Vascular occlusive disease countered by marriage between da Vinci robot-assisted and laparoscopic techniques

Richmond 07 June 2001Henrico Doctors' Hospital is the first hospital in the world to perform a fully laparoscopic aortofemoral bypass, assisted with the da Vinci Surgical System, according to William E. Kelley Jr., M.D. The minimally invasive alternative to a highly invasive open procedure has been performed by Dr. Barklie W. Zimmerman and Dr. Kelley, who both are members of the Richmond Surgical Group. Only four other da Vinci-assisted laparoscopic aortofemoral bypasses have been performed in the world, all in Europe. However, these cases were performed as partially open procedures, and therefore were not fully laparoscopic.


Drs. Zimmerman and Kelley performed an aortofemoral bypass on a 50-year-old male patient who suffered from incapacitating leg pain upon exercise due to advanced aorto-iliac occlusive disease. Despite being recently treated with iliac balloon angioplasty and stenting, the patient developed a recurrence of his leg pain and re-occlusion of his iliac artery. By combining the da Vinci's robotic precision with laparoscopic techniques, the surgeons performed the bypass by laparoscopically dissecting the infrarenal aorta, and by using the da Vinci to perform the end-to-side anastomosis.

"This procedure means a significant step in drastically reducing the trauma, both physical and emotional, associated with the surgical treatment of aorto-iliac occlusive disease", Dr. Zimmerman reported. Typically associated with large surgical incisions which often result in lengthy and uncomfortable patient recovery, the traditional open aorto-iliac bypass procedures generally require a five to seven day hospital stay and a two-to-three month recovery period. The da Vinci-assisted laparoscopic surgery reduces hospital stay to two-to-three days and recovery period to one week.

Although the advantages of minimally invasive surgery extensively have been documented, and the managed-care environment supports procedures which result in shorter hospitalisation and recovery times, laparoscopic procedures for vascular occlusive disease are extremely rare. "Currently only a few centres across the USA and Canada are performing laparoscopic vascular surgery", Dr. Kelley noted. Although the procedure is feasible, effective, and safe, a co-operation between experienced laparoscopists and vascular surgeons is needed to overcome procedural challenges. "As experience increases, these more difficult minimally invasive procedures that previously have been performed only by the most experienced surgeons could become routine with robotic assistance", Dr. Kelley explained.

Aorto-iliac occlusive disease is the arterial narrowing or obstruction which occurs as a result of the athero-sclerotic process that reduces blood flow to the lower limbs during exercise or rest. Studies indicate that up to 5 percent of men, and 2.5 percent of women of age sixty or older have symptoms of intermittent leg pain or claudication. The prevalence is at least threefold higher when sensitive non-invasive tests are used to make the diagnosis of arterial insufficiency in asymptomatic and symptomatic patients.

With a greater percentage of the North American population older than 65, the incidence of lower extremity arterial disease has progressively increased over the past few decades. Because patients with either symptomatic or asymptomatic lower extremity arterial disease have widespread arterial disease, they have a significantly increased risk of myocardial infarction, stroke, and cardiovascular death.

Surgical treatment is indicated to relieve symptoms of limb-threatening ischemia, including ischemic pain at rest, ischemic ulcers, gangrene, and debilitating ambulatory leg pain due to arterial insufficiency. There is much concern by physicians regarding the advisability of open re-vascularisation surgery, especially because patients undergoing these major procedures often require multiple transfusions, prolonged hospitalisation, and intensive care. "This is precisely why minimally invasive surgery is such an important direction for this patient population", Dr. Zimmerman said. "The da Vinci facilitates the delicate surgical tasks associated with these procedures, while the laparoscopic approach significantly reduces patient pain, blood loss, and recovery time."

The da Vinci Surgical System consists of a surgeon's viewing and control console having an integrated, high-performance 3D vision system, a patient-side cart consisting of three robotic arms which position and precisely manoeuvre endoscopic instruments and an endoscope, and a variety of articulating EndoWrist instruments. By integrating computer-enhanced technology with surgeons' technical skills, the system enables surgeons to perform surgery in a manner never before experienced. The da Vinci Surgical System seamlessly and directly translates the surgeon's natural hand, wrist, and finger movements on the instrument controls at the surgeon's console outside the patient's body into the corresponding micro-movements of the instrument tips positioned inside the body through small puncture incisions, or ports.

In July 2000, Dr. Kelley performed the first abdominal operation with the da Vinci Surgical System in the United States. Dr. Craig Owens assisted Dr. Kelley in the laparoscopic gallbladder operation. For more information on robotically enhanced surgery at the Henrico Doctors' Hospital, you can read the VMW April 2001 article Thoroscopic surgery robots now FDA-approved for use in United States hospitals.

Leslie Versweyveld

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