Retroperitoneal Approach to AAA Repair

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Retroperitoneal Approach to AAA Retroperitoneal Approach to AAA RepairRepair

George E. Hajjar MD. FRCSCDivision of Vascular and Endovascular

SurgeryUniversity of Ottawa

Canada

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Ottawa Canada The Nations Capital. Pop 990,000

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Retroperitoneal AAA Repair

• Advantages:Advantages:• Lesser post-op pain, easier respiratory

functions.• Less third spacing and fluid shift. • Less hypothermia• Less bowel oedema, and transient ischemia• Less post op ileus and need for NG suction• Better exposure of suprarenal aorta• The Aorta is a retroperitoneal structure

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Retroperitoneal AAA Repair• Advantages (Contd):Advantages (Contd):• Avoids going through intra-abdominal adhesions

and scarring• Prevents development of intra-abdominal

adhesions and scarring• Decreases the chances of duodenal injury, and

intramural haematoma• Decreases the incidence of Aorto-duodenal fistula

development• Possibly decreases length stay.

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Retroperitoneal AAA Repair

• Not widely used:Not widely used:• Unfamiliarity with the approach• Reserved for selective difficult cases• Fear of incisional complications : muscle eventration

although it does occur it is well tolerated in this patient population. No incisional hernias or eviscerations.

• Fear of difficulty exposing associated iliac disease: Right iliac aneurysm or femoral exposure if needed.

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Retroperitoneal AAA Repair• Procedure of choice InProcedure of choice In• Hostile abdomen• Juxta-renal or supra-renal aneurysms• Horseshoe Kidney• Redo Aortic Surgery• Inflammatory aneurysms

• Avoided:Avoided:• If concurrent right renal repair is needed• Left sided vena cava, other venous anomalies• Ruptured aneurysm with large left sided haematoma

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Retroperitoneal AAA RepairHorseshoe kidney

• Requires Re-implanting renal branches to the isthmus

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Ruptured AAA

• Avoid left sided ruptures. Unless low down and neck is accessible

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Redo Aortic Surgery

• Remote ABF. Proximal aortic aneurismal degeneration

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Right iliac aneurysms

• Mobilization of the retroperitoneum low down in the left pelvis• Relaxing the upper incisional retractors• Ligating and transecting the IMA , allows further aneurysm mobilization .

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Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada

Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada

Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada

Retroperitoneal AAA Repair

Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada

Draining Lumbar vein

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Retroperitoneal AAA Repair venous anomalies

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Suprarenal exposure

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Iliac Exposure

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Retroperitoneal AAA Repair

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Retroperitoneal AAA Repair

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Retroperitoneal AAA Repair: our experience

• Demographics:251 consecutive Patients (2004-2012)251 consecutive Patients (2004-2012)M : 195 F: 56M : 195 F: 56Age: 87-52 Av:71.5 Mean: 71Age: 87-52 Av:71.5 Mean: 71

• Co morbidity:Co morbidity:CAD: CAD: 112112COPD: (1 or 2 puffers) COPD: (1 or 2 puffers) 40 40 Diabetes: Diabetes: 4444Obesity: (BMI>30)Obesity: (BMI>30) 4646Hx of smoking:Hx of smoking: 230230HTN:HTN: 165165

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Retroperitoneal AAA Repair: our experience

• Aneurysm Characteristics:Aneurysm Characteristics:• PrimaryPrimary:: 246 patients 246 patients

• Redo Redo :: 5 patients 5 patients1 pat. 1 yr post REVAR1 pat. 1 yr post REVAR2 pats. Secondary ADF, in a Type IV AAA post remote 2 pats. Secondary ADF, in a Type IV AAA post remote aortic Sx.aortic Sx.1 pat. IAAs post ruptured AAA repair 4 years earlier1 pat. IAAs post ruptured AAA repair 4 years earlier1 pat. Had an AAA 10 years post ABF end to side graft1 pat. Had an AAA 10 years post ABF end to side graft

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Retroperitoneal AAA Repair: our experience

• Aneurysm Characteristics:Aneurysm Characteristics:231231 electiveelective15 15 acute /symptomaticacute /symptomatic5 5 ruptured (3 acute, 2 chronic)ruptured (3 acute, 2 chronic)

• Other findings:Other findings:2 horseshoe kidneys2 horseshoe kidneys6 inflammatory6 inflammatory89 IAA. 54 bilat. 15 R. 20 L.89 IAA. 54 bilat. 15 R. 20 L.46 patients had previous abdominal 46 patients had previous abdominal surgery.surgery.

