Totally laparoscopic aortobifemoral bypass surgery in the treatment of aortoiliac occlusive disease or abdominal aortic aneurysms – a systematic review and critical appraisal of literature

Figures & data

Table 1 Inclusion and exclusion criteria applied in the evaluation of the eligibility of the articles

	Inclusion criteria	Exclusion criteria
Population	Patients with severe symptomatic AIOD and/or AAA	Non-human subjects
Intervention	Totally LABF	Not total laparoscopic aortic surgery for AIOD and/or AAA treated with aortobifemoral bypass. For example:
		HALS or mini-laparotomy
		Laparoscopic surgery for celiac artery compression syndrome
		Laparoscopic management of endoleaks after endovascular treatment
		Laparoscopic aortorenal or aortomesenteric bypass
		The management of vascular injuries during a laparoscopic procedure for a “non-vascular” condition
		Studies reporting procedures other than aortobifemoral bypass and bifurcated grafts. For example:
		Aortounifemoral bypass
		Aortoiliac bypass
		Use of tube grafts
Comparison	OABF or no comparison	Anything other than OABF
Outcome	Mortalitya	Not reporting any of the relevant outcomes
	Morbidity and complicationsa
	Surgical data: operation time and clamping time
	Postoperative hospital stay
	Primary and secondary patency
Study design	Systematic reviews	Case reports
	Prospective or retrospective patient series with or without control group	Non-systematic reviews
	Randomized controlled trials
Publishing year	1990–2016	Before 1990
Language	English or Norwegianb	All other languages

Notes:

a Perioperative and/or first 30 days postoperative.

b Articles with an English abstract but full text in another language were included but evaluation was purely based on the abstract. Randomized controlled trials or systematic reviews in languages other than English or Norwegian were translated.

Abbreviations: AIOD, aortoiliac occlusive disease; AAA, abdominal aortic aneurysm; LABF, laparoscopic aortobifemoral bypass; OABF, open aortobifemoral bypass; HALS, hand-assisted laparoscopic surgery.

Table 2 Aortoiliac occlusive disease

Author and publication year	Patients (n)	TASC group	Operating time (min)	Clamping time (min)	Blood loss (mL)	Conversion rate (n%)	30-day mortality (n%)	30-day morbidity (n)e	Hospital stay (days)
Barbera et al, 1998^Citation61	11	NR	279	70	563	3 (27)	NR	NR	10.1
Dion et al, 1999^Citation66	16	NR	351	107	820	3 (19)	0	3	7
Dion et al, 1998^Citation65,a	10	NR	376	121	820	3 (33)	0	3	7.8
Dion et al, 2004^Citation64,b	40	B, C, D	290	99	497	5 (10)	1 (0.025)	7	5
Fourneau et al, 2008^Citation62	50	C, D	328	69	600	11 (22)	0	16	NR
Fourneau et al, 2010^Citation71	139	C, D	250	59	514	19 (13.7)	3 (2.2)	23	5.8
Gracia and Dion, 1999^Citation67	25	NR	NR	100	820	3 (12)	1 (0.04)	NR	7
Jongkind et al, 2011^Citation59,c	24	B, C, D	360	113	1150	4 (17)	1 (0.04)	4	5
Novotny et al, 2011^Citation58,bc	19	C, D	324	68	NR	1 (5)	0	NR	NR
Remy et al, 2005^Citation68	21	NR	240	60d	500	1 (5)	0	5f	7

Notes: Operative and postoperative outcomes of included studies, LABF. Patient series without comparison.

a Might be repeated data.

b Comparison may be inappropriate due to different style of reporting the results.

c Robotic surgery.

d Reported as time consumed to create the anastomosis, not clamping time.

e Number of patients suffering from any systemic or local complication.

f No intraoperative complications reported.

Abbreviations: LABF, laparoscopic aortobifemoral bypass; TASC, Trans-Atlantic Inter-Society Consensus; NR, not reported

Table 4 Summary of findings table and grading the level of evidence of the results from the comparative studiesa

Outcomes	Comparison		Number of studies	Quality of evidence (GRADE)	Comments
	LABF	OABF
Operating time	Range 231–273 minutes	Range 136–215 minutes	5	Lowb,c,d (●●○○)	p<0.05 in three studies
Clamping time	Range 48–89.5 minutes	Range 17.2–55 minutes	5	Lowb,c,e (●●○○)	p<0.05 in three studies
Blood loss	Range 400–725 mL	Range 982–1010 mL	4	Lowb,c,f (●●○○)	p<0.05 in two studies
Hospital stay	Range 4–12.1 days	Range 5–12.8 days	5	Lowb,c,d (●●○○)	p<0.05 in four studies
Morbidity/complications	Range 5–12 complications	Range 4–40 complications	4	Very lowb,c,g (●○○○)	Uncertain effect estimates
Mortality	0%–4.5%	0%–2%	4	Lowb,c,h (●●○○)	No significant differences

