were treated medically. Disease was classified in accordance with the American Society of Anesthesiologists’ (ASA) classification. Sixteen patients (43%) were classified ASA II, 20 patients (54%) were ASA III, and one patient (3%) was ASA IV. Patients with ASA class V and/or significantly persistent abnormal cardiac, hepatic, and renal test results were not offered a laparoscopic procedure. Severe chronic pulmonary disease was not a contraindication for laparoscopic aortic reconstruction. Preoperative data are summarized in Table I.

Table I. Preoperative data
Mean age (years)69 (46-82)
BMI (kg/m2)a31.9 (30.1 –40)
ASA class II16 (43%)
ASA class III20 (54%)
ASA class IV1 (3%)
Tobacco use31 (84%)
Hypertension26 (70%)
Dyslipidemia18 (49%)
Diabetes12 (32%)
LVEFa60% (47-75)
FEV1a2.7 L (1.23 –3.39)
AIOD10 (27%)
AAA27 (73%)
Previous abdominal surgery16 (43%)

aMedian.

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Results 

Aortic exposure was totally laparoscopic in 36 cases (97.3%). One conversion was needed because of limited exposure through RP. Median operative time was 290 min (range 160-480) and duration between incision and clamping was 130 min (range 40-265). The laparoscopic approach to the aorta was obtained through TPRC, TPRR, and RP in 17 (46%), 17 (46%), and three (8%) patients, respectively. Median duration of infrarenal clamping was 77.5 min (range 40-105). Six patients (16%) underwent combined procedures, including inferior mesenteric artery reimplantation (n = 1), infrainguinal bypass (n = 1), superficial femoral artery angioplasty (n = 1), iliofemoral endarterectomy (n = 1), femorofemoral bypass (n = 1), and carotid bypass (n = 1). Median blood loss was 1,000 mL (range 200-4,000). Median body temperature at the end of the operation was 36.8°C (range 33.8-38.5°C). Orotracheal extubation was possible at the end of the intervention for 19 patients (51.4%), between the end of the intervention and H6 for 13 patients (35.1%), and between 6 hr and 24 hr for three patients (8.1%).

One 82-year-old man (2.7%) died at day 2 from a colonic ischemia. Major nonlethal complications were observed in two patients (5.4%). One ASA IV patient presented an early pneumopathy due to Escherichia coli, which necessitated prolonged mechanical ventilation. Another patient presented acute hemodynamic lung edema due to a postoperative silent myocardial infarction, which necessitated prolonged mechanical ventilation and tracheotomy. The further postoperative course of these patients was uneventful, with return to baseline. Three patients experienced mild or moderate systemic complications (8.1%), including transient renal insufficiency (n = 1), localized lung atelectasia (n = 1), and angina pectoris (n = 1). Two patients had local nonvascular complications (5.4%) including cholecystitis necessitating a cholecystectomy at day 7 (n = 1) and arm lymphangitis (n = 1). Apart from these complications, patients had a fast recovery with minimal wound discomfort. Median time to resumption of diet and ambulation were, respectively, 1.5 (range 1-13) and 3 (range 2-26) days. Median lengths of intensive care unit stay and hospital stay were, respectively, 48 hr (range 12-624) and 8 days (range 4-35). Peri- and postoperative data are summarized in table II.

Table II. Peri- and postoperative data
Operative time (min)a290 (160-480)
Clamping time (min)a77.5 (40-105)
Approach to the aorta
Prerenal17 (46%)
Retrorenal17 (46%)
Retroperitoneal3 (8%)
Blood loss (mL)a1,000 (200-4,000)
Temperature at the end of intervention (°C)a36.8 (33.8-38.5)
Postoperative stay (days)a8 (4-35)
Intensive care unit stay (hr)a48 (12-624)
Time to ambulation (days)a3 (2-26)
Time to general diet (days)a1.5 (1-13)

aMedian.

With a median follow-up of 21.5 months (range 1-78), one patient was lost at 2 years without anomalies. Complete recovery was observed in other patients, and all grafts were patent without morphological anomalies (duplex ultrasonography or CT-scan control). There was no graft infection. No patient presented incisional hernia.

