LVADs are implanted in patients with severe heart failure as BTT or DT. Because LVAD implantation improves survival and quality of life, DT accounts for approximately half of all LVAD implantation according to the Intermacs Database . In addition, cases of long-term survival exceeding 5 years after LVAD implantation have been observed, and the number of cancer patients with LVADs is increasing . Therefore, the number of patients with LVADs requiring surgery for abdominal cancer is likely to increase. Laparoscopic surgery in patients with LVADs has been reported in various types of abdominal surgery and more recently in bariatric surgery. However, reports of laparoscopic colectomy for LVAD patients with cancer are limited [3, 5,6,7]. It has also been recognized that, in patients with LVADs, the presence of the pump and the driveline in the abdominal wall necessitates the careful positioning of the trocars during laparoscopic surgery. Nevertheless, these reports do not show how the trocar positions were determined or how the pump and the driveline were inspected from the abdominal cavity.
In patients with certain types of LVAD, a pump is implanted in the epigastric region. A driveline is also implanted that is subcutaneously looped across the abdomen, as in the present case. In the case of laparotomy, the choice of an incision is technically difficult due to the pump and the driveline . However, laparoscopic surgery is possible given that the trocar positions do not interfere with the pump and the driveline. In addition, a small incision is often made in the umbilicus and it is less likely to interfere with the pump and the driveline. Therefore, laparoscopic surgery is probably more useful than open surgery in the patients with LVAD. In laparoscopic right colectomy, as in the present case, the operator's ports are often on the left or lower abdomen and less likely to face interference from the pump or the driveline. On the other side, in laparoscopic left colectomy, the port sites may be limited by the driveline because the operator’s ports are often on the right abdomen. Therefore, careful preoperative simulation is considered necessary in laparoscopic left colectomy.
In the present case, we assessed the location of the driveline using 3D CT imaging prior to surgery. This imaging method was useful because it allowed us to easily identify the location of the driveline. There are two important points about the positional relationship between the driveline and trocars. First, interference between the driveline and the operator’s port may affect the surgical operation. Recently, laparoscopic surgery in patients with LVADs has been reported in various abdominal surgeries, especially in bariatric surgery. These reports discuss little about trocar positions and operative manipulation as, unlike cancer surgery, such operations require minimal vessel ligations or mobilization of the gastrointestinal tracts. However, Ishida et al. reported that changing the trocar positions from its usual positions may make surgical manipulation difficult . Consequently, preoperative simulation should be performed sufficiently in upper abdominal surgeries with vessel ligations or mobilization of the gastrointestinal tracts. In the present case, performing a preoperative 3D CT image indicated the closeness of the left and right upper abdominal trocars to the driveline. We assessed that the left upper abdominal operator’s port could be inserted in our usual position. In fact, the trocar could be inserted in the same position as usual and did not interfere with the operation. However, if there is a need to alter the trocar positions, then such a change should be determined by preoperative simulating the surgical manipulation. Second, incisions near the pump or the driveline should be avoided because injury of these components can be fatal. The risk of infection of these components is related to how close they are to the incision . Previous reports do not mention the distances between the trocar insertion sites and the driveline [3, 5,6,7]. By using 3D CT imaging to measure these distances, it is possible to avoid the trocar insertion sites close to the driveline. Laparoscopic surgery may be converted to open surgery in cases of bleeding or severe adhesions. In conversion cases from laparoscopic to open surgery, the driveline may need to be repositioned. Therefore, simulation for conversion to laparotomy should be performed before surgery. The 3D CT image, which makes it easy to identify the location of the driveline is useful for simulating conversion to laparotomy. In the present case, we simulated repositioning of the driveline to the right side of the abdomen due to the presence of the driveline across the lower abdomen. In cases where the driveline does not cross the lower abdomen, repositioning of the driveline would not be necessary.
Prevention of infection or bleeding is important in patients with LVADs. With regard to infectious complications, surgeons need to pay attention to SSI, because, if infection occurs, early intervention is necessary to avoid infection of the pump or the driveline. Laparoscopic surgery may reduce the risk of infection in comparison to open surgery and may therefore be useful for LVAD patients . In the present case, superficial SSI was observed at the umbilicus incision. Fortunately, superficial SSI was observed at the umbilicus incision, yet did not spread to the site of the driveline or pump pocket due to early drainage and washing. With regard to bleeding complications, it is known that LVADs induce acquired von Willebrand syndrome [12, 13]. Therefore, surgeons need to be aware that the patients with LVADs tend to bleed even after anti-coagulation therapy is stopped.