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Retroperitoneal Approach for Elective Abdominal Aortic Aneurysmectomy
The abdominal aorta, located posterior to the parietal peritoneum and adjacent to the spine, is by definition a retroperitoneal structure. The ease of aortic exposure from the supradiaphragmatic level to the iliac bifurcation makes a retroperitoneal approach an ideal option for both routine and complex aortic reconstruction. Techniques and appropriate indications vary for left-sided and right-sided retroperitoneal approaches in treating abdominal aortic aneurysms (AAA).
Indications and Contraindications
A traditional retroperitoneal exposure is the preferred approach to an AAA repair in the hostile abdomen, which includes patients with prior intraabdominal surgery resulting in adhesions, the presence of stomas, peritoneal dialysis, reoperative aortic surgery, prior abdominopelvic radiation treatment, inflammatory aneurysm, and morbid obesity. Relative contraindications to the retroperitoneal approach include limited exposure of the right renal and iliac arteries as well as the inability to fully examine the intraabdominal cavity for additional pathology at the time of surgical intervention. Most recently, this approach has been used for complex aortic reconstructions owing to the excellent exposure of the suprarenal and infradiaphragmatic aorta. It is also useful when treating pararenal aortic aneurysms as well as explanting failed endografts.
Surgical Techniques
Left Posterolateral Retroperitoneal Approach
After the induction of general anesthesia, the patient is placed on a suction bean bag (Olympic Vac Pac, Marlin Medical, Victoria, Australia) in a modified right lateral decubitus position. The patient is positioned with the table break 5 to 10 cm cephalad to the left iliac crest ( Figure 1 ). The patient’s torso is elevated 45 to 60 degrees from the horizontal position, and the pelvis is rotated 15 to 30 degrees to allow access to both groins. The left upper extremity is brought across the chest and supported by blankets or a stand. The left thigh is elevated above the horizontal plane by means of blankets or an additional suction beanbag to relax the ipsilateral iliopsoas muscle and improve access to the distal aorta and left iliac arteries. To open the space between the iliac crest and the costal margin, the table is flexed 20 to 30 degrees in a reverse V position at the table break.
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