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Results of 256 consecutive abdominal aortic aneurysm repairs using extraperitoneal approach
Cardiovascular Surgery, Vol. 9, No. 3, pp. 249–253, 2001 2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd All rights reserved. Printed in Great Britain 0967-2109/01 $20.00
PII: S0967-2109(00)00134-4
www.elsevier.com/locate/cardiosur
Results of 256 consecutive abdominal aortic aneurysm repairs using extraperitoneal approach T. Igari, S. Hoshino, F. Iwaya, H. Satokawa, H. Midorikawa, S. Takase and Y. Hoshino Fukushima Medical University School of Medicine, Department of Cardiovascular Surgery, 1 Hikarigaoka, Fukushima City, 960-1295, Japan Two hundred and fifty-six consecutive abdominal aortic aneurysms were repaired using three approaches for extraperitoneal exposure of the aorta and iliac vessels from February 1990 through September 1998. The perioperative mortality rate was 3.1% in 228 elective repairs and 14.3% in 28 ruptured cases. The initial 23 cases were repaired using Sicard’s method. The duration of endotracheal intubation was 1.0±2.8 h, alimentation initiation was 2.7±1.6 days, and narcotic requirements were 1.2±1.1 times. Following these initial cases, we employed Williams’ method for 192 abdominal aneurysms, however; repeated incisional pain and three cases of deforming bulge led us to avoid dividing muscles. In the last 13 cases, our approach was performed without muscle dividing. The narcotic requirements decreased to 0.3±0.7 times. As for postoperative complications, the larger skin incision approach had no shower embolism. However, the shorter skin incision had four cases of shower embolisms, one lymphorrhea and one vascular trauma by the aortic clamp. The extraperitoneal approach offers certain physiologic advantages with minimal disturbance of gastrointestinal and respiratory function. We believe that this method is useful for rapid approach to the proximal aorta in case of emergency. Postoperative wound complications could be prevented via an oblique incision without muscle dividing. 2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: abdominal aortic aneurysm; extraperitoneal approach; rupture
The advantages of the extraperitoneal approach in aortoiliac reconstruction have been recognized since 1963 [1]. The extraperitoneal approach offers a smoother, faster, and less complicated postoperative course with low incidence of pulmonary complications and ileus [2]. The purpose of this paper is to review the advantage of the extraperitoneal approach to the infrarenal abdominal aneurysm.
Materials and methods From February 1990 through September 1998, 256 consecutive patients underwent repair of the infrarenal abdominal aortic aneurysm (AAA) at Fukushima Medical University Hospital. Of these 256 cases, 222 Correspondence to: Tsuguo Igari, MD. Tel.: +81-24-548-2111 (ext. 2492); fax: 81-24-548-3926; e-mail: [email protected]
CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
cases were elective operations for non-ruptured AAA (Table 1). This paper focuses primarily on the elective cases. Ruptured cases are briefly described. The nonrupture elective extraperitoneal approach group was divided into three groups. The initial 23 cases were repaired using Sicard’s method [3], dividing bilateral rectus abdominis muscle (S group). After these initial experiences, we changed to original Williams’ method [4], extended oblique incision. 192 infrarenal AAAs were repaired using this method (W group). From April 1998, the last 13 cases were repaired using oblique incision without muscle dividing (O group). In addition to assessing the changing course of patients undergoing aortoiliac reconstruction, 128 infrarenal AAA patients undergoing elective repair via the transperitoneal approach prior to 1990 were compared. All values are expressed as mean±standard deviation of the mean. Statistical analysis of the data was performed using the Student’s t-test. 249
Abdominal aortic aneurysm repairs: T. Igari et al. Table 1
Elective repaired abdominal aortic aneurysmsa
Cases Age (yr) Sex (male/female) Origin Arteriosclerosis Traumatic So called inflammatory Risk Hypertension Smoking Ischemic heart disease Hyperlipidemia Cerebral vascular disease (CVD) Obesity Malignant neoplasama Diabetes mellitus Obstructive pulmonary disease
EP 229
TP 128
71.2±7.0 (50–93) 192/37
66.2±8.6 (40–82) 101/27
225 2 2
128 0 0
141 (61.6%) 107 (46.7%) 49 (21.4%) 35 (15.3%) 26 (11.4%) 20 (8.7%) 20 (8.7%) 14 (6.1%) 11 (4.8%)
69 (53.9%) 53 (41.4%) 6 (4.7%) 5 (3.9%) 11 (8.6%) 6 (4.7%) 7 (5.5%) 9 (7.0%) 3 (2.3%)
a
EP: extraperitoneal approach; TP: transperitoneal approach
Operative technique The patient is positioned with the hips parallel to the table and the left (or right) thorax elevated 30–40°. The incision is begun midway between the umbilicus and symphysis pubis and extended in a curvilinear fashion to the left (or right) lateral portion of the flank, 5-cm medial to the anterior superior iliac spine and extended posteriori to the eleventh intercostal space. Bilateral rectus muscles are divided [3] in the S group. In the cases of W group, the skin incision is started from the outer edge of the rectus muscle and included the distal paramedian line to prevent the division of the rectus muscle. The muscles are divided with electocautery to minimize blood loss. The peritoneum is mobilized medialy and cephalad with exposure of the distal aorta and common and external iliac arteries. A self-retaining retractor system is routinely used. To avoid retraction trauma, as well as to provide better access to the juxtarenal space, the ureter is never mobilized from its position. The kidney and ureter are left in place in a case needed to expose ipsilateral renal artery. The gonadal vein is ligated at the junctional of the renal vein to avoid retraction avulsion, if necessary. Division of the inferior mesenteric artery is only permitted, when exposure of the opposite side of the aorta and right iliac system was difficult. In the last cases, O group, the muscles are not divided and skin incision is about 10–12 cm from the lateral border of the rectus muscle to the 12th rib (Figure 1).
