A Short Series of Laparoscopic Mesenteric Bypasses for Chronic Mesenteric Ischemia

Figures & data

Figure 1 Different phases of a laparoscopic retrograde aorto-mesenteric bypass to the superior mesenteric artery. (A): Paramedian vertical lines are midclavicular and anterior axial lines. Upper transverse is subcostal, and lower transverse is the line joining the two anterior superior iliac spines. Trocar position 6 for 30° laparoscope, 1 and 9 for aortic clamps and 4, 5, 7 for working instruments. The rest of the trocar positions for other helping instruments. (B): Partially dissected superior mesenteric artery (

) and infrarenal aorta (

). Treitz ligament is divided, and duodenum mobilized distally and held under a retractor (

). Inferior mesenteric vein (

). (C): End-to-side anastomosis with superior mesenteric artery. (D): Completed anastomoses on superior mesenteric artery and infrarenal abdominal aorta. Ring enforced expanded polytetrafluoroethylene graft with an end-to-side anastomosed 6 mm graft. Side graft (

) is being flushed with heparinized NaCl to check the patency of anastomoses before the aortic and superior mesenteric artery clamps are removed. Laparoscopic bulldog artery clamp (

).

Figure 2 (A). Trocar positions for laparoscopic retrograde aorto-splenic bypass. Trocar positions 5 for 30° laparoscope and 1 for Nathanson’s liver retractor. Position 2, 4, and 3 for working trocars for splenic artery dissection and anastomosis. Positions 7 and 6 for infrarenal aortic dissection and anastomosis. Other positions are used for helping instruments. (B): Distal end of a tunneled ring enforced expanded polytetrafluoroethylene graft anterior to the left renal vein (

). Cross-clamped infrarenal aorta and left gonadal vein (

). (C): Ring enforced expanded polytetrafluoroethylene graft is bein anastomosed end-to-side to a clamped splenic artery. Nathanson’s liver retractor is elevating the left liver lobe. (D): Completed end-to-side anastomosis to the infrarenal aorta.

Table 1 Demographic Data, Risk Factors, Comorbidities, and Clinical Findings in the Group of Patients with Chronic Mesenteric Ischemia Treated with Laparoscopic Mesenteric Bypass Procedures

	Total Number = 9
Median age, years (range)	60.5 (47–77)
Female gender	8
Risk factors
Diabetes mellitus	2
Renal failure	1
Smoking	5
Hypertension	6
Hypercholesterolemia	4
Comorbidities
Prior stroke	2
CAD	2
CVD	2
ASA
Class 2	1
Class 3	7
Class 4	1
Median BMI kg/m^2 (range)	21.2 (13.4–29.4)
Prior abdominal surgery	7
Prior mesenteric PTA and Stent	6
Symptoms and findings
Postprandial pain	9
Changes in food intake	9
Weight loss	9
Constant pain	2
Diarrhea/Nausea	3
Weight loss in kg, median (range)	9.5 (6–25)
Symptoms duration in months, median (range)	24 (12–48)
Endoscopy findings
Gastroesophagitis	4
Irritable bowel syndrome	2
Statin treatment	6
Antiplatelet	9
Anticoagulation	1
Proton Pump Inhibitors	8
Opioids	2
Others medicines	6

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CAD, Coronary artery disease; CVD, Cerebrovascular disease; PTA, Percutaneous Transluminal Angioplasty.

Table 2 Perioperative Data of 9 Chronic Mesenteric Ischemia Patients Treated with Laparoscopic Mesenteric Bypass Procedures

Case/Year	1/2015	2/2016	3/2017	4/2017	5/2017	6/2018	7/2018	8/2018	9/2018	Median
CTA findings	Stenosis Common trunk SMA and hepatic artery, Occlusion IMA	Occluded stent in SMA, Occlusion IMA	Fractured and occluded stent CA	Occluded stent in SMA, stenosis	Stenosis of an isolated origin of splenic artery direct from aorta	Occlusion all mesenteric vessels	Occlusion SMA, Stenosis CA and IMA	Occluded stent in SMA, stenosis CA and IMA	Occlusion CA and SMA, Stenosis IMA
Prior mesenteric endovascular/vascular procedure	None	Twice stent in SMA	Stent in celiac artery and open surgery for celiac artery compression syndrome	Stent and twice repeat PTA of SMA	None	Unsuccessful PTA attempt	None	Stent in SMA	None
Operative procedure	Laparoscopic iliaco-SMA bypass from previous aortic bifurcation graft	Laparoscopic retrograde aorto-SMA bypass	Laparoscopic retrograde aorto-splenic bypass	Laparoscopic retrograde aorto-SMA bypass	Laparoscopic retrograde aorto-splenic bypass	Iliaco-SMA bypass	Laparoscopic retrograde aorto-SMA bypass	Laparoscopic retrograde aorto-SMA bypass	Laparoscopic retrograde aorto-SMA bypass
Operation time in minutes	492	358	431	355	343	457	247	315	328	356
Anastomoses time in minutes Mesenteric/aortic or iliac	56/44	43/33	50/29	40/29	35/36	57/34	21/16	28/24	26/23	41/31
Bleeding in mL	950	300	100	500	100	500	600	250	400	400
Complication and treatment	Left ureter injury; open ureter repair	None	Graft thrombosis 2nd post-operative day; laparoscopic thrombectomy	Graft thrombosis 2nd post-operative day; open thrombectomy	Graft kinking 2nd post-operative day; laparoscopic resection of graft and revision of aortic anastomosis	Mesenteric anastomosis with open technique	Venous bleeding from inferior mesenteric vein; converted to open	None	None
Follow-up in months	49	36	31	29	24	23	21	20	18	26.5
Patent (Yes/No)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes

Abbreviations: CA, Celiac artery; SMA, Superior mesenteric artery; IMA, inferior mesenteric artery; PTA, Percutaneous Transluminal Angioplasty; CTA, Computed Tomography Angiography.

Figure 3 (A). 3D reconstruction of a laparoscopic retrograde aorto-mesenteric bypass to the superior mesenteric artery (yellow arrow). Occluded stent in the superior mesenteric artery (green arrow). (B): 3D reconstruction of a laparoscopic retrograde aorto-mesenteric bypass to the superior mesenteric artery (blue arrow), from the left graft limb of a prior laparoscopic aortobifemoral bypass graft (red arrow). (C): A 6 mm expanded polytetrafluoroethylene graft, end-to-side anastomosed to an 8 mm ring enforced expanded polytetrafluoroethylene graft with graduated length markings and spatulated end.

Figure 4 (A). 3D reconstruction of the laparoscopic retrograde aorto-splenic bypass, with graft kinking (green arrow). Hem-o-loc clips on the excised side graft (yellow arrow). (B and C). Anterior and left lateral view of the revised laparoscopic aorto-splenic bypass.