Laparoscopie pour AAA:
État de l’art
Marc Coggia
Service de Chirurgie Vasculaire
CHU Ambroise Paré, Boulogne-Billancourt
Collège Français de Chirurgie Vasculaire, Paris, 15 mai 2009
2001: Coelioscopie / AAA sous-rénaux
(Y.M. Dion / J Vasc Surg 2001;33:181-5)
January 2001 • Volume 33 • Number 1
Case Reports
Totally laparoscopic abdominal aortic aneurysm repair
Yves Marie Dion, Carlos R. Gracia, Hassen Ben El Kadi
Discussion
TOP
The introduction of laparoscopy in general surgery for procedures like hernia repair, cholecystectomy, and
fundoplication was associated with less early postoperative pain and disability and an earlier return to
full activity.4,13,14 Similar advantages are expected for patients who undergo AAA repair.
Recent studies6,7,15 confirmed that laparoscopic AAA repair is a feasible technique. The studies also
suggest that the benefits of laparoscopy seen in general surgery could be translated to AAA repair.
Among the various approaches currently described (ie, transperitoneal vs retroperitoneal, AAA exclusion
vs AAA endoaneurysmorrhaphy), we believe that the peritoneal apron technique, which provides an
adequate exposure to the aorta with no intrusion of any peritoneal organ in the operative field,
coupled with endoaneurysmorrhaphy, is the technique of choice, after our studying of animals and
humans.5,10,16
2004:Coelioscopie / AAA sous-rénaux
(M. Coggia / J Vasc Surg 2004;40:448-454)
November 2004 • Volume 40 • Number 3
Clinical research study
Total laparoscopic infrarenal aortic aneurysm repair:
Preliminary results
Marc Coggia, Isabelle Javerliat, Isabelle Di Centa, Giovanni Colacchio, Pierre Cerceau, Michel Kitzis, Olivier
Goëau-Brissonnière
Discussion
TOP
Laparoscopic treatment of infrarenal aortic aneurysms has been recently reported.10-18 It appears to be a
reproducible technique for dissection. Previously described techniques of laparoscopic AAA repair
have been performed either in an assisted fashion10, 12-15, 17, 18 or with aneurysm exclusion.11,14
However, exclusion is not a definitive repair because of the persistent flow in the aneurysmal sac in
about 4% to 7%, with a possible progression to rupture.19 Only 1 case of laparoscopic AAA repair
was performed according to the criterion standard endoaneurysmorrhaphy.16
This short series demonstrates that total laparoscopic AAA repair is feasible with acceptable short-term
outcomes. Our transperitoneal laparoscopic approach allows a stable aortic exposure during the
performance of endoaneurysmorrhaphy and anastomoses. The operative field remains free from
intrusion of intra-abdominal organs, which are dropped in the right part of the abdomen.
2008: Coelioscopie / AAA juxta-rénaux
(M. Coggia / J Vasc Surg 2008;48:37-42)
July 2008 • Volume 48 • Number 1
Clinical research study
Total laparoscopic juxtarenal abdominal aortic aneurysm repair
Marc Coggia, Pierre Cerceau, Isabelle DiCenta, Isabelle Javerliat, Giovanni Colacchio, Olivier GoëauBrissonnière.
Results
TOP
Postoperative data
No in-hospital deaths occurred (Table II). A severe systemic nonlethal complication occurred in one
patient (7.7%), whose indication for surgery was a growing and painful JAAA that reached 8 cm
diameter. Five months before, he underwent a coronary angioplasty with a coated stent for unstable
angina. He was treated with clopidogrel and aspirin until the procedure. Laparoscopic JAAA repair
was uneventful, with suprarenal clamping time of 24 minutes and blood loss of 1500 mL. We
observed a postoperative hemorrhagic syndrome, probably due to the double antiplatelet therapy. The
patient required intensive medical care and a prolonged ICU stay but no reintervention. His further
postoperative course was uneventful.
Chirurgie open
Endoprothèse
Fiabilité 100%
Résultat tardifs ++
Fiabilité 85%
Traumatisme limité ++
Traumatisme
!
Résulats tardifs
Coelioscopie
Pas de laparotomie+++
!
CHIRURGIE OPEN
• Sécurité / Fiabilité / Durabilité
•
!
Laparotomie / Lombotomie
• Clampage aortique
June 2002 • Volume 35 • Number 6
Open infrarenal abdominal aortic aneurysm repair:
The Cleveland Clinic experience from 1989 to 1998
Norman R. Hertzer, Edward J. Mascha, Mathew T. Karafa, Patrick J. O'Hara, Leonard P. Krajewski, Edwin G.
