The classic procedure for aortobifemoral bypass is open surgery. Laparoscopy has been accepted by several authors as a minimal invasive alternative for aortoiliac occlusive disease. The totally retroperitoneal laparoscopic procedure has been described as an alternative to the transperitoneal approach. Whatever the approach, the aortoprosthetic anastomosis is a major difficulty making those techniques unpopular despite obvious advantages for the patients. We report a clampless and sutureless approach for the proximal anastomosis of a totally retroperitoneal laparoscopic aortobifemoral bypass using an EndoVascular REtroperitoneoScopic Technique (EVREST). This approach was proposed to a 56-year-old man with severe aortoiliac occlusive disease. There was no indication for endovascular re-vascularization. The patient was placed in a 30 degrees right lateral decubitus position. The dissection of the retroperitoneal space was performed and the infrarenal aorta was exposed. A bifurcated graft was inserted into the retroperitoneal space. Under videoscopic control the prosthetic limbs were brought to the groins. The main body of the graft was connected on the left side of the aorta by an intra and extra aortic covered stent-graft. This connection was performed without the use of an aortic clamp and without suture. The femoral anastomoses were performed by classic open surgery.

EVREST greatly facilitates laparoscopic aortic surgery in occlusive disease with no need for suture or clamping of the aorta. This technique performed in a single center on 12 patients, seems to be feasible and safe. It offers the advantages of laparoscopy and those of endovascular surgery, especially in the challenging conditions encountered during aortic laparoscopic surgery. Early experience supports procedural and initial postprocedural safety and demonstrates proof-of-concept for EVREST.

Purpose Conduction block of the brachial plexus block at the humeral canal, as described by Dupre, has certain clinical indications. The aim of this preliminary study was to assess the feasibility of this technique under ultrasound guidance. Methods After ultrasound evaluation of the brachial plexus at the humeral canal in 61 adult volunteers, we performed ultrasound-guided blocks in another 20 adult patients. A linear 38 mm probe, 13-6 MHz, and a 50-mm insulated block needle were used to guide injection of lidocaine 1.5% with epinephrine. Results Ulnar and median nerves are superficial and located at similar depths. Ultrasound imaging showed the musculocutaneous nerve to be located dorsally. The radial nerve is dorsal to the plane of the musculocutaneous nerve. Relative to the brachial artery, the median nerve is situated between 12 and 1 o'clock in 66% of the cases. Relative to the basilic vein, the ulnar nerve is situated at 3 o'clock in 46% of the cases. The evaluated block sequence was radial, ulnar, musculocutaneous and median nerve; two points of puncture were mandatory, and 6.85 ± 0.37 min were required to perform the blocks. Sensory onset times were similar for the four nerves. Injectate volume was lower for the musculocutaneous nerve compared to other nerves (P \ 0.05). All 20 patients experienced complete sensory and motor blocks. ConclusionWe describe an approach to, and the feasibility of ultrasound-guided block of the brachial plexus at the humeral canal. Further study will be required to establish the effectiveness and the safety of this technique. RésuméObjectif Les blocs de conduction du plexus brachial au niveau du canal hume´ral tels que de´crits par Dupre ont certaines indications cliniques. L'objectif de cette e´tude pre´liminaire e´tait d'e´valuer la faisabilite´de cette technique par e´choguidage. Méthode Apre`s une e´valuation ultrasonographique du plexus brachial au niveau du canal hume´ral chez 61 volontaires adultes sains, nous avons re´alise´des blocs par e´choguidage chez 20 autres patients adultes. Une sonde line´aire de 38 mm, 13-6 MHz, et une aiguille de bloc isole´e de 50 mm ont e´te´utilise´es pour guider l'injection de lidocaı¨ne 1,5% avec e´pine´phrine. Résultats Les nerfs cubital et me´dian sont superficiels et situe´s à des profondeurs similaires. L'imagerie par ultrason a montre´que le nerf musculocutane´e´tait situe´en position dorsale. Le nerf radial est dorsal au plan du nerf musculocutane´. Par rapport a`l'arte`re brachiale, le nerf me´dian se situe entre midi et une heure dans 66% des cas. Par rapport a`la veine basilique, le nerf cubital se situe a`3 heures dans 46% des cas. La se´quence de bloc e´value´e se situait au niveau des nerfs radial, cubital, musculocutaneé t me´dian; deux points de ponction e´taient requis, et 6,85 ± 0,37 min ont e´te´ne´cessaires pour re´aliser les blocs. Les de´lais d'action sensitifs e´taient semblables pour les 4 nerfs. Le volume de la dose injecte´e e´tait plus bas pour le nerf musculocutane´comparativement aux autres nerfs (P ...

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