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Discussion 

This study demonstrates that LAS is feasible and worthwhile in obese patients. Obesity is considered an important operative risk factor for conventional abdominal surgery. Several studies have demonstrated that obesity is associated with an increased incidence of diabetes,21 hypertension,22 coronaropathy,9, 10 and chronic restrictive ventilatory dysfunction.11, 12 We also observed these comorbidities in our series (Table I). As reported, they can lead to complications during the postoperative course, especially acute respiratory failure. The capacity of ventilation of obese patients is reduced after abdominal interventions through transperitoneal midline incision,23 and the benefit of transversal or retroperitoneal incisions remains controversial.23, 24, 25, 26, 27

The first advantage of laparoscopy is to reduce the operative trauma of open surgery by avoiding large abdominal incisions. Several studies have reported advantages of laparoscopy in obese patients, especially regarding bariatric surgery,28, 29 appendectomy,30 cholecystectomy,31 colectomy,32 and hysterectomy.33 In the early postoperative course, laparoscopy is associated with fewer parietal, pulmonary, and infectious complications. On long-term follow-up, incidence of incisional hernias is significantly lower. These advantages seem valid in LAS. In our series, postoperative morbidity and mortality rates were acceptable and close to figures previously reported in major series (Table III). Unlike open surgery, there were no complications related to difficult exposure of retroperitoneal vessels, especially injuries and narrowing during clamping and anastomoses. Our rate of pulmonary complications (5.4%) was also comparable to those observed in other important series of LAS (Table III) and rather low compared with open surgery. As reported in prospective studies, early postoperative pulmonary complication rates were 7-28% for midline longitudinal incisions,24, 25, 26, 27 20% for transversal incisions,25 and 2-16% for retroperitoneal incisions.24, 26, 27 The benefit of laparoscopy could relate to several factors including avoidance of large abdominal incision, reduced pain, quicker gastrointestinal motility, and faster postoperative physiotherapy (Fig. 1). Otherwise, other advantages of LAS are maintained in obese patients, such as postoperative normothermia, which is important in vascular surgery considering the risk of coagulopathy and myocardial events due to hypothermia. On follow-up, a major advantage of LAS in obese patients is the lack of incisional hernia. In a recent review, Takagi et al.34 demonstrated that the rates of postoperative incisional hernia in patients with AAA and AIOD repair through midline incision were, respectively, 21.0% and 9.8%. Moreover, several studies have found that obesity was associated with an increased incidence of this risk even when retroperitoneal incisions were used.17 Also, it has been reported that laparotomy was the main cause of late rehospitalization after open AAA repair.35

Table III. Results of previously reported series of totally laparoscopic abdominal aortic reconstructions (>40 patients)

The second main advantage of LAS in obese patients is from a technical point of view. Laparoscopy allows large exposure of the operative field. This is the main drawback of open aortic surgery, with difficulties in accessing the abdominal aorta and obtaining a stable exposure.13 Moreover, in obese patients, there is the risk of injuries to organs excluded from the visual field, especially if a short laparotomy is used.36 Technical tricks are useful to limit the technical challenge of LAS in obese patients. The choice of laparoscopic approach is essential to avoid pitfalls. The larger laparoscopic exposure is obtained via a TPRR.19 This approach uses a complete right mediovisceral rotation and allows large exposure of the abdominal aorta. TPRR is contraindicated when the left renal vein is retroaortic or in cases of perisplenic adherences. In obese patients, TPRR is challenging when perirenal fat is very thick. In these cases, the operator is hampered by the interaction between the instruments and the left kidney. A technical trick is to move the trocar line laterally on the left. If TPRR is unusable, TPRC can be used. It allows large exposure, but its drawback is the left renal vein, which crosses the juxtarenal aorta and hampers the exposure.18 In obese patients, TPRC with the left kidney in place allows a larger working space for the operator. The RP approach is interesting in obese patients with severe respiratory insufficiency. However, the working space is reduced, internally behind the retroperitoneal fat and externally for the placement of trocars.20 We used it three times in three cases but needed one conversion to open repair. The transperitoneal direct approach seems inappropriate for LAS in obese patients because of transverse and left mesocolon thickness, which hampers exposure of the infrarenal aorta.

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Conclusion 

Obesity is not an operative risk factor for LAS. Benefits of laparoscopy that have been reported for obese patients in other surgical specialties are also valid in aortic surgery. The postoperative course is not worsened by unavoidable comorbidities in this subset. Our results confirm the feasibility and midterm durability of LAS despite a higher technical challenge. Laparoscopy should be considered as the technique of choice whenever direct AAA repair is planned in obese patients.

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 Presented at the Twenty-third Annual Congress of the French Society of Vascular Surgery, Strasbourg, France, June 14-17, 2008.

PII: S0890-5096(09)00036-3

doi:10.1016/j.avsg.2009.01.003

Annals of Vascular Surgery
Volume 23, Issue 6 , Pages 717-721, November 2009

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