Beve
Discussion
TOP
Nine hundred and thirty-nine patients (83%) had no complications of any kind, and the median hospital length of stay was 8
days (quartiles: 7 days, 11 days) for the entire series. The median postoperative length of stay declined from 10 days in
1989 to 8 days in 1998 (P < .001), and the median length of the entire hospitalization (including preoperative days)
declined from 13 days in 1989 to 8 days in 1998 (P < .001). Single complications occurred in 150 patients (13%), and
46 patients (4.1%) had multiple complications (Table III ). Cardiac complications were most common (5.2%), but
most of these (38/59) were confined to arrhythmias that responded to medical management. At least
none set of %
postoperative cardiac isoenzymes was routinely obtained in most patients, and 16 perioperative MIs (1.4%) were
documented. Postoperative pulmonary events occurred in 4.1% of patients, wound complications in 3.3%, and renal
insufficiency (defined as an increase in the serum creatinine level of 1 mg/dL or more in comparison with the
preoperative value) in 1.7%. Only six patients (0.5%) who were not undergoing preoperative dialysis needed new
dialysis after surgery, however, and the incidence rate of most other serious complications was similarly low. FortyDeaths
five early reoperations were necessary in 28 patients (2.5%), the most frequent indication being a fascial wound
dehiscence (n = 15; 1.3%).
Cardiac
3
0.3
The overall complication rate was higher in men and in patients who had a previous history of CHF, COPD, renal
insufficiency, or dialysis. Advancing
age contributed to the incidence of cardiac complications. Otherwise,
the 0.3
Pulmonary
3
incidence of organ-specific (ie, cardiac, pulmonary, or renal) complications was predictably related to preoperative
risk factors, such as CHF, remote Multisystem
CABG, COPD, and severe
renalfailure
dysfunction.
organ
4
0.3
Late survival
In addition to the 14 postoperativeOther
deaths, another
300 of the 1185 patients (25%) eventually died at
causes
4 a mean follow-up
0.3
interval of 44.4 ± 31.6 months (median, 38 months). The principal causes of these 314 deaths were card
Table III. 30-day mortality and complication rates
1.2
September 2008 • Volume 48 • Number 3
Lifeline registry of endovascular aneurysm repair: Open repair
surgical controls in clinical trials
Robert M. Zwolak, MD, Anton N. Sidawy, Roy K. Greenberg, Marc L. Schermerhorn,
Rebecca J. Shackelton, Flora S. Siami, Society for Vascular Surgery Outcomes Committee *
Discussion
TOP
This aggregate data set represents a contemporary group of patients treated with open surgery for
infrarenal aortic aneurysms at institutions participating in IDE clinical endograft trials. Patients were
enrolled prospectively, and follow-up was carefully monitored with comprehensive adjudication of events.
Although the four trials enrolled different numbers of patients, and they differed to some extent in
inclusion and exclusion criteria, definitions, and end points, it was determined that the data were poolable.
Specific differences noted between the trials included the incidence of hypertension, smoking, cardiac
arrhythmias, and aneurysm size.
AAA size variation was likely related to the 2002 publication of the prospective randomized trial of
immediate open surgical repair vs closely monitored watchful waiting for AAAs <5.5 cm diameter. That
study failed to demonstrate a survival benefit for immediate open surgical repair, and recruitment for the
ongoing and subsequent EVAR trials was likely shifted towards larger diameter AAAs after its release. 13
Our analysis failed to demonstrate a difference in operative mortality between large and small AAAs, with
rates of 3.6% and 2.4%, respectively (P = .54).
Operative mortality for men and women undergoing elective open surgical repair has been reported in
population-based reports to be 3.5% to 4.6%, whereas the mortality rate in these four pooled studies was
2.8%.14-18.
Open surgical repair of abdominal
aortic aneurysms is safe and effective in
preventing aneurysm rupture and
avoiding AAA-related death.
February 1997 • Volume 25 • Number 2
Graft-related complications after abdominal aortic aneurysm
repair: Reassurance from a 36-year population-based
experience
John W. Hallett Jr., Donna M. Marshall, BA, Tanya M. Petterson, Darryl T. Gray, MD, Thomas C. Bower,
Kenneth J. Cherry Jr., Peter Gloviczki, Peter C. Pairolero.
Discussion
TOP
Since the initial EVAR performed at our hospital in 1994, the debate relative to the compromise between improved
perioperative morbidity and mortality and uncertain long-term durability of EVAR has evolved considerably.
