Development and comparison of transperitoneal and retroperitoneal approaches to laparoscopic-assisted aortofemoral bypass in a porcine model

Purpose: Transperitoneal and retroperitoneal approaches to video-assisted aortofemoral bypass were developed and compared using gasless laparoscopic techniques in a porcine model. Methods: Ten pigs were randomized to either a transperitoneal or retroperitoneal approach. Aortic clamp time, total operative time, and complications were recorded. Both operations used an external lift device to maintain the working space. Retroperitoneal operations first used serial balloon inflation to dissect the retroperitoneum. After exposure of the infrarenal aorta, a graft was tunneled under endoscopic visualization. End-to-side aortic and femoral anastomoses were created with conventional instruments through 4 cm incisions. Results: Mean ± SEM aortic clamp time, operative duration, and graft patency rates were similar for both approaches (difference not significant by unpaired t test). Intraoperative complications related to the use of the laparoscopic technique included injury to the bladder and small bowel (n = 2) and occurred only in the transperitoneal group. Conclusions: The use of a gasless technique allowed direct visualization, standard instrumentation, and conventional anastomotic techniques. The retroperitoneal approach used the peritoneal sac to exclude the bowel, simplifying the aortic dissection. Gasless laparoscopic-assisted aortofemoral bypass can be performed by both transperitoneal and retroperitoneal approaches and holds promise as a minimally invasive treatment for aortoiliac occlusive disease.