Transperitoneal and retroperitoneal approach to the abdominal aorta: short-term results
(Portuguese PDF version)

Orlando Caetano Júnior,1 Bonno van Bellen2

1. Former fellow of Angiology and Vascular Surgery, Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficiência de São Paulo, São Paulo, Brazil.
2. Chief of Angiology and Vascular Surgery, Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficiência de São Paulo, São Paulo, Brazil. Associate professor of Peripheral Vascular Diseases, School of Medicine, Universidade de Campinas (UNICAMP), Campinas, São Paulo, Brazil.

Correspondence:
Orlando Caetano Júnior
Rua Banco das Palmas, 124
CEP 02016-020 - São Paulo, SP, Brazil
Phone/Fax: +55 (11) 6977.0711
E-mail: orlandocaetano@terra.com.br

ABSTRACT

Objective: The transperitoneal approach to the abdominal aorta is the most frequent procedure for the reconstruction of occlusive or aneurysmal diseases, although the retroperitoneal approach is frequently mentioned as being less prone to complications. The purpose of this study was to compare the two approaches with respect to early complications.

Patients and methods: Early results were studied prospectively in 84 patients (45 cases of aortic aneurysm and 39 cases of obstructive disease) submitted to surgeries for abdominal aortic aneurysm repair. Forty-one patients underwent the retroperitoneal approach and 43 the transperitoneal one.

Results: The retroperitoneal access was associated with less fluid replacement, shorter tracheal intubation time, earlier bowel movements restoration, oral food intake, and active mobilization. There was no difference in blood loss and length of hospital stay.

Conclusion: The retroperitoneal approach to the aorta has some advantages over the transperitoneal, especially as for early postoperative results.

Key-words: abdominal aorta, vascular access ports, surgery

J Vasc Br 2004;3(4):331-8

Historically, the approach to the aorta and its branches was performed through the retroperitonel access. It was preferred because of violation of the peritoneal cavity was almost always lethal. Abernethy, in 1796, performed the first successful aortic approach for ligation of the external iliac artery in the management of a femoral aneurysm as described in 1808,1 by Cooper. More recent and modern approaches still use the retroperitoneal technique, as used by Leriche, Oudot and Dubost et al.1-2 However, the peritoneal aortic access gained wider acceptance, maybe because the pioneers in vascular surgery were general surgeons, already familiar with surgeries in the peritoneal cavity.

In 1963, Rob3 reported 500 retroperitoneal surgeries, calling the attention again to the extraperitoneal access. Since then, a number of different positive reports about the improvement in the postoperative period of retroperitoneal aortic approach has been published, claiming its indication for high-risk or obese patients.4 However, other works were not able to show differences between these two approaches.5-11

This study was designed to compare both approaches (retroperitoneal and transperitoneal) as for short-term postoperative results in a series of patients submitted to abdominal aortic reconstruction.

PATIENTS AND METHODS

Patients

Eighty-four patients submitted to aortic reconstructions (from 1988 to 1991) were included in this study. The following variables were assessed:

  • operative time;
  • fluid replacement during the first 24 postoperative hours (crystalloids and blood, including derivatives);
  • extubation time;
  • return to the normal digestive functions (bowel sounds and food intake);
  • postoperative walking;
  • time of postoperative hospital stay;

The transperitoneal approach was performed in 43 patients, 23 with abdominal aortic aneurysm (AAA) (20 male and three female), and 20 with aortoiliac occlusive disease (AOD) (18 male and two female). Mean age for male and female groups was 63 years as well as for the whole group.

The transperitoneal approach was performed in 41 patients, 22 with AAA (18 male and four female), and 19 with AOD (16 male and three female). Mean age was 61 years, 62 for males and 58 for females.

