Robotic Assisted Laparoscopic Aorto Bifemoral Bypass: Evaluation of Initial Learning Curve

Background: Despite improved technology for endovascular treatment of aorto iliac occlusive disease, aorto bifemoral bypass (ABF) continues to offer superior long term patency. In an effort to reduce the morbidity of surgical aorto bifemoral bypass, multiple minimally invasive techniques have been reported, including 1) laparoscopic dissection with mini laparotomy, 2) hand-assisted laparoscopic ABF, 3) completely laparoscopic ABF and 4) robotically assisted laparoscopic ABF. Because of the steep learning curve associated with minimally invasive aortic reconstruction, only a handful of dedicated centers have persevered in an attempt to develop a safe and reproducible surgical technique. The laparoscopic anastomosis requires a long period of dedicated laboratory practice and a steep learning curve. The DaVinci robot, however, allows reconstruction of a minimally invasive aortic anastomosis using standard vascular suture techniques with superior dexterity and visualization. We report our initial experience in the development of a minimally invasive surgical aortic reconstruction program.
Methods: After extensive time in the laboratory developing the surgical technique in human cadavers and a pig model, our team initiated a robotic vascular surgery program in 2007. A retrospective review of our initial six robotic assisted laparoscopic aorto bifemoral bypass cases was conducted. The aorta was exposed using the Stadler technique and the aortic anastomosis performed with the DaVinci robot. These results are compared to currently published reports and alternative methods of minimally invasive aortic reconstruction.
Results: From January 2007 to August 2007, six robotic assisted laparoscopic aorto bifemoral bypasses were performed. Three patients had prior abdominal surgical procedures. Four patients had prior endovascular or surgical aorto iliac reconstruction including one previous aorto iliac bypass. Operative time varied from 5 hours 26 minutes to 8 hours 12 minutes. Total clamp time, including the aortic and both femoral anastomoses ranged from 126 minutes to 167 minutes with a mean of 140 minutes. Estimated blood loss ranged from 300 ccs to 2,000 ccs with a mean of 850 ccs. Conversion with a short upper midline incision was required in one patient with an associated abdominal aortic aneurysm. Post operative length of stay ranged from 5 to 10 days with a median of 7 days. There was no operative mortality.
Conculsions: This report describes the learning curve which could be expected in a vascular surgery program dedicated to beginning minimally invasive aortic surgery. While several hundred cases of total laparoscopic aorto bifemoral bypass have been reported, only 40 cases of robotically assisted laparoscopic aorto bifemoral bypass have been published to date. The results of robotically assisted laparoscopic aorto bifemoral bypass are equivalent to other alternatives while allowing for a much shorter learning curve. Nevertheless, robotic surgery requires dedication and commitment. Using the technique described, minimally invasive aorto bifemoral bypass was accomplished in a safe and reliable manner despite prior vascular treatment. If a reliable minimally invasive aorto bifemoral procedure can be reproduced, patients will benefit from a superior procedure, encouraging treatment of Tasc B and C disease with surgical bypass.
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