HALS, EVAR and robot-assisted surgery as minimally invasive approaches for abdominal aneurysm treatment

Dear Editor, We read with great interest the article by Berchiolli et al. [1] entitled “Hand-assisted laparoscopic surgery versus endovascular repair in abdominal aortic aneurysm treatment”, recently published by Journal of Vascular Surgery. In last decade, we have seen a paradigm shift in aneurysm repair towards a minimally invasive approach, mainly related to the preeminence of endovascular aneurysm repair (EVAR). Actually, laparoscopy and robot-assisted surgery also have a role in this field. Many studies have also described the benefits of EVAR, considered one of the most important options, in the acute setting [2], with faster recovery and shorter hospitalization. However, the main drawback remains its long-term seal. In fact, despite the advent of a new model of vascular graft, more than 5% of EVAR patients require reintervention [3]. Another concern is the cumulative radiation and iodinated contrast exposure in patients undergoing EVAR. In this setting, laparoscopic surgery is an appealing alternative, because it represents a minimally invasive option with a potentially higher long-term success rate. One of the main criticisms of this approach is the learning curve, which can be particularly steep for vascular surgeons, who are not used to it. On the contrary, the hand-assisted laparoscopic surgery (HALS), thanks to the manual control of the sac during dissection and sutures, is associated with a higher level of safety and with a shorter learning curve, still maintaining the advantages of minimally invasive surgery [4]. HALS has been introduced for abdominal aortic aneurysm treatment in some centers [5], showing encouraging results and a lower risk of aneurysm-related reintervention if compared to EVAR. An important remark on this work [1] concerns costs. In fact, a preliminary cost analysis of the perioperative period has shown a lower cost of HALS compared to EVAR and this difference could be even greater if we consider the economic impact of a stricter follow-up, which is mandatory for patients underwent EVAR, and the possible costs related to the risk of reoperation, which is higher in the EVAR group. Another possible minimally invasive alternative for aneurysm repair is robot-assisted surgery (RAS). Indeed, the robotic assistance can be very useful in this field, overcoming the kinematics limitations of laparoscopy and resulting in a potential higher level of precision and control and in a shorter learning curve [6]. This is even more evident with the latest da Vinci Xi [7], which combines the functionality of a boom-mounted system with the flexibility of a mobile platform allowing the operating surgeon to quickly scan over a wider operative field. The scope can be placed on any of the 8-mm robotic trocar, improving versatility. RAS could have also a specific role in Type-II Endoleak, the most frequent complication after EVAR [8], allowing the operating surgeon the ligation of aortic collaterals responsible for endoleak inflow and outflow in an easier way with respect to laparoscopy and in a definitive manner with respect to endovascular embolization, which is the first-line treatment option, but still has high recurrence rates. The main issues about RAS remain those related to costs; however, recent articles have suggested an economic gain with increasing surgeon’s experience and with the use of da Vinci Xi [9, 10], and this could also finally open the way for RAS for these procedures. For these reasons, we believe that the diffusion of HALS and RAS between vascular surgeons should be encouraged. Since literature lacks prospective studies about their use in vascular surgery, it would be interesting to value on a larger scale the usefulness and the application of these two well-consolidated minimally invasive techniques also to the vascular field.