Results Non-ruptured cases The age, operating time, and intraoperative bleeding amount of the TP group and three groups of the 250
Figure 1 Skin incision of three extraperitoneal approaches. S group: from midway between the umbilicus and symphysis pubis to the 11th intercostal space; W group: from the outer edge of the rectus muscle to the 11th intercostal space, earlier cases started from midway between the umbilicus and symphysis and later cases started at the level of the umbilicus (similar as O group); O group: from the outer edge of the rectus muscle at the level of the umbilicus to the 12th rib
extraperitoneal approach are shown in Figure 2. No significant differences were found. The duration of endotracheal intubation, initiation of alimentation, and narcotic requirements after operation are shown in Figure 3. The duration of endotracheal intubation became shorter in extraperitoneal approach, especially in the S group which was 1.0±2.8 h. This was significantly shorter than the TP group. However, the W group and the O group needed more intubation. Also, initiation of alimentation became shorter and narcotic requirement was less necessary in groups of the extraperitoneal approach. Narcotic requirement became significantly less in the O group. As Table 2 shows, surgical outcome of the non-ruptured AAA cases had a mortality rate of 3.1% (7/229 cases). So far, nine late deaths have occurred among 222 patients. Complications are shown in Table 3. In the S group, the largest approach among the extrapeitoneal approach had no complications. Small incision approaches had shower embolism, bulge, lymphorrhea, and vascular injury. Ruptured cases As Table 4 shows, 28 ruptured cases were operated through the extraperitoneal approach, Williams’ method. Hospital death was 4 and mortality rate was 14.3%. Follow-up duration was 60.6±30.8 months in 24 patients walking out from our hospital. Among 24 cases, three patients were lost due to pneumonia and senile death.
Discussion The extraperitoneal approach to the iliac arteries was originally performed in 1796 [2]. The first successful repair of an infrarenal aortic aneurysm was performed through the extraperitoneal approach in 1951 [5]. Since that time, a few articles have been published on the use of this technique for reoperative aortoiliac surgery, the treatment of juxtarenal or suprarenal abdominal aortic aneurysms, and in other CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
Abdominal aortic aneurysm repairs: T. Igari et al.
Figure 2 Age, operating time, and bleeding amount during surgery
Figure 3 Duration of endotracheal intubation, initiation of alimentation, and narcotic requirements after surgery
selected elective cases. Several reports have mentioned the advantages of the extraperitoneal approach for aortic surgery in patients with morbid obesity, multiple previous intraperitoneal operations and in high-risk patients [6,7]. These reports, irrespective of the exact approach, have commented on the uneventful postoperative course as demonstrated by a decrease in postoperative ileus, less respiratory CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
complications, better tolerance of incisional pain, and shortened hospitalization [2]. Even though, our transperitoneal results were historical controls, our experience corroborates the findings of other authors. To date, only one prospective randomized study comparing the extraperitoneal and transperitoneal approach has been reported [8]. They were unable 251
Abdominal aortic aneurysm repairs: T. Igari et al. Table 2 Deaths of elective repaired abdominal aortic aneurysms through extraperitoneal approach 229 cases Hospital death ⱕ30 days >30 days Late death Malignant neoplasm Other surgery Ruptured TAA CVD Pneumonia Unknown
7 2a 5b 9 2 2 1 1 1 1
a
Acute myocardial infarction;1, CVD;1 Respiratory failure;4, sepsis;1
b
Table 3
Complication of three extraperitoneal approaches
Cases Elective Rupture Complications Shower embolism Bulge Lymphorrhea Vascular injury
S group
W group
O group
23 23 0 0 (0%) 0 0 0 0
220 192 28 8 (3.6%) 3a 3b 1 1
13 13 0 1 (7.7%) 1 0 0 0
a
Major amputation (1), minor amputation (1) Operation (1)
b
Table 4
Ruptured cases repaired extraperitoneal approach
Cases
28
Age (yr) Sex (male/female) Shock Hospital death
70.8±10.2 (45–83) 23/5 23/28 (82.2%) 4/28 (14.3%) Blood loss (1) MOF (1) CHF (1) MRSA pneumonia (1) 3/24 Pneumonia (2) Senile death (1)
Late death Follow-up period 60.6±30.8 mo.(19–115 mo.)
