Midline retroperitoneal versus midline transperitoneal approach for abdominal aortic aneurysm repair

PURPOSE: The purpose of this study was to compare the midline retroperitoneal approach with the midline transperitoneal approach for abdominal aortic aneurysm (AAA) repair with respect to operative details, gastrointestinal complications, and wound complications. METHODS: From January 1990 through January 1998, 128 patients underwent elective aortic reconstruction for infrarenal AAA. Of these, 64 patients (the transperitoneal group) underwent conventional transperitoneal midline aortic exposure, whereas the remaining 64 patients (the retroperitoneal group) underwent retroperitoneal midline exposure of the aneurysm. RESULTS: Preclamp time, that is, the time from skin incision to aortic clamping, was significantly shorter in the transperitoneal group than in the retroperitoneal group (P <.001). However, the midline retroperitoneal approach was associated with decreased incidence of ileus (P <.01), earlier resumption of oral intake (P <.01), and decreased wound pain (P <.01), in comparison with the transperitoneal approach. Furthermore, there was no incidence of wound complications such as abdominal bulge or wound pain in any of the patients in the postoperative period or over the long term. CONCLUSIONS: The midline retroperitoneal approach for AAA was associated with fewer postoperative gastrointestinal and wound complications than the midline transperitoneal approach. Over the long term, there was no wound complication such as abdominal bulge and wound pain in any of the patients.     

Selective use of a right retroperitoneal approach to abdominal aortic aneurysm.

The repair of infrarenal abdominal aortic aneurysm by right retroperitoneal dissection using a standard midline transperitoneal incision has previously been described but its clinical application has not been evaluated. Over a 14-year period 144 elective abdominal aortic aneurysm grafts were performed by a single surgical firm. Of these, 11 were carried out by a right retroperitoneal exposure (seven men and four women, aged 63-81 (median 70) years). The indications were to improve access for large juxtarenal aneurysms (n = 6) and because of dense abdominal adhesions (n = 3), horseshoe kidney (n = 1) and retroperitoneal fibrosis (n = 1). In each instance, good proximal control of the aorta was achieved. There were no major operative or postoperative complications and all patients were discharged from hospital (median stay 15 days). Follow-up (median 29 months) has revealed no procedure-related complications.     

Extraperitoneal placement of renal allografts in children weighing less than 15 kg

PURPOSE: Extraperitoneal renal transplantation is not routine in small recipients, in whom transperitoneal engraftment is the norm. The outcome of extraperitoneal placement of renal allografts in children weighing less than 15 kg. was evaluated at 2 institutions. MATERIALS AND METHODS: We retrospectively reviewed all pediatric renal transplantations at 2 institutions from 1988 to 2000 and identified 29 children 14 to 72 months old (mean age 29.2) weighing less than 15 kg. (range 8 to 14.8, mean 11.2). All children underwent allograft placement extraperitoneally via a modified Gibson and low midline retroperitoneal incision in 27 and 2, respectively. A concurrent procedure was done via the same incision during 2 ipsilateral and 2 bilateral nephrectomies. RESULTS: Of the 29 patients 25 have a functioning renal allograft. In 2 cases the initial allograft was lost due to early postoperative thrombosis and acute rejection in 1 each. Two patients with a functioning allografts died of medical complications greater than 2 years after transplantation. One child required reexploration secondary to fascial dehiscence and an additional recipient required pyeloureterostomy due to ureteral necrosis after living related donor transplantation. CONCLUSIONS: Extraperitoneal renal transplantation is technically feasible in children who weigh less than 15 kg. This approach preserves the peritoneal cavity, limits potential gastrointestinal complications and allows the confinement of potential surgical complications, such as bleeding and urinary leakage. In addition, this approach provides complete access to the retroperitoneum to enable concurrent retroperitoneal surgery, such as nephrectomy, to be performed safely. We recommend that extraperitoneal renal engraftment should become routine in children weighing less than 15 kg. rather than using the more common transperitoneal approach for allograft placement.     