Twenty-nine patients (67%) were randomly submitted to transperitoneal approach and 32 (78%) to retroperitoneal access. The remaining patients were submitted to transperitoneal approach (14 patients) because of specific indications determined by the surgeon:

" wide access to the right iliac artery required (eight cases - 19%)
" association with other procedures required, mainly cholecystectomy (5 cases - 12%);
" right renal artery access required (one case - 2%)

Nine patients underwent the retroperitoneal approach (22%) also because of specific indications:

" hostile abdomen because of previous abdominal surgeries (five cases - 12%);
" suprarenal aortic disease (two cases - 5%)
" severe chronic obstructive pulmonary disease (two cases - 5%)

There were no statistically significant differences among groups as for associated diseases (diabetes mellitus, coronary insufficiency, renal insufficiency, arterial hypertension and chronic obstructive pulmonary disease). Coronary insufficiency and arterial hypertension were highly prevalent in both groups (Table 1).

click hereTable 1 - Demographic data and risk factors

Disease Transperitoneal Retroperitoneal
Coronary insufficiency 44% 37%
Renal insufficiency 2% 5%
Systemic arterial hypertension 54% 63%
Diabetes mellitus 12% 15%
Chronic obstructive pulmonary disease 2% 5%
P > 0.05 - Proportion analysis: large sample theory.

Patients who underwent other concomitant surgical procedures, as sympathectomy, iliac artery endarterectomy, surgery for isolated aneurysm of the common iliac artery, trauma, ruptured aneurysm, thoracoabdominal aneurysm and extra-anatomic bypass were not included in the study.

Mortality was not statistically significant and was not a consequence of incisions per se, therefore it was not considered in the discussion.

Description of surgical access

In the transperitoneal approach, a xyphopubic midline incision was performed with the patient in the supine position. The incision began over the abdominal midline, between the xyphoid process and the pubic symphysis,12 and it was carried to the left at the umbilicus, involving the skin and the subcutaneous tissue. The incision reached aponeurosis at the linea alba, between the xyphpoid process and the pubic symphysis. The peritoneum was opened and, after analyzing the abdominal cavity, viscera were rotated toward the right portion of the abdominal cavity, exposing the retroperitoneal region.

In the retroperitoneal approach, incision was performed as described by Rob,3 but some modifications were made as for the height and approach to the left abdominal rectus muscle. The patient was turned to right lateral decubitus with hips and thorax rotated 30° and 60° in relation to the operating table, with upper limb abducted to 90° beside the head. The operating table was gently flexed in the middle (Figure 1). The incision began at the midline, about 3 cm below the umbilicus toward the 10th or 11th intercostal space up to the axillary line or on the level at which aorta needed to be approached (Figure 2). The external oblique aponeurosis and the edges of the left abdominal rectus muscle were incised with the abdominal muscle being retracted to the right. It was only devided in cases where a higher approach to the iliac arteries was needed. The external and internal abdominal oblique muscles were sectioned, and the transversus abdominis was preferably split to gain access. After the fascia transversalis was opened, the peritoneal sac was retracted to the right. In higher aortic approaches, made by thoraco-phreno-laparotomy, the kidney had to be dislodged. Supraceliac clamping was performed by splitting the left diaphragmatic pillar; the aorta was approached at its posterolateral portion.

click hereFigure 1 - Patient's position.

click hereFigure 2 - Retroperitoneal incision.

The Student test with significance level 0.05 was used to compare findings.

RESULTS

As for early recovery, surgery time was shorter for patients submitted to aortic aneurysm management with aorto-aortic interposition grafts in the retroperitoneal group. Mean time was 228 minutes for the transperitoneal (TP) and 180 minutes for the retroperitoneal approach (RP). In patients submitted to aortobifemoral bypasses for AAA or AOD, there were no statistically significant differences (mean of 252 minutes in TP and 266 minutes in RP).

The retroperitoneal approach required less crystalloyd replacement (4,993 ml for TP and 3,808 ml for RP), shorter intubation time (22 hours for TP and 11 hours for RP), bowel movements restored earlier (51 hours in TP and 23 hours in RP), oral food intake started earlier (87 hours in TP and 40 hours in RP) as well as active mobilization (89 hours in TP and 59 hours in RP).

Blood or derivatives replacement was equal among the two groups (1,382 ml in RP and 1,122 ml in TP). Hospital stay was not significantly different between the two approaches (9.7 days in TP and 7.5 days in RP). Local complications in patients submitted to the retroperitoneal approach were haematoma of surgical wound in five cases (12%), hernia in two cases (5%), and inguinal infection in one case (2%). In the transperitoneal approach, there were four cases of evisceration (9%) and two cases of abdominal wall seroma (5%) (Table 2).

click hereTable 2 - Local complications

Type of approach Retroperitoneal Transperitoneal
Haematoma 5 cases 0
Hernia 2 cases 0
Evisceration 0 4 cases
Seroma 0 2 cases
Inguinal infection 1 case 0
P > 0.05

Systemic complications in cases of retroperitoneal approach were predominantly renal insufficiency, in three cases (7%), which needed suprarenal aortic clamping (one patient with type IV aneurysm, one with suprarenal aneurysm and other with pseudoaneurysm). No dialysis was required and all patients had their renal function restored to baseline levels. Other complications were deep venous thrombosis, pulmonary atelectasis and cerebral vascular accident (CVA) with one case each. All of them were completely healed. One patient developed occlusion of an aortobifemoral graft due to lack of flow, which caused severe ischemia and needed reoperation.

