Current modifications to totally laparoscopic “apron technique”

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Presentation transcript:

Current modifications to totally laparoscopic “apron technique” Yves-Marie Dion, MD, MSc, Fabien Thaveau, MD, Shirley J Fearn, MD, PhD Journal of Vascular Surgery Volume 38, Issue 2, Pages 403-406 (August 2003) DOI: 10.1016/S0741-5214(03)00230-1

Fig 1 A, Patient position and sequence of trocar insertion. B, Left lateral peritoneal incision is made approximately 8 cm anterosuperior to Toldt’s line. C, Cephalad, the peritoneal incision ends at the level of the spleen (arrow). Journal of Vascular Surgery 2003 38, 403-406DOI: (10.1016/S0741-5214(03)00230-1)

Fig 2 A, Dissection of proximal aorta from the patient’s right side. The renal vein has already been dissected. B, Left gonadal vein (long arrows) constitutes left lateral limit of safe dissection, the ureter being lateral to it. The aorta has been dissected down to the inferior mesenteric artery (short arrows). Procedure will then proceed from the patient’s left side. C, Undersurface of an aneurysm (arrowheads). A left lumbar artery has been clipped and incised (short arrow). A right lumbar artery has just been clipped (long arrow). D, Infrarenal clamping. Left renal artery (arrow) and vein (arrowhead) are seen just cephalad to aortic clamp. Note aneurysm mass distal to clamp. A retractor is visible to the right of the illustration. Journal of Vascular Surgery 2003 38, 403-406DOI: (10.1016/S0741-5214(03)00230-1)

Fig 3 A, Anastomosis begins posteriorly with a 3-0 polypropylene suture, which will be run up the right lateral aspect of the aorta. The right- hand needle driver is seen tightening the suture to approximate the graft to the aorta. The left-hand needle driver is not seen, but is holding the suture on the other side of the knot (arrow). B, The second running suture has been tied posteriorly, close to the first knot, and is being run up the left lateral aspect of the aorta. Arrow points to needle coming out the aortic wall. C, Before the anastomosis is completed, the first running suture is tightened with a laparoscopic nerve hook (arrow). D, Needle (arrowhead) is grasped with the needle driver while the anastomosis is completed. Note that running suture coming from left has passed the site where the first running suture (arrow) has reached. E, Anastomosis has been unclamped and flow restored to the limbs. Note how close the left ureter is to the aorta. With the modified technique, these two organs are not located so close. F, Angiogram shows four pairs of lumbar arteries that needed interruption during the laparoscopic Creech procedure performed. Journal of Vascular Surgery 2003 38, 403-406DOI: (10.1016/S0741-5214(03)00230-1)