Total Robotic Ligation of Inferior Mesenteric Artery for Type II Endoleak after Endovascular Aneurysm Repair Judith C. Lin, 1 Daniel Eun, 2 Alok Shrivastava, 2 Alexander D. Shepard, 1 and Daniel J. Reddy, 1 Detroit, Michigan We present a case of totally robotic ligation of the inferior mesenteric artery (IMA) for treatment of a persistent endoleak from the IMA into the aneurysm sac after endovascular aneurysm repair (EVAR). An 84-year-old male underwent EVAR with a Gore Excluder stent graft for an asymp- tomatic infrarenal abdominal aortic aneurysm. Follow-up computed tomographic (CT) scan showed persistent type II endoleak from the IMA, with progressive enlargement of the aneurysm sac from 5 to 6.1 cm over an 18-month period. In this case, the patient underwent ligation of the IMA using the da Vinci Surgical System for the treatment of retrograde flow into the aneurysm sac. The total operating time was 249 min; of this, the robotic assistance time was approximately 180 min. No intraoperative complications occurred. The estimated blood loss was 50 mL and the urine output 650 mL. The patient was extubated immediately after the procedure and tolerated a regular diet the following day. He was discharged home with a urinary catheter on postopera- tive day 2. CT scan postoperatively and at 3-month follow-up demonstrated an occluded IMA and stabilization of the aneurysm sac size. Type II endoleaks from retrograde flow of the infe- rior mesenteric (IMA) and lumbar arteries can occur in 20-30% of patients after endovascular repair of abdominal aortic aneurysm (AAA). 1 Persistent en- doleaks with aneurysm sac enlargement are associ- ated with adverse clinical outcomes, such as the need for open conversion, reintervention, and rup- ture. 2 Therefore, patients with sac enlargement dur- ing surveillance computed tomographic (CT) scan are advised to undergo endovascular coil emboliza- tion or open conversion and repair of type II endo- leak. In this case, the patient underwent a totally robot-assisted ligation of the IMA for the treatment of retrograde flow into the aneurysm sac. According to the current literature, we are the first center to report a successful, totally robotic repair of type II endoleak using the da Vinci Ò Surgical System (Intu- itive Surgical, Sunnyvale, CA). CASE REPORT An 84-year-old male with an asymptomatic infrarenal AAA underwent endovascular aortic aneurysm repair (EVAR) with a Gore (Flagstaff, AZ) Excluder stent graft on November 10, 2005, at an outside institution. The orig- inal AAA was reported to be 5 cm in maximal diameter. Follow-up CT scan showed a persistent type II endoleak from the IMA, with progressive enlargement of the aneu- rysm sac (Fig. 1). The sac had enlarged to 5.9 x 5.4 cm on November 4, 2006, and to 6.1 x 5.7 cm on May 5, 2007, over an 18-month period. The patient has a history of essential hypertension, chronic obstructive pulmonary disease, bladder carci- noma, benign prostatic hypertrophy, depression, and macular degeneration. He weighed 100 kg and mea- sured 1.88 m in height, with a body mass index of 28.3 kg/m 2 . Currently, the da Vinci Ò Surgical System has not been approved by the U.S. Food and Drug Administration 1 Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, Detroit, MI. 2 Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI. Correspondence to: Judith C. Lin, MD, FACS, Division of Vascular Surgery, Department of Surgery, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202, USA, E-mail: jlin1@hfhs.org Ann Vasc Surg 2009; 23: 255.e19-255.e21 DOI: 10.1016/j.avsg.2008.02.019 Ó Annals of Vascular Surgery Inc. Published online: April 14, 2008 255.e19