Dr Ashok Gupta
MS, FRCS(E), FRCS
Consultant Vascular & Endovascular Surgeon
Email: gupta_ashok2000@yahoo.com

 

Open vascular surgery has come of it's own over the last fifteen years or so. Most of the procedures done have been standardized over the last five decades, as far as techniques and results are concerned. Most, if not all, trained and accredited vascular surgeons are able to reproduce standard results with acceptably low rates of complications. As laparoscopy took the world by storm in
the mid eighties and has never looked back since then, the vascular surgeon also joined the group of laparoscopy supporters.

As practicing vascular surgeons, we have been aware of the obvious advantages that a laparoscopic approach to major vascular procedures, could provide to the patients. Even though this approach has had good support internationally, the actual performing of surgeries either by lap-assistance or by a total laparoscopic technique has been a slow affair. There have been a number of reasons for this—there are a few surgeons even at the international level, who are competent enough to handle a major vascular procedure by laparoscopic surgery.

This problem has now been circumvented by people who are ready to work in teams—a vascular surgeon and a laparoscopic surgeon, each providing his /her expertise for the patient. The other limitation to rapid progress in this regard has been the non -availability of vascular clamps and other instruments that can be applied through ports. This problem is temporary and it is only a matter of time, before the industry comes up with appropriate solutions.

Total laparoscopic or lap-assisted aortic surgery is one
area where significant progress has been made over the
last ten years or so. Traditionally, infra-renal aorta is either approached trans or retroperitoneally, both approaches are extremely good as far as exposure is concerned, however, both involve long incisions, extensive dissection and prolonged retraction. All of these contribute to the morbidity attached to traditional aortic surgery. The advantages to the patient, that minimal access surgery has offered in other surgical specialties, including in cardiac surgery, could easily apply to infrarenal aortic surgery. In the mid nineties, lap-assisted aortic surgery came in vogue in Europe and in the United States, this concept has taken deep roots in the new millennium.

It has been my good fortune to associate with some of the most visionary and truly gifted medical professionals of our time. Dr P K Chowbey and his Department of Minimal Access Surgery at the SGRH need no introduction. While I was working at the vascular unit at the Sir Gangaram Hospital, I was involved in four cases of lap-assisted aortic procedures.

The preferred approach was through the retro- peritoneum, fortunately, both the laparoscopic as well as the vascular teams were well versed with the area, not only was the procedure carried out with minimal blood loss and dissection, the post operative course of the patient was completely different as compared to patients who undergo an open procedure.

As vascular surgeons, we were particularly pleased with the additional benefit of having the prosthetic graft tunneled for us, in the extra peritoneal space, a step that requires considerable dissection in the open technique, many times not totally under the vision of the operating surgeon.

Although this can only be called an initial experience
from a single group, a few points are worth highlighting.

Perhaps the only point which may be considered a drawback
in this approach was the longer time taken, for the doing these procedures, by the retro peritoneal laparoscopic
technique. One can safely say that these were only the initial cases and once the teams (both vascular and laparoscopic) get to do more of these cases together, the
total operating time is bound to come down. A lot of work is being done both in Europe and the United States on lap-assisted and total laparoscopic infra-renal aortic surgery, more scientifically correct and representative results from high volume centers are awaited which will support these early observations.

The future for minimal access aortic surgery is bright and with innovations in instrumentations and techniques coming up rapidly, we will see more and more commitment from surgeons and patients to accept this technique.

SUB-FASCIAL ENDOSCOPIC PERFORATOR SURGERY
(SEPS)

Perforator incompetence between the deep and superficial
system of veins in the lower limbs, leads to high-pressure
leaks into the superficial venous system causing venous
hypertension and ulcers. An incompetent perforator is defined as a venous communicating channel that shows bidirectional blood flow on duplex that lasts for more than 2
seconds. Isolated perforator incompetence occurs in less
than 5 % of patients with venous ulcers of the lower limbs,
sub-fascial endoscopic surgery is a new development in the
management of this subset of patients.

The procedure involves an access to the sub-fascial plane of the limb after the incompetent perforator is marked by duplex pre-operatively. A special access port, which allows the operator to dissect and create a plane through it, is used to perform the necessary dissection and once the perforator is visualized, it is divided between clips. Since the plane of dissection is maintained either by a continuous irrigation with saline or by lifting the superficial tissues, even a small amount of bleeding can reduce vision considerably.

This technique has it's fair share of supporters and opponents, particularly those who contend the role of incompetent perforators in the etio- pathogenesis of venous
ulcers. However, endoscopic technique does provide all the advantages of a minimal access approach and will continue to appeal to both the operator and patient in the future.

In conclusion, it should suffice to say that the way forward in modern vascular procedures in through minimalaccess, either by cath-lab based techniques or laparoscopic or by duplex controlled laser. It is for us (vascular surgeons) to keep this view in mind, keeping team-work and new techniques as the mantras for future success.

Fig-1: Infra-renal aorta dissected out in the retroperitoneum from the Left side

Fig-2: Infra renal aorta dissected and slung with an umbilical tape

Fig-3: Prosthetic graft tunneled in the retroperitoneum through lap ports. (with permission of Dr. Chowbey)