Impressed with EVAR results in clinical trial data, we have progressively applied EVAR to an increasing percentage of
patients after Food and Drug Administration approval in 1999, and indeed, recently reported data from our institution
indicate that in the calendar year 2005, 70% of our AAA repairs were performed with EVAR.10
Reduced morbidity and mortality with EVAR compared with open AAA is documented with level I evidence.6,12,17 As
anticipated, particular benefit is seen in high-risk patients.11 Clinically relevant late outcomes are also favorable
except for a 10% to 14% need for secondary interventions.10,18,19 Because EVAR and open repair are compared with
short-term and intermediate follow-up, the early advantage of lower perioperative morbidity and mortality seen with
EVAR may be negated by the need for long-term surveillance, frequent reinterventions, and the perhaps undue
emphasis on a lack of a late survival benefit after EVAR.10,18,20 However, the advantage in perioperative mortality
seen with EVAR is apparent neither in single-center studies nor in our own experience. Contemporary series with
EVAR indicate perioperative mortality rates ranging from 1.2% to 3% in patients who were considered fit for open
repair.6,12,21 These figures are then often compared with open mortality rates exceeding 5% (particularly in
administrative database studies),22 thus promulgating the notion that EVAR is safer in the perioperative period.
Indeed, a recent survey of the National Surgical Quality Improvement Program database showed that after riskadjusted analysis, the 30-day morbidity and mortality of open repair were more than twofold higher than those of
EVAR.11 In this series, the perioperative mortality of 3%
Type
%
(yrs)
Anastomotic aneurysm
3.0
6.1 (1-17)
Graft thrombosis
2.0
1.4 (0.34-8.5)
Graft-enteric fistula
1.6
4.3 (0.23-7.5)
Graft infection
0.3
np
Volume 358:464-474 • January 5, 2008 • Number 31
Endovascular vs. open repair of abdominal aortic
aneurysms in the Medicare population.
Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE.
Results
Randomized trials have shown reductions in perioperative mortality and morbidity with endovascular repair of abdominal
aortic aneurysm, as compared with open surgical repair. Longer-term survival rates, however, were similar for the two
procedures. There are currently no long-term, population-based data from the comparison of these strategies. METHODS:
We studied perioperative rates of death and complications, long-term survival, rupture, and reinterventions after open as
compared with endovascular repair of abdominal aortic aneurysm in propensity-score-matched cohorts of Medicare
beneficiaries undergoing repair during the 2001-2004 period, with follow-up until 2005. RESULTS: There were 22,830
matched patients undergoing open repair of abdominal aortic aneurysm in each cohort. The average age of the patients was
76 years, and approximately 20% were women. Perioperative mortality was lower after endovascular repair than after
open repair (1.2% vs. 4.8%, P<0.001), and the reduction in mortality increased with age (2.1% difference for those 67 to
69 years old vs. 8.5% for those 85 years or older, P<0.001). Late survival was similar in the two cohorts, although the
survival curves did not converge until after 3 years. By 4 years, rupture was more likely in the endovascular-repair cohort
than in the open-repair cohort (1.8% vs. 0.5%, P<0.001), as was reintervention related to abdominal aortic aneurysm (9.0%
vs. 1.7%, P<0.001), although most reinterventions were minor. In contrast, by 4 years, surgery for laparotomy-related
complications was more likely among patients who had undergone open repair (9.7%, vs. 4.1% among those who had
undergone endovascular repair; P<0.001), as was hospitalization without surgery for bowel obstruction or abdominal-wall
hernia (14.2% vs. 8.1%, P<0.001).
by 4 years, surgery for laparotomy-related
complications was more likely among
patients who had undergone open repair
(9.7%...)… as was hospitalization without
surgery for bowel obstruction or abdominalwall hernia (14.2% …).
!
COELIOSCOPIE
• Sécurité / Fiabilité / Durabilité à 5 ans
• Pas de laparotomie
Pas de laparotomie
• Traumatisme pariétal réduit
• Pas de manipulation digestive
• ↓ ↓ douleurs postop.
• Réhabilitation précoce
• ↓ ↓ complications pulmonaires
• ↓ ↓ adhérences péritonéales
• ↓ ↓ ↓ risque d’éventration +++
Technique chirurgicale classique
• Anastomoses classiques, mise-à-plat AAA
• Prothèse vasculaire standard
 Résultats à long terme
Procédure standardisée
• Exposition aortique +++
• Restauration aortique
Voie d’abord aortique
sous coelioscopie
Voie d’abord aortique traditionnelle
+
Technique d’exposition coelioscopique
TPRC:
VRG rétroAo
Rate fixée
Obèse ?
Petite cavité ?
