Staple occlusion of the infrarenal aorta: A videoscopic retroperitoneal approach

Purpose: The purposes of this study were to determine whether available laparoscopic stapling devices could be used to interrupt the diseased human aorta, and to develop a videoscopic technique for retroperitoneal exposure and control of the infrarenal aorta in pigs. Our long-term goal is to develop a minimally invasive approach to the treatment of abdominal aortic aneurysms by exclusion and extraanatomic bypass. Methods: Ten diseased, formalin- preserved human cadaver aortas underwent stapling using a laparoscopic stapling device. The aortas were then pressurized to superphysiologic levels to assess the integrity of the staple line. Ten swine underwent retroperitoneal video-assisted exploration with control and staple occlusion of the aorta and iliac artery. Results: The staple line was complete and remained intact after pressurization in nine of 10 cadaver aortas, despite the presence of complex calcified disease. One aorta had a 2-mm opening through the staple line. Through the left retroperitoneal approach, the infrarenal aorta and left iliac artery could be dissected and controlled. A modified pledgeted technique used for stapling resulted in hemostasis of the staple line and exclusion of flow without injury to adjacent structures. Conclusions: The diseased human aorta can be occluded using available laparoscopic staplers. These swine experiments demonstrate the feasibility of the retroperitoneal approach for exclusion of infrarenal aortic aneurysms.