Videotunneler for minimal and direct access aortoiliac reconstructive surgery.

UNLABELLED: Despite improvements in surgical practice and postoperative care, the large vertical midline or transverse transperitoneal approaches used in abdominal aortic surgery are still associated with a relatively high perioperative morbidity and mortality rate even in patients who are considered good risks for undergoing aortic surgery. This significant perioperative morbidity is partly caused by the major surgical trauma. To decrease the surgical stress on these patients we have developed a less-extensive procedure for this type of vascular reconstruction. TECHNIQUE: The abdominal aorta is explored using a special retractor through a short upper median minilaparotomy utilizing modified conventional surgical hand instruments. For an aortobifemoral graft implantation, a retroperitoneal tunnel is necessary. During the creation of this tunnel special care should be exercised to avoid troublesome hemorrhage with iliac and other vein lacerations. To overcome these difficulties, we have developed a new tunneling device, which allows us to have visual control of the tunneling procedure. This prototype device contains a semiflexible tube with an inflatable balloon and a flexible videoendoscope. It is introduced along the external iliac artery into the retroperitoneal space and creates a tunnel through step-by-step inflation of the balloon. After this, the graft is implanted in the usual manner. To date, 19 abdominal vascular reconstructions have been performed with this method.