Objective:

To describe our technique, evaluate access related complications and factors contributing to adverse outcomes in patients undergoing retroperitoneal anterior lumbar interbody fusion (ALIF).

Methods:

Retrospective analysis of prospectively collected data on patients undergoing ALIF at our institution from January 2008 to December 2017. Access was performed by a vascular surgeon who remained present for the duration of the case. Data collected included patients’ demographics, comorbidities, exposure related complications and ileus. Study endpoints included major adverse events (MAEs) and minor complications. MAEs included any vascular injuries requiring repair, bowel and ureter injuries, postoperative bleeding requiring reoperation, myocardial infarction (MI), stroke, venous thromboembolism (pulmonary embolism (PE)/deep venous thrombosis (DVT)), wound dehiscence and death. Minor complications included postoperative paralytic ileus, urinary tract and surgical site infections (SSI). Incidence of incisional hernia was also evaluated.

Results:

During this period, 1178 patients (Male: 514; F: 664, mean age: 54.1 ± 13.8) underwent a total of 2352 levels ALIF at our institution (single level: 422 patients, 2 levels: 450, 3 levels: 205, 4 levels: 98, 5 levels: 6, 6 levels: 1 and 7 levels: 1). The median estimated blood loss was 25 mL [25,50]. There were 57 (4.8%) exposure-related complications, including vascular injuries (venous: 13, arterial: 4) in 17 (1.4%) patients, bowel injuries in three patients (serosa tear in two and arterial embolization with subsequent bowel ischemia in one). Eleven of the thirteen venous injuries (84.6%) occurred while exposing the L4-L5 lumbar level. Two of the 4 patients with arterial injuries developed acute limb ischemia requiring embolectomy. One embolized to the superior mesenteric artery (SMA) and underwent bowel resection. Twenty patients (1.7%) developed VTE, two of which had sustained left iliac vein injury during exposure. Sixteen patients (1.4%) developed retroperitoneal hematoma/seroma with nine requiring evacuation in the operating room. Thirty-six patients (3.1%) developed postoperative ileus, defined as inability to tolerate diet on postoperative day 3. Four (0.4%) patients had a postoperative MI, two had a stroke and two (0.17%) died within the first 30 postoperative days. Thirty-one patients developed incisional complications, including SSI in twenty-four and incisional hernia in seven.

Conclusions:

Our findings suggest that ALIF exposure can be performed safely with a relatively low overall complication rate. The majority of vascular injuries associated with this procedure are venous in nature, occurring predominantly while exposing the L4-L5 level and can be safely addressed by an experienced vascular team.