We describe early and mid-term results of total laparoscopic aortofemoral bypass (TLAFB). TLAFB was performed in 150 cases of severe aortoiliac occlusive disease. Aortic approaches included transperitoneal left retrocolic (n = 86), left retrorenal (n = 51), and direct (n = 4); the retroperitoneoscopic approach was used in nine cases. The procedure was totally laparoscopic in 145 patients (96.6%). Median operative and clamping times were 260 (120-450) and 81 (36-190) min, respectively. Thirty-day mortality was 2.7%. Nonlethal systemic, local vascular, and local nonvascular complications occurred in 21 (14.3%), seven (4.8%), and two (1.3%) patients, respectively. Median return to general diet and ambulation were, respectively, days 2 and 3. Median hospital stay was 7 days. Follow-up was 25.2 +/- 17.6 months (range 1-60) with 3-year primary and secondary actuarial patency rates of 93% and 95.6%, respectively. TLAFB gives early and mid-term patency rates comparable to open direct repair. Laparoscopy allows faster recovery and reduces operative trauma.