The less incisional retroperitoneal approach for abdominal aortic aneurysm repair to prevent postoperative flank bulge

One of the postoperative complications of retroperitoneal incision is a flank bulge that is suggested to be caused by 11th intercostal nerve injury leading to denervation of the ipsilateral muscles. To avoid this complication, we have tried to minimize retroperitoneal incision for abdominal aortic aneurysm (AAA) repair. The feasibility of the less incisional retroperitoneal approach for the repair of AAA to prevent postoperative flank bulge was investigated. Twenty-seven patients undergoing elective repair for infrarenal AAA through the left retroperitoneal approach were divided into group-L (less incision: 11.9+/-1.8 cm, n = 7) and group-C (conventional incision: 17.8+/-1.9 cm, n = 20). All operations were performed by a traditional hand-sewn anastomosis without laparoscopic support. Five bifurcated grafts were used in group-L and 15 in group-C. The postoperative course of all patients was uneventful except that one patient in group-C required reoperation for bleeding. Intraoperative parameters of both groups were almost comparable. All patients in group-L were extubated in the operating theater, whereas it was possible only for 11 patients in group-C. Resumption of alimentation was significantly earlier in group-L (P = 0.0117). There was no significant difference in postoperative hospital stay between groups. No late flank bulge was experienced. Significant late atrophy of the left rectus muscle (left/right thickness-ratio = 0.59+/-0.24) was seen in group-C (P = 0.0042 vs preoperative value), which was not observed in group-L (P = 0.0008 between groups). The less incisional retroperitoneal AAA repair seems feasible and safety technique that might prevent postoperative flank bulge and reduce surgical stress.     

Left Retroperitoneal Approach Using a Retractor to Repair Abdominal Aortic Aneurysms: A Comparison with the Transperitoneal Approach

Abstract. Purpose: The purpose of this study was to compare the effectiveness of the retroperitoneal approach (RP) using a Thompson retractor with the conventional transperitoneal approach (TP), to repair infrarenal abdominal aortic aneurysms (AAA). Methods: A total of 91 consecutive patients were divided into two groups; group A (n= 21) underwent surgery using the TP, and group B (n= 70) underwent surgery using the RP with a Thompson retractor. Results: There were no significant differences in the operation time, aortic cross-clamp time, incidence of postoperative cardiac events, or the development of wound complications; however, a significantly higher rate of postoperative respiratory complications and ileus was observed in group A. Moreover, oral feeding was commenced later and the hospital stay was prolonged in group A (P < 0.01). Conclusion: These findings clearly demonstrate that our RP method, especially when using a Thompson retractor, is a preferable alternative to TP for AAA surgery. Received: February 26, 2001 / Accepted: January 8, 2002     

Open repair for pararenal abdominal aortic aneurysm: the strategy and pitfalls for safe surgery

Pararenal abdominal aortic aneurysm (PRAAA) includes two types of AAA : juxtarenal (JRAAA) and suprarenal (SRAAA). JRAAA is defined as aneurysms that extend up to but do not involve the renal arteries, necessitating suprarenal aortic clamping for repair. SRAAA is defined as aneurysms that extend up to the superior mesenteric artery, involving one or both renal arteries to be repaired. The surgical repair of PRAAAs requires more extensive aortic exposure and may result in ischemic injury to kidneys and visceral organs with higher morbidity and mortality compared with infrarenal AAAs. The four approaches to PRAAA repair are: 1) midline abdominal incision, transperitoneal, left renal vein divided or mobilized; 2) midline abdominal incision, transperitoneal, left medial visceral rotation technique 3) left flank incision, retroperitoneal; and 4) thoracoabdominal incision, thoracoretroperitoneal approach. The four positions of proximal clamping are: 1) suprarenal; 2) interrenal; 3) supramesenteric; and 4) supraceliac aorta. The surgical strategy should be determined based on computed tomography and magnetic resonance angiography imaging, and severe atherosclerotic or calcified aorta should never be clamped to prevent lethal embolic complications. Although developing fenestrated endovascular technology can be used in some cases of PRAAA repair, open surgery with thorough preoperative assessment and careful utilization of techniques to prevent visceral and renal ischemic injury is safe, effective, and durable and remains the gold standard for repair.     