Notes: GRADE Working Group grades quality of evidence. Every closed circle indicates the level of evidence from very low quality to high quality. High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are uncertain about the estimation.

a Studies lacking a control group were not included in the SoF table.

b All but one study were observational studies.

c Weak effect estimates. All studies report range values, no studies reported confidence intervals.

d One study did not report p-values.⁶⁹

e Two studies did not report p-values.^5,69

f Two studies did not report p-values.^69,70

g Imprecision of results. Great diversity in the kind of complications reported. Only one study reported p-value.⁴

h One study did not report p-value.⁶⁹

Abbreviations: GRADE, Grading of Recommendations Assessment, Development and Evaluation; LABF, laparoscopic aortobifemoral bypass; OABF, open aortobifemoral bypass; SoF, summary of findings.

Figure 1 Flow chart of systematic search for literature and inclusion regarding laparoscopic aortobifemoral bypass surgery compared with open aortobifemoral bypass.

Notes: A total of 66 articles met the inclusion criteria. Sixteen of them were also eligible for inclusion in quantitative synthesis.
Abbreviation: RCT, randomized controlled trial.

Table 3A Aortoiliac occlusive disease – operative data of included studies, LABF compared with OABF

Author and publication yeara	Randomized	Patients (n)		TASC group		Operating time (min)			Clamping time (min)			Blood loss (mL)
		LABF	OABF	LABF	OABF	LABF	OABF	p-value	LABF	OABF	p-value	LABF	OABF	p-value
Bruls et al, 2012^Citation4	No	95	156	C, D	NR	242	200	0.0003c	62	33.3	<0.0001	682	1010	<0.0001
Kazmi et al, 2015^Citation72,b	No	50	30	D	D	265	214	0.0003	59.5	36.5	<0.0001	400	1000	0.0001
Olinde et al, 2005^Citation69	No	22	18	NR	NR	267	180	NR	89.5	55	NR	690	NR	NR
Rouers et al, 2005^Citation70	No	30	28	NR	NR	231	136	<0.0001	56.8	17.2	<0.0001	NR	NR	NR
Tiek et al, 2012^Citation5	Yes	14	14	C, D	C, D	273	215	0.101	48	37	NR	725	982	0.28
Total		211	246

Notes:

a All comparative studies are non-robotic.

b This study reports composite endpoints.

c A different p-value (p=0.10) is reported in the article text.

Abbreviations: LABF, laparoscopic aortobifemoral bypass; OABF, open aortobifemoral bypass; TASC, Trans-Atlantic Inter-Society Consensus; NR, not reported.

Table 3B Aortoiliac occlusive disease – postoperative outcomes of included studies, LABF compared with OABF

Author and publication yeara	Conversion (n%)		30-day mortality (n%)			30-day morbidity (n)			Hospital stay (days)
	LABF	OABF	LABF	OABF	p-value	LABF	OABF	p-value	LABF	OABF	p-value
Bruls et al, 2012^Citation4	21 (22)		0	3 (2)	0.17	5	40	<0.0001	7	12.8	<0.0001
Kazmi et al, 2015^Citation72,b	7 (14)		c	c		d	d		5	11	0.0001
Olinde et al, 2005^Citation69	2 (9)		1 (4.5)	0	NR	5	4	NR	4	5	NR
Rouers et al, 2005^Citation70	6 (2)		0	0		12	14	NR	12.1	11.5	<0.0001
Tiek et al, 2012^Citation5	0		0	0		1e	7e	NR	4.5	9.5	0.0095
Total	36 (17)		1	3	0.64f

Notes:

a All comparative studies are non-robotic.

b This study reports composite endpoints.

c This study reports total mortality and morbidity at the end of the study and could not be included in the comparison of mortality between the two groups.

d The study reports number of systemic complications and graft thrombosis altogether at the end of the study.

e No major complications in either group, only minor.

f Note that the study by Kazmi et al⁷² could not be included in the calculation.

Abbreviations: LABF, laparoscopic aortobifemoral bypass; OABF, open aortobifemoral bypass; NR, not reported.

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PubMed Search to find articles not yet published in medline
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