A Short Series of Laparoscopic Mesenteric Bypasses for Chronic Mesenteric Ischemia

Abstract

Background: Laparoscopic aortomesenteric bypass may be performed to treat the chronic mesenteric ischemia patients who are not suitable for endovascular treatment. This study presents an initial experience with a limited series of laparoscopic mesenteric artery revascularization for the treatment of mesenteric ischemia.

Methods: Chronic mesenteric ischemia (CMI) patients with previous unsuccessful endovascular treatment or with arterial occlusion and extensive calcification precluding safe endovascular treatment were offered laparoscopic mesenteric revascularization. From October 2015 until November 2018, nine patients with CMI underwent laparoscopic revascularization. In addition to demographic data and perioperative results of the treatment, graft patency was assessed with Duplex ultrasound at 1, 3, 6 and 12 months, and annually thereafter. A descriptive analysis of the data was performed.

Results: All bypasses were constructed with an 8 mm ring enforced expanded polytetrafluoroethylene graft in a retrograde fashion (from infrarenal aorta or iliac artery) to either superior mesenteric artery or splenic artery (2 cases). Median operation time was 356 mins (range 247-492 mins). Five patients had a history of unsuccessful endovascular treatment. Laparoscopic technical success was 78%, and the primary open conversion rate was 22%. All laparoscopic revascularization procedures remained patent after discharge during a median follow-up time of 26 months (range 18-49 months). The primary graft patency at 30 days was 78%. Primary assisted, and secondary graft patency was 78% and 100%, respectively. Median weight gain was 2 kg (range 2-18 kg), and all patients achieved relief from postprandial pain and nausea. No mortality was observed during the follow-up period.

Conclusion: Laparoscopic aortomesenteric revascularization procedures for chronic mesenteric ischemia are feasible but require careful patient selection. These procedures should only be performed at referral centers by vascular surgeons with prior experience in laparoscopic vascular surgery.

Keywords: bypass; chronic mesenteric ischemia; intestinal ischemia; laparoscopy; mesenteric ischemia.

Figure 1

Different phases of a laparoscopic retrograde aorto-mesenteric bypass to the superior mesenteric artery. (A): Paramedian vertical lines are midclavicular and anterior axial lines. Upper transverse is subcostal, and lower transverse is the line joining the two anterior superior iliac spines. Trocar position 6 for 30° laparoscope, 1 and 9 for aortic clamps and 4, 5, 7 for working instruments. The rest of the trocar positions for other helping instruments. (B): Partially dissected superior mesenteric artery () and infrarenal aorta (). Treitz ligament is divided, and duodenum mobilized distally and held under a retractor (). Inferior mesenteric vein (). (C): End-to-side anastomosis with superior mesenteric artery. (D): Completed anastomoses on superior mesenteric artery and infrarenal abdominal aorta. Ring enforced expanded polytetrafluoroethylene graft with an end-to-side anastomosed 6 mm graft. Side graft () is being flushed with heparinized NaCl to check the patency of anastomoses before the aortic and superior mesenteric artery clamps are removed. Laparoscopic bulldog artery clamp ().

Figure 2

(A). Trocar positions for laparoscopic retrograde aorto-splenic bypass. Trocar positions 5 for 30° laparoscope and 1 for Nathanson’s liver retractor. Position 2, 4, and 3 for working trocars for splenic artery dissection and anastomosis. Positions 7 and 6 for infrarenal aortic dissection and anastomosis. Other positions are used for helping instruments. (B): Distal end of a tunneled ring enforced expanded polytetrafluoroethylene graft anterior to the left renal vein (). Cross-clamped infrarenal aorta and left gonadal vein (). (C): Ring enforced expanded polytetrafluoroethylene graft is bein anastomosed end-to-side to a clamped splenic artery. Nathanson’s liver retractor is elevating the left liver lobe. (D): Completed end-to-side anastomosis to the infrarenal aorta.

Figure 3

(A). 3D reconstruction of a laparoscopic retrograde aorto-mesenteric bypass to the superior mesenteric artery (yellow arrow). Occluded stent in the superior mesenteric artery (green arrow). (B): 3D reconstruction of a laparoscopic retrograde aorto-mesenteric bypass to the superior mesenteric artery (blue arrow), from the left graft limb of a prior laparoscopic aortobifemoral bypass graft (red arrow). (C): A 6 mm expanded polytetrafluoroethylene graft, end-to-side anastomosed to an 8 mm ring enforced expanded polytetrafluoroethylene graft with graduated length markings and spatulated end.

Figure 4

(A). 3D reconstruction of the laparoscopic retrograde aorto-splenic bypass, with graft kinking (green arrow). Hem-o-loc clips on the excised side graft (yellow arrow). (B and C). Anterior and left lateral view of the revised laparoscopic aorto-splenic bypass.