The retroperitoneal approach combined with epidural anesthesia reduces morbidity in elective infrarenal aortic aneurysm repair

In elective open infrarenal aortic aneurysm repair the surgical approach and the use of epidural anesthesia (EDA) may determine patients' outcome. Hence we analyzed our results after elective open aneurysm repair in the light of the surgical approach and the use of EDA. Retrospective analysis of a prospective data base. From December 2005 to April 2008, 125 patients with infrarenal aortic aneurysm underwent elective open repair. Patients were divided into four groups: retro- and transperitoneal approach with and without epidural anesthesia (RP+/-EDA and TP+/-EDA). In terms of age, sex, aneurysm diameter, ASA score and clamping time all groups were comparable. In the retroperitoneal groups significantly more tube grafts were implanted (63 vs. 27; P=0.001). The rate of surgical complications did not differ between the groups. The RP+EDA group had the lowest rate of postoperative assisted mechanical ventilation (5.1% vs. 35.7%; P=0.002) and medical complications (17.9% vs. 42.8%; P=0.032). Concerning frequency of surgical complications, the retroperitoneal incision was comparable to the transperitoneal approach in infrarenal aortic reconstruction. Supplementation with EDA resulted in a decreased rate of postoperative assisted mechanical ventilation and in lower morbidity rates.     

Extraperitoneal approach for repair of inflammatory abdominal aortic aneurysm

Inflammatory abdominal aortic aneurysms are characterized by dense perianeurysmal fibrosis involving the adjacent organs. Attempts to isolate the aneurysm can lead to operative injuries of these structures, thus increasing the rates of complications and mortality. In the last 12 years 45 patients with inflammatory abdominal aortic aneurysms underwent aneurysm resection at the Department of Vascular Surgery of the University of Rome. The aneurysm was resected through a standard, midline transperitoneal approach in 39 patients, through a thoracophrenolaparotomy in two patients, and through a left-flank extraperitoneal approach in the last four patients. The extraperitoneal approach simplified aneurysm dissection and aortic clamping with no cases of postoperative morbidity or death. In addition, we reviewed the CT scan findings of 12 patients surgically treated for inflammatory abdominal aortic aneurysm. The amount of fibrosis in the anterior wall of the aneurysm was greater than in the left posterolateral aspect (p = 0.008). We conclude that the left-flank extraperitoneal approach is the most anatomically advantageous route for repair of inflammatory abdominal aortic aneurysm.     

Transperitoneal versus retroperitoneal suprarenal cross-clamping for repair of abdominal aortic aneurysm with a hostile infrarenal aortic neck

Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60 degrees ), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.     

Intestinal Manipulation During Elective Aortic Aneurysm Surgery Leads to Portal Endotoxaemia and Mucosal Barrier Dysfunction

OBJECTIVES: to investigate the effect of intestinal manipulation on intestinal permeability and endotoxaemia during elective abdominal aortic aneurysm (AAA) surgery. DESIGN: prospective randomised controlled study. PATIENTS AND METHODS: fourteen patients undergoing elective infrarenal AAA repair were randomised into either the transperitoneal (n=7) or extraperitoneal approach (n=7). Intestinal permeability was measured preoperatively (PO), and at day 1 (D1) and day 3 (D3) after surgery using the lactulose/mannitol absorption test. Portal and systemic blood samples were taken before clamping, at completion of proximal and distal anastomoses and immediately before abdominal wound closure, for endotoxin measurement using the chromogenic limulus amoebocyte lysate assay. RESULTS: intestinal permeability was significantly increased at D1 (0.107+/-0.04 (mean+/-S.E.M.)) in the transperitoneal group compared to the PO level (0.020+/-0.004, p<0.05) and to the extraperitoneal group at D1 (0.020+/-0.004, p<0.05) which showed no change in comparison with the PO level. No correlation was seen between increased intestinal permeability and aortic clamp time, operation time, amount of blood lost or transfused. However, a significantly higher concentration of portal endotoxin was detected intraoperatively in the transperitoneal group of patients in comparison to the extraperitoneal group (p<0.05). There was a significant positive correlation between portal endotoxaemia and intestinal permeability (r(s)=0.955 p=0.001). CONCLUSION: an increase in intestinal permeability and a greater degree of portal endotoxaemia are observed during transperitoneal approach to the aorta. This suggests that intestinal manipulation may impair gut mucosal barrier function and contribute to the systemic inflammatory response seen in AAA surgery.     