In the transperitoneal approach, the most frequent general complication was respiratory failure, in 7% of cases, followed by congestive cardiac insufficiency and renal insufficiency with 5% each. Only one patient underwent suprarenal clamping. Other complications were hemorrhage of the superior digestive tract and cerebral vascular accident with one case each. One patient had occlusion of the aortoiliac graft and received an aortofemoral graft with good recovery (Table 3).

click hereTable 3 - Systemic complications

Type of Access Transperitoneal Retroperitoneal
Renal insufficiency 3 cases (7%) 2 cases (5%)
Atelectasis 1 case (2%) 0
Cerebral vascular accident 1 case (2%) 1 case (2%)
Stent thrombosis 1 case (2%) 1 case (2%)
Respiratory failure 0 3 cases (7%)
Congestive cardiac insufficiency 0 2 cases (5%)
High digestive hemorrhage 0 1 case (2%)
P > 0.05

DISCUSSION

Although the transperitonal approach is preferred in surgery for aortic reconstruction, it poses some drawbacks. The goal of the present article was to compare the retroperitoneal against the classical approach to determine whether one technique was superior to the other with respect to the early postoperative.

There was a significant decrease in the operating time of patients submitted to aorto-aortic grafting, in the retroperitoneal approach, but not in the aortobifemoral. Literature is not uniform concerning findings, and there are reports associating shorter and longer8 operating times to the retroperitoneal approach,13-15 although all of them analyzed only the total of surgical procedures. Nevertheless, the analysis of the majority, especially the most recent ones, tend to show that there are not significant differences between the two approaches,5,7,9-11,16-18 probably due to higher technical expertise acquired over the last years.

Less crystalloid and blood replacement was required in the first 24 postoperative hours in patients submitted to the retroperitoneal approach, however, this was not enough to cause a significant difference in blood replacement. Literature reports on series that had less fluid replacement18-20 and other with findings similar to ours.5,14,21 Although blood loss is a fact that affect the prognosis of aortoiliac reconstruction,22 we understand that less requirement of crystalloid replacement should not be disregarded, once it can lead to possible complications, especially pulmonary. Other studies have found the same results in both groups as for crystalloid replacement, but some aspects should be mentioned, as for example autotransfusion and specialized anesthesiologists, with fluids replacement standardization,5-7,9-11 which are not always available. Although they were available in our Service, they seem not to have affected results. One of our series had higher blood and colloids replacement in the retroperitoneal approach, but no difference was found in the replacement of crystalloids and, most significantly, in the prevalence of complications, including lung complications.8 With relation to operating time, recent series tend to show replacement volumes with no statistically significant difference.

In accordance with the literature, there was an improvement in the extubation time of patients submitted to the retroperitoneal approach.15,19,20,23,24 However, there are reports that do not show significant differences concerning general anesthesia.6,8-10 There is another situation, in which difference was not statistically significant as well, in which we employed a combination of epidural and inhaling anesthesia, allowing patients to be extubated in the surgery room.7-11 Literature tends to show the absence of significant differences between both approaches.7,8-11 The digestive functions normalized earlier in the retriperitoneal approach, as reported in the literature.5,7-10,13-19,23-28 Some of the reports considered the time the patients remained with the nasogastric tube. The use of this tube was abandoned soon after the first cases of retroperitoneal approach were handled in our Service, once it showed not to be necessary. This parameter was assessed after the return of normal digestive functions (bowel sounds and food intake). Even in studies without statistical significance, the clinical assessment was favorable to the retroperitoneal approach.11

Walking started earlier in patients submitted to the retroperitoneal surgery, evidencing the patients had a better postoperative recovery.
As for length of hospital stay, there was no significant difference, as in other series,7,10,11 nevertheless, the literature mentions some cases of decreased hospital stay in the retroperitoneal approach.5,6,13-15,17-19,26,27