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Retroperitoneal AAA Repair: our experience

• Proximal control:Proximal control:212 infrarenal33 Suprarenal6 Supraceliac, type IV AAA repair.

• Type of Repair:Type of Repair:136 Tube graft89 AIs. 54 Bilat, 15 R, 20 L24 ABFs.2 pericardial patch aortic closures

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Retroperitoneal AAA Repair: our experience

• Additional procedures:Additional procedures:

IMA re-implantation 5Renal re-implantation /graft 6

2 horseshoe kidneys1 accessory renal3 left renal grafts.

AxBfem &aortic graft excision 2Duodenal closure 2

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Retroperitoneal AAA Repair: our experience

• Mortality:Mortality:• No intra-op mortality• 30 day Mortality30 day Mortality : 2 patients

1 cardiogenic shock 1 respiratory failure

• In hospital deathIn hospital death : 2 patients1 Ischemic colitis and MSOF1 progressive renal failure, resp failure

• Total in hospital mortalityTotal in hospital mortality:4 (1.6%)

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Retroperitoneal AAA Repair: Length of stay

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Retroperitoneal AAA Repair: Complications

• Cardiac:Cardiac:Arrhythmias 12, (1 Pneumo: pacemaker)CHF10, (1 needed mitral repair)MI: 8 ( 2 required intervention)

• Renal:Renal:20 transient rise in Creatinine6 ARF: 2 hemofiltration only, 3 transient dialysis, 1 permanent

• Respiratory:Respiratory:Exacerbation of COPD:5 ( 1 needed home O2)1 PEDVT

• Post-op bleed:Post-op bleed:6 total. 4 no source was found. 2 splenectomy

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Retroperitoneal AAA Repair: Complications

• GI:GI:Ischemic colitis: 8 transient, 4 C.diff, 2 colectomiesUGI bleeding. 6 gastro duodenal erosions ( 1 required cauterization)4 post-op ileus.

• Peripheral ischemia:Peripheral ischemia: 4 patients:Ext iliac occlusion (1), bilat SFA thrombosis post RAAA(1)popliteal artery occlusion (thrombectomy and fasciotomy)SFA atheroembolic diseaseAcute occlusion of one ABF limb, required urgent revision

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Retroperitoneal AAA Repair: Incisional complications

• 13 patients.13 patients.• Wound infection:6Wound infection:6

2 proven cultures with purulent drainage4 erythema. No culture Rx with Abx.

• Wound haematomaWound haematoma: 4: 4• Serosanguinous drainageSerosanguinous drainage: 3: 3

• Late incisional complications:Late incisional complications:1 Intercostal neuralgia(tip of 111 Intercostal neuralgia(tip of 11thth rib was excised rib was excised for higher exposure)for higher exposure)2 excision of Prolene knot2 excision of Prolene knot6 specific complaints about asymmetric bulge 6 specific complaints about asymmetric bulge needed reassuranceneeded reassurance

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Conclusion• Retroperitoneal approach for AAA repair is easily

feasible.• Can be used in a variety of conditions including right

iliac aneurismal disease, aortoiliac disease.• Approach of choice for hostile abdomens, redo aortic

surgery, inflammatory aneurysm, horseshoe kidney, suprarenal aneurysms

• Does not provide access to right renal artery if needed• Avoided in large left retroperitoneal haematomas and

ruptured AAA

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Ottawa: The Parliament buildings