The right retroperitoneal approach for abdominal aortic surgery

Retroperitoneal exposure of the abdominal aorta is usually performed through a left flank incision. An alternative approach to the abdominal aorta is described utilizing a right flank incision. Indications for the use of the right retroperitoneal approach during surgery for aortic aneurysms include right renal artery stenosis, right iliac artery aneurysm, need for simultaneous cholecystectomy, multiple or recent intraabdominal procedures, and sigmoid colostomy. A series of 17 patients is presented to illustrate the utility of this approach. There was one operative death in an emergent patient; the cause of death was not related to the method of aortic exposure. The remaining patients recovered quickly. The anatomic advantages and limitations of this exposure are discussed. We believe that retroperitoneal aortic exposure is superior to midline transperitoneal exposure. Aortic exposure utilizing a right retroperitoneal approach is a useful option in the surgical armamentarium.     

Can the retroperitoneal approach be used for ruptured abdominal aortic aneurysms?

The retroperitoneal approach for elective treatment of abdominal aortic aneurysms is an accepted alternative to midline transperitoneal approaches and may provide less physiologic insult and a smoother postoperative course. In recent years we have preferentially used the extended retroperitoneal approach for ruptured abdominal aortic aneurysms to derive similar physiologic benefits for these patients. Over a 6-year period (1983 to 1989) 76 cases of ruptured abdominal aortic aneurysms were treated by emergency aortic replacement. After exclusion of 13 patients whose aneurysmal ruptures were unusual, such as aortoenteric fistula, aortocaval fistula, chronic contained rupture, or visceral involvement, 63 patients were retrospectively studied. Thirty-eight patients were treated via a standard transperitoneal celiotomy and 25 via a left retroperitoneal incision. No significant differences were found between the two groups in regard to cardiac or pulmonary function or duration of preoperative hypotension. Operative mortality was lower in the retroperitoneal group (three of 25, 12%) as compared to the transperitoneal group (13 of 38, 34.2%). Furthermore, the retroperitoneal group required less ventilatory support and tolerated enteral feedings quickly. Length of stay in the hospital was also significantly reduced in the retroperitoneal group. These data indicate that many ruptured abdominal aortic aneurysms can be successfully treated through the left retroperitoneal approach. In this nonrandomized clinical series increased survival rates and shorter periods of postoperative recovery were noted in the patients operated with the retroperitoneal approach.     

Transverse abdominal incisions compared with midline incisions for elective infrarenal aortic reconstruction: Predisposition to incisional hernia in patients with increased intraoperative blood loss

Purpose: Both midline and transverse abdominal incisions are used for exposing the infrarenal aorta. Transverse incisions are said to cause less pulmonary and systemic complications, but the claimed advantages may be because most transverse incisions are extraperitoneal, whereas midline incisions are intraperitoneal. This study compares intraperitoneal transverse and midline incisions with respect to perioperative and late complications, especially incisional hernia.Methods: Three hundred twenty-nine patients undergoing infrarenal aortic reconstruction (239 aneurysms; 90 occlusive disease) were analyzed retrospectively according to whether the abdominal wall incision was midline (154 patients) or transverse (175 patients). In all patients, the subsequent dissection was transperitoneal and not retroperitoneal.Results: Perioperative survival rates and intraoperative blood loss were comparable, but the transverse incision tended to be followed by a shorter period of postoperative ileus ( p = 0.07), perhaps because the small bowel was not always exteriorized during operation with transverse incisions. Mean time spent in the intensive care unit was not different between the groups, but those with transverse incisions remained in hospital 5 days less than those receiving midline incisions ( p = 0.0005). When an aortic graft greater than 18 mm in diameter was used, survival was reduced compared with that after smaller grafts ( p = 0.028). At 1 to 6 years follow-up in 235 patients (109 midline; 126 transverse), 35 (14.9%) incisional hernias were detected, with no statistical difference according to incision (16.5% midline; 13.4% transverse). Analysis by univariate and multivariate logistic regression showed that blood loss at operation exceeding 1000 ml increased the risk of later incisional hernia by a factor of 3.07. Wound infection increased the risk of hernia by 3.70.Conclusion: Excess blood loss and wound infection exerted this predisposition to incisional herniation independent of other variables. (J V ASC S URG 1994;20:27-33.)     

