Endoaneurysmorrhaphy with intraluminal straight graft placement in infrarenal abominal aortic aneurysm - Vascular Surgery

Infrarenal AAAs greater than 5 cm in diameter and aneurysmal neck angulation greater than 60° do not lend themselves to EVAR.

Perform median laparotomy from xiphoid down to symphysis, carrying the incision to the left of the umbilicus.

Tips:

1. Maintain adequate distance from the umbilicus and do not incise the skin tangentially as this runs the risk of wound edge necrosis.

2. If the incisdion damages the cartilage of the xiphoid, it may trigger heterotopic ossification in the scar. Therefore start the incision somewhat lateral to the xiphoid.

After exploring the abdomen, sweep the small intestine to the right and the transverse colon into the upper quadrants. Coagulate smaller vessels and open the retroperitoneum slightly to the right of the right iliac axis, sparing the inferior mesenteric artery (AMI) and lymphatic pad. Carry the incision to the right of the AAA. Mobilize the duodenojejunal flexure.

Expose the right common iliac artery by dissecting directly on the vessel and sweep the preaortic lymphatic and adipose tissue pad to the left. Expose the left common iliac artery. Expose the aneurysmal neck after definitive identification and exposure of the crossing left renal vein.

Tips:

1. In difficult conditions, first obtain central control before any bleeding, i.e., obtain control of the aneurysm neck.

2. Sometimes the left renal vein crosses posterior to the aorta. If this is not heeded, the vein may be easily injured during cross-clamping of the aneurysm neck, resulting in catastrophic venous hemorrhage. Carefully study the preoperative CT images for such anatomic variants before the procedure!

Wrap the small intestine in plastic sheeting or place it in a plastic bag. Sweep the transverse colon to the upper abdomen once again.

Tip:

Placing the small bowel in a plastic bag or wrapping it in plastic sheeting ensures that the bowel remains moist and does not sustain serosal lesions. This can also help prevent postoperative adhesions.