A laparoscopic access technique for endovascular procedures: Surgeon training in an animal model

Purpose: To present a laparoscopic technique for placing a transperitoneal conduit in the common iliac artery (CIA) or distal aorta to circumvent stenosed or occluded iliac systems and to assess the success of this laparoscopic access in a live animal model. Technique: A porcine model was used owing to similarities in anatomy and size of the pig aorta to the human common iliac artery (CIA). Ethical approval was obtained, and the technique was developed in 8 animals under general anesthesia. A curved hollow needle, a partially stented Dacron conduit, an airtight laparoscopic port and a sealing sheath and valve were developed specifically for percutaneous access through the abdominal wall. A transperitoneal approach was used to the distal aorta. Cannulation by the curved hollow needle via the new port was under direct vision. The conduit was inserted over a guidewire after needle removal and deployed under fluoroscopy. The distal end of the conduit was secured by the sealing sheath and valve, enabling wire and catheter exchange thereafter. A 2-day educational workshop was held for 12 vascular surgeons with a range of laparoscopic experience. After learning the technique on a simulator model, they worked in pairs, alternating surgeon/assistant roles to insert conduits into 12 animals under general anesthesia. Laparoscopic cannulation in all 12 animals was successful. There was no bleeding around the conduit at the aortic arteriotomy. All animals were euthanized after confirmation of conduit patency by back-bleeding. Conclusion: This novel technique bridges the gap between laparoscopic and endovascular techniques in striving for minimally invasive solutions to the treatment of vascular disease. Adaptation to human beings is currently underway and will mean increasing the applicability of endovascular solutions to those patients in whom it would otherwise be denied. The technique would appear not to require specialist laparoscopic skills.