TPD:
Néphrec G
TPRR:
Cas standards
RP:
Abd .hostile
AAA / TPRR: clamp proximal
AAA / TPRR: Fil tracteur dans le sac
AAA / TPRR: contrôle des lombaires
AAA / TPRR : clampage iliaque
AAA / TPRR: Mise-à-plat de l’AAA
AAA / TPRR: anastomoses distales 1ères
AAA / voie TPRR
Cas 1
Cas 2
Cas 3
Cas 4
Données peropératoires
AAA
Durée opératoire (min)
260 (100*-540)
Clampage aortique (min)
80 (20-150)
Pertes sanguines (L)
1 (0.2-6.9)
Conversions
5,6%
* Conversion immédiate
Données postopératoires
AAA
Mortalité J30
2,5%
Complications syst. sévères
5,4%
Complications syst. modérées
11,5%
Complications vasculaires
4,4%
Complications locales
5,4%
Données postopératoires
AAA
Alimentation légère
2 (1-16)
Marche
3 (2-31)
USI
2 (0.5-57)
Hospitalisation
8 (3-74)
December 2008 • Volume 48 • Number 6S
Laparoscopic aortic surgery: Technique and results
Jérôme Cau, Jean-Baptiste Ricco, Jean Marc Corpataux.
Review of the published series
TOP
Since the initial EVAR performed at our hospital in 1994, the debate relative to the compromise between improved
perioperative morbidity and mortality and uncertain long-term durability of EVAR has evolved considerably.
Impressed with EVAR results in clinical trial data, we have progressively applied EVAR to an increasing percentage of
patients after Food and Drug Administration approval in 1999, and indeed, recently reported data from our institution
indicate that in the calendar year 2005, 70% of our AAA repairs were performed with EVAR.10
Reduced morbidity and mortality with EVAR compared with open AAA is documented with level I evidence.6,12,17 As
anticipated, particular benefit is seen in high-risk patients.11 Clinically relevant late outcomes are also favorable
except for a 10% to 14% need for secondary interventions.10,18,19 Because EVAR and open repair are compared with
short-term and intermediate follow-up, the early advantage of lower perioperative morbidity and mortality seen with
EVAR may be negated by the need for long-term surveillance, frequent reinterventions, and the perhaps undue
emphasis on a lack of a late survival benefit after EVAR.10,18,20 However, the advantage in perioperative mortality
seen with EVAR is apparent neither in single-center studies nor in our own experience. Contemporary series with
EVAR indicate perioperative mortality rates ranging from 1.2% to 3% in patients who were considered fit for open
repair.6,12,21 These figures are then often compared with open mortality rates exceeding 5% (particularly in
administrative database studies),22 thus promulgating the notion that EVAR is safer in the perioperative period.
Indeed, a recent survey of the National Surgical Quality Improvement Program database showed that after riskadjusted analysis, the 30-day morbidity and mortality of open repair were more than twofold higher than those of
EVAR.11 In this series, the perioperative mortality of 3%
Edoga
Kolvenbach
Cau
(1998-n22)
(2004-n37)
(2006-n23)
Durée opératoire (min)
391
227
251
Durée de clampage (min)
146
81
101
6
6
6
Mortalité
10%
0%
4,3%
Conversions
10%
16,2%
30%
Séjour
Data postopératoires
Patients à bon risque (AFSSAPS=0)
EVAR+
EVAR-
N=57
N=58
0%
0%
3,5%
3,4%
7%
15,5%
Complications vasculaires
3,5%
1,7%
Complications locales
3,5%
3,4%
Mortalité J30
Complications syst. sévères
Complications syst. modérées
Data postopératoires
Patients à haut risque (AFSSAPS ≥1)
EVAR+
EVAR-
N=30
N=34
10%
2,9%
Complications syst. sévères
16,7%
14,7%
Complications syst. modérées
3,3%
23,5%
Complications vasculaires
0%
8,8%
Complications locales
10%
2,9%
Mortalité J30
Patients à haut risque opératoire
Bénéfice pour les obèses et les octogénaires
Obèse BMI>30
Octogénaires
N=29
N=25
Mortalité J30
3,4%
4%
Complications syst. sévères
6,9%
16%
Complications syst. modérées
10,3%
12%
0
8%
3,4%
8%
Complications vasculaires
Complications locales
OPEN ou COELIO pour AAA ?
EVAR
Hybride
OPEN
Haut risque
Bon risque
Discussion cas par cas:
ATCD abdominaux
VRG rétroaortique
Morphologie AAA
COELIO
OPEN
Conclusion (1)
• La COELIO pour AAA est sûre et fiable
Conclusion (2)
• La coelioscopie est complémentaire des autres techniques
• Dans les équipes entraînées, la coelioscopie remplace la
chirurgie OPEN
• La chirurgie OPEN est réservée aux cas difficiles et à
certains malades à haut risque
Conclusion 3: Règle d’Or +++
Conversion toujours possible!!