Management of Juxtarenal Aortic Occlusive Disease by Retroperitoneal and Transperitoneal Exposure of the Pararenal and Suprarenal Aorta

Transperitoneal Exposure of the Supraceliac Aorta and Celiac Artery

The exposure of the supraceliac aorta and the celiac artery is required for antegrade bypass to the visceral vessels (both SMA and celiac artery) in the setting of mesenteric ischemia and for the more common scenario when proximal control of the abdominal aorta is required as in the case of a ruptured infrarenal or juxtarenal abdominal aortic aneurysm. The origin of the celiac artery and a 5- to 8-cm segment of the aorta caudal to its origin may be exposed using this approach, although a more limited approach and dissection is usually sufficient if the objective is only to apply a proximal aortic clamp. The supraceliac aorta is usually relatively free of atherosclerotic occlusive disease and therefore is a good inflow source for antegrade visceral bypass. The exposure of the segment of aorta caudal to the celiac artery is somewhat limited through this approach given the overlying anatomic structures and should be exposed through an alternative approach.

The procedure can be performed using either a midline or bilateral subcostal incision; the choice is contingent upon the surgeon’s preference and the patient’s body habitus. The midline incision is slightly easier to close, although a bilateral subcostal incision with a midline extension to the xiphoid provides optimal exposure of the upper abdomen. A lumbar bump can augment the aortic exposure for all of the transperitoneal approaches.

After a general exploration of the abdomen, the left triangular ligament of the liver is incised and the left lateral segment of the liver is reflected to the patient’s right side using a self-retaining retractor such as a Bookwalter. Care should be exercised during incision of the triangular ligament to avoid injuring the hepatic veins. The gastrohepatic ligament is then incised, although caution should be exercised during this maneuver because a replaced left hepatic artery, a common anatomic variant, passes through the ligament. The esophagus and stomach are then retracted to the patient’s left, and identification of the esophagus is facilitated by palpation of the nasogastric tube or transesophageal echocardiography probe. The exposure can be facilitated at this point by placing the patient in a significant amount of reverse Trendelenburg, allowing the abdominal structures to retract caudally by gravity.

The median arcuate ligament and the crus of the diaphragm are incised to expose the underlying aorta; this can be facilitated by incising the muscle fibers between the jaws of a large right-angle clamp using electrocautery ( Figure 1 ). The dissection of the aorta cephalad to the celiac artery can be exposed relatively quickly, although care should be exercised in the segment adjacent to the celiac artery to avoid inadvertent injury to the vessel. Additionally, a dense neural plexus, further complicating the dissection, encases the origin of the celiac artery.

The extent of the aortic dissection required is dictated by the clinical situation. It is not usually necessary to dissect the aorta circumferentially, but it can be helpful to place an umbilical tape around the aorta to serve as a handle should difficulties arise. Importantly, the intercostal vessels come off the posterior aspect of the aorta at this location and can be easily injured. Occasionally the pleura of the lung is entered during the dissection. This is usually obvious and of little consequence, although a chest radiograph should be obtained in the immediate postoperative period to confirm that the lungs are fully expanded. Vascular control of the supraceliac aorta can be obtained very expeditiously if necessary (e.g., unstable patient with ruptured aneurysm) by bluntly dissecting the crus of the diaphragm with the index and long fingers and using them as a guide to position an aortic clamp.