Paramedian extraperitoneal approach for combined nephrectomy and augmentation ureterocystoplasty in children with neurovesical dysfunction

OBJECTIVES: We describe and evaluate our approach to combined nephrectomy and augmentation ureterocystoplasty using a single paramedian extraperitoneal incision. PATIENTS AND METHODS: Three patients with neurogenic bladders (2 posterior urethral valves and 1 myelodysplasia) underwent nephrectomy and augmentation ureterocystoplasty. The mean age of the patients was 4.6+/-1.5 years. The indications for the procedure included control of urinary incontinence or preservation and stabilization of renal function. RESULTS: The integrity of the peritoneal cavity was easily preserved throughout the procedure using a paramedian incision. No complications were encountered in these patients. Early postoperative resumption of normal diet and activity was noted in all patients. CONCLUSION: The paramedian extraperitoneal approach through a single incision provides the advantages seen with other extraperitoneal techniques combining two incisions. The single paramedian incision has the potential to save on operative time and obviates the need to change the patient's position on the operating table while under anesthesia. Furthermore, the paramedian extraperitoneal approach provides the reconstructive surgeon with the chance to convert the procedure into a transperitoneal technique to incorporate bowel segments in order to complement ureterocystoplasty.     

Incisional hernia following aortic surgery

Summary Controversy exists in the literature regarding the incidence of incisional hernia formation after aortic reconstruction and the rate of incisional hernia formation in vertical midline and transverse incisions. We reviewed the incidence of incisional hernia after aneurysm (AAA) or occlusive disease (OCC) aortic operations and the incidence of incisional herniorrhaphy for vertical midline versus transverse incisions. Through a retrospective chart review of patients between 1970 and 1998, 618 patients who underwent incisional herniorrhaphy, 265 who underwent AAA repairs, and 331 who underwent OCC repairs were identified. These three groups were cross-referenced to identify patients who underwent incisional herniorrhaphy following aortic reconstruction. Patients were analyzed and compared according to presence of AAA or OCC and the incision and suture material used during the aortic repair. Thirty-six patients underwent incisional herniorrhaphy following aortic reconstruction. Twenty-six patients (9.8%) required incisional herniorrhaphy after AAA repair (22 vertical midline incisions, 4 transverse incisions). All ten patients (3%) who underwent incisional herniorrhaphy after OCC repair had vertical midline incisions. The difference in the incidence of incisional hernia repair (9.8% vs 3.0%) between AAA and OCC was statistically significant (p<0.001). In AAA patients, there was an 11.3% incisional hernia repair rate after vertical midline incisions versus 5.6% after transverse incisions, but the difference was not statistically significant. We have demonstrated a significantly higher incidence of incisional hernia repair following aortic reconstruction for AAA than for OCC repair. Furthermore, we identified a trend towards increased incisional hernia repair after employing vertical midline incisions versus transverse incisions in AAA patients, and a significant risk for incisional hernia after AAA repair when absorbable suture was used.     

Open aneurysm repair at an endovascular center: value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms

OBJECTIVE: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. METHODS: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P =.04-.001) in the retroperitoneal group. All factors were correlated with outcome. RESULTS: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P >.2). CONCLUSION: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.     