Early complications were not statistically significant, in accordance with the literature,6-8 but there were four cases of dehiscence in patients submitted to the transperitoneal approach which needed to be surgically corrected and therefore increased morbidity. Diabetes mellitus, hypercholesterolemia, hypertension, obesity, malnutrition and even the technical conditions of the abdominal suture should be faced as potential factors for the development of complications, regardless of the incision procedure. Studies show that complications were higher in the transperitoneal approach,5,10,11,15 especially pulmonary complications, such as atelectasis and pneumonia.5,15

With relation to the prevention of possible complications, an analysis of different systemic parameters of inflammatory response has shown that the transperitoneal approach is more aggressive than the retroperitoneal one, probably because of bowel manipulation and mesenteric traction.29 However, the clinical importance of these outcomes remains uncertain.

We have not approached issues concerning the reduction of costs, although it has been a current reason of concern. The retroperitoneal approach shows a reduction of 22% per patient as for mean hospital costs.5,6,10 As a way of reducing costs, the standardization of procedures has been proposed and effectively deployed in many services.5

Technical aspects of the retroperitoneal approach are described in the literature.30 They can be an extension of an inguinal ,21,25 transverse,17 paramedian,26,28 and median incision.9,16,31 The flank incision can be anterolateral, as used by Rob3 and Sicard et al.,10,18 and posterolateral, as claimed by Leather et al.,19 Shepard et al.20 and Williams et al.24 Despite differences, they have quite enough similarities to be compared against the xyphopubic median incision.

The retroperitoneal approach is not time-consuming, it is easy and safe,1,4,32 although surgeons should require some time to get familiar with it.

The left ureter is easily visualized, providing safety to the necessary medial dissection and thus preventing possible injuries. This is also the case with variations of retroperitoneal vessels, avoiding also dangerous bleeding. We underline the need for dissecting the left kidney in order to ease a higher approach to the aorta. Although some authors consider the ligature of the inferior mesentery artery must be performed7,15,18 and others consider it can be optional,3,14,28,33 it was undertaken in some cases of our study. For obese patients, the retroperitoneal approach yields better patient management. Our Service has reported cases of previous retroperitoneal incision where the new approach through the same via is safe and straightforward.

On the other hand, both inguinal incision and femoral anastomosis may be precluded by the patient's position, as well as the dissection towards the inguinal region. These drawbacks are easily solved by inclining the operating table laterally towards the surgeon. Some authors say it is impossible to perform a non-ostial revascularization of the right renal artery, as well as to approach the right iliac artery.13-15,17,18,20,23,24,27 The theory points to an approach through the right flank in the same access,17,21,34 or through the midline.9,16,31

The retroperitoneal approach is better indicated in high-risk situations, such as important cardiopulmonary disorder, suprarenal aortic occlusive or aneurysmal disease, thoracoabdominal aneurysm35,36, inflammatory aneurysm, visceral disease, aortic reoperation37 and horseshoe kidney. In case of a hostile abdomen,30 due to multiple previous operations, intraabdominal sepsis or previous radiotherapy, the retroperitoneal incision is better indicated, preventing the time-consuming lysis of adhesions, always associated with the risk of visceral perforation and consequent infection. The retroperitoneal approach is usually indicated for overweight patients, as well as for patients submitted to peritoneal dyalisis or presenting with intestinal stoma,30 especially on the right side. We emphasize the need for a detailed preoperative clinical examination to diagnose situations that require the exploration of the peritoneal cavity, as tumors38 and colelithiasis,19 although, if there is any doubt, the peritoneum can be opened during surgery for cavity inspection. The preoperative arteriography is also important, as it can show possible renal diseases, accessory renal arteries and/or the presence of horseshoe kidney. The transperitoneal access should also be performed in cases with suspicion of venous malformation (left inferior vena cava) and with the presence of an aorto-cava fistula.30 So far, there has not been reported any case of aortoenteric fistula after the retroperitoneal approach. The retroperitoneal approach is not recommended in the management of ruptured aneurysms.3,39

CONCLUSION

We conclude that the retroperitoneal approach can be used as a routine procedure, once it is associated with fewer morbidity and is technically easier to manage, except in specific cases.

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