Selective use of retroperitoneal aortic exposure in the emergency treatment of ruptured and symptomatic abdominal aortic aneurysms

Emergency surgery is the only effective treatment of ruptured abdominal aortic aneurysms, even though morbidity and mortality rates remain high. We have studied the feasibility of left retroperitoneal aortic exposure in these cases in an effort to reduce postoperative complications. Over a 33 month period, 29 patients underwent emergency surgery for either a ruptured or symptomatic infrarenal abdominal aortic aneurysm. Of 13 patients with ruptured aneurysms, 4 underwent repair through a midline transperitoneal approach (3 deaths) whereas the remaining 9 were repaired through the retroperitoneal exposure (1 death). Supraceliac aortic clamping through the same incision prior to aneurysm exposure maintained hemodynamic integrity. The remaining 16 patients with symptomatic aneurysms were all treated through the retroperitoneal exposure (3 deaths). In the retroperitoneal groups, the cause of death was cardiac in two patients, hypertensive stroke in one, and necrotizing pancreatitis in one. Morbidity consisted of prolonged intubation, respiratory distress syndrome, and thrombophlebitis in one patient each and acute tubular necrosis in two patients. We believe that the left retroperitoneal approach is a useful option in the emergent treatment of abdominal aortic aneurysms.     

Management of juxtarenal aortic aneurysms and occlusive disease with preferential suprarenal clamping via a midline transperitoneal incision: technique and results

Surgical management of juxtarenal aortic (JR-Ao) aneurysms and occlusive disease may include supraceliac aortic clamping, a retroperitoneal approach, or medial visceral rotation. The authors report their results using preferential direct suprarenal aortic clamping via a midline transperitoneal incision. Between July 1, 1992, and July 31, 2001, they treated 58 patients with JR-Ao disease (44 aneurysmal, 14 occlusive) via a midline incision without medial visceral rotation. Preferential suprarenal aortic clamping was used in 53 cases (42 proximal to both renal arteries, 11 proximal to the left renal artery only) and supraceliac or supramesenteric clamping in 5 cases when there was insufficient space for an aortic clamp between the superior mesenteric artery and renal arteries. This strategy avoided mesenteric ischemia associated with supraceliac clamping in the majority of cases and afforded better exposure of the right renal artery than obtainable with a left retroperitoneal approach or medial visceral rotation. Eleven patients underwent concomitant renal revascularization. Critical adjuncts included the following: (1) selective left renal vein (LRV) division if the vein stump pressure was < 35 mm Hg (suggesting sufficient renal venous collaterals existed), (2) bilateral renal artery occlusion during aortic clamping to prevent thromboembolism, (3) flushing of aortic debris before restoring renal perfusion, and (4) routine administration of perioperative intravenous mannitol and renal-dose dopamine. Patients with type IV thoracoabdominal aneurysms, ruptured aneurysms, or JR-Ao disease approached via a retroperitoneal incision (severely obese patients, re-do aortic surgery) were excluded. No patients died or required dialysis during their hospital stay. The LRV was divided in 12 (21%) cases and reanastomosed in 2 cases (elevated stump pressures). The average suprarenal clamp time was 26 minutes (range, 10-60). Postoperative serum creatinine remained > 0.5 ng/dL above baseline in 3 (5%) patients. These results support suprarenal aortic clamping with a midline transperitoneal incision as the optimal strategy for treating juxtarenal aortic aneurysms and occlusive disease. The authors believe that selective left renal vein division enhances juxtarenal aortic exposure, and routine administration of renal protective agents, along with occlusion of both renal arteries during suprarenal aortic clamping, are critical adjuncts in performing these operations.     

"Fast-track" abdominal aortic aneurysm repair

The "open" repair of abdominal aortic aneurysm (AAA) continues to evolve with incorporation of less invasive methods for surgical exposure and the use of patient care pathways for shorter hospital stays. In a consecutive series of 30 patients with infrarenal AAA, a "fast-track" hospital care pathway was implemented that included the following: AAA exposure via a limited (10-15 cm) retroperitoneal incision, use of self-retaining retractor and special vascular clamps/instruments, and prosthetic graft endoaneurysmorrhaphy. Excellent anatomic exposure for graft implantation was achieved with an average operative time of 175 minutes. Use of oral metoclopromide and patient-controlled epidural analgesia resulted in patient ambulation and oral diet on postoperative day 1. Average length of hospital stay was 3.6 days (range: 3-7 days), and no patient required readmission for AAA repair-related or gastrointestinal problems. One patient died (30-day mortality rate of 3.3%) caused by delayed recognition of a splenic injury, and 1 patient sustained an intraoperative ureter injury that was repaired and stented. Although stent-graft exclusion for AAA repair has become popular, the major advantages of endovascular therapy, such as shorter ICU and hospital stays, earlier dietary feeding, and reduction in postoperative morbidity, can also be achieved by using minimal incision exposure for AAA interposition grafting combined with traditional hand-sewn vascular anastomoses. "Fast-track" AAA repair is applicable to the majority of patients with infrarenal AAAs, and vascular surgeons can easily master the technique of "limited" incision retroperitoneal exposure. This approach avoids the concerns of endovascular stent-graft durability and the mandatory vascular imaging follow-up to identify endoleak development and AAA enlargement.     

Retroperitoneal approach for aortic surgery: is it worth it?

BACKGROUND: Previous reports suggest that earlier hospital discharges and reduced postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an effort to determine the most cost efficient method for aortic surgery in our institution, while maintaining high standards of care and outcome, we compared the retroperitoneal approach to the conventional transperitoneal aortic operation. PATIENTS AND METHODS: Between December 1995 and April 1998, 120 patients underwent aortic surgery by either the transperitoneal (n=60) or retroperitoneal approach (n=60). All patients were enrolled prospectively in a vascular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons. A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated with respect to demographics, comorbidities, preoperative risk stratification, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic surgery were similar in both groups - 64% for aneurysm disease and 36% for occlusive disease. Both symptomatic and asymptomatic aneurysms were included and size ranged from 4.4 to 14cm. All aortic reconstructions were done in the standard manner using knitted Dacron velour prostheses in either the aortic tube, bi-iliac or bi-femoral configuration. Statistical analysis of means and medians was accomplished using the Wilcoxin Rank-sum test and percentages were compared using Fisher's Exact test. P values less than 0.05 indicate statistical significance. RESULTS: There were no statistically significant differences in patient demographics. The incidence of atherosclerotic coronary artery disease, obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lower extremity occlusive disease and the results of chemical myocardial stress evaluations were similar in both groups. Comorbidities of pre-existing renal insufficiency/failure and morbid obesity were increased in the retroperitoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal group. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2-3l more intraoperative intravenous (IV) crystalloid than the retroperitoneal group (P<0.0001). Statistically significant reductions in ICU days, postoperative ileus and total lengths of stay were observed in the retroperitoneal group (P<0.0001). This resulted in substantial reductions in hospital costs for the retroperitoneal group (P<0.01). Postoperative complications were similar for both groups except for statistically significant increases in pulmonary edema (P<0.01) and pneumonia (P<0.001) in the transperitoneal group. Cardiac arrhythmias, primarily atrial dysrhythmias, were more frequent in the transperitoneal group but this failed to reach statistical significance (P<0.16). Combined thirty day mortality was 0.9%. Time of recovery to full activity and patient satisfaction substantially favored the retroperitoneal group. CONCLUSION: Our clinical pathway and algorithm for aortic surgery was easily followed by those patients in the retroperitoneal approach group and resulted in decreases in ICU time, postoperative ileus, volume of intraoperative crystalloid and total length of stay. The patients in the transperitoneal group often failed to progress appropriately on the pathway. Reduced hospital costs associated with aortic surgery using the retroperitoneal approach has increased the profitability for this surgery in our institution by an average of $4000 per case and has increased the value (quality/cost) of this surgery to our patients and our institution.