to demonstrate any statistical difference between the two approaches. However, they observed a trend towards reduced mortality, morbidity, postoperative ileus and hospitalization in the extraperitoneal group [2]. The data presented in this series verify the advantage of the extraperitoneal approach in improving the postoperative course in patients with abdominal aortic aneurysm. Earlier reports have observed decreased operating time [6,9] while recent reports have found the same operating time [3,8]. Our 252
results demonstrate same operating time. The protective effect of the peritoneal cavity accounts for less operative trauma to the small bowel, as well as decreased insensible fluid loss. This was reflected in the decreased intraoperative crystaloid requirements and the decrease in postoperative ileus. Moreover, the extraperitoneal approach would isolate the graft from peritoneal dialysate and allow for the postoperative use of peritoneal dialysis [10]. At first, we chose Sicard’s method [3], a more extended modification of Williams’ method [4], because it is easier for a beginner to do surgery through an extraperitoneal approach. The duration of endotracheal intubation and initiation of alimentation became shorter and the narcotic requirements after surgery became decreasingly significant compared with the transperitoneal approach. After 23 initial experiences, we moved up to the original Williams’ method for preventing dividing rectus muscle and epigastric vessels. With some modification of the technique described by Williams et al. [4], we were able to obtain access to the entire aortoiliac system, thereby making this technique useful for repair of routine abdominal aortic aneurysms. An important application of this technique includes patients with juxtarenal aneurysms or severely calcified aortas since the aorta can be controlled at the supraceliac level [6]. Making incisions shorter did not increase the operating time and the amount of bleeding during surgery. The tendency of shortened initiation of alimentation and decreased narcotic requirements was also apparent. Our earlier experiences to make shorter incisions in the W group resulted in shower embolism due to manipulation in a smaller operating field. Repeated complaints of postoperative wound pain, lumbosacral neuritic pain, incisional hernia, and deforming abdominal bulge were the disadvantages of the extraperitoneal approach. For preventing these disadvantages, incisions without muscle dividing were recommended [11]. In the last 13 cases, we tried without muscle dividing for decreasing the wound complication. This change also did not increase the operating time or amount of bleeding during surgery and it showed the shortened the initiation of alimentation and the narcotic requirements. Narcotic requirement showed significant decrease compared, particularly, with the S group. So far, results are satisfying. Ligation of the inferior mesenteric artery and mobilization of the aorta from the overlying peritoneum has permitted us to reach the juxtarenal vena cava and the proximal renal arteries in unusual circumstances. The extraperitoneal approach provides easy access to the incisional side renal artery if concomitant ipsilateral renal revascularization is warranted. If the contralateral renal artery requires CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
Abdominal aortic aneurysm repairs: T. Igari et al.
revascularization, the kidney and ureter are left in place. A disadvantage of the extraperitoneal exposure is the inability to detect lesions of the intraperitoneal viscera. In any case, routine use of fecal occult blood testing, computed tomographic scanning, sonography, and barium studies has decreased the incidence of unexpected findings. The extraperitoneal approach for ruptured abdominal aneurysms has similar physiologic benefits. Studies of 63 cases of ruptured abdominal aneurysms (transperitoneal 38, extraperitoneal 25) showed a lower operative mortality in the extraperitoneal group (12%) as compared to the transperitoneal group (34.2%) [12]. Our results displayed this same trend. On the basis of the experience reported herein, we believe that the extraperitoneal approach should be the standard approach for elective surgery of infrarenal abdominal aneurysms, and should be considered in emergency procedures.
4. 5.
6. 7.
8.
9.
10.
11.
References 1. Rob, C., Extraperitoneal approach to the abdominal aorta. Surgery, 1963, 53, 87–89. 2. Grace, P. A. and Bouchier-Hayes, D., Infrarenal abdominal aortic disease: a review of the retroperitoneal approach. British Journal of Surgery, 1991, 78, 6–9. 3. Sicard, G. A., Freeman, M. B., VanderWunde, J. C. et al, Com-
CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
12.
parison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. Journal of Vascular Surgery, 1987, 5, 19–27. Williams, G. M., Ricotta, T., Zinner, M. et al, The extended retroperitoneal approach for treatment of extensive atherosclerosis of the aorta and renal vessels. Surgery, 1980, 88, 846–855. Dubost, C., Allary, M. and Oeconomos, N., Resection of an aneurysm of the abdominal aorta. Archives of Surgery, 1952, 64, 405–408. Shepaed, A. D., Scott, G. R., Mackey, W. C. et al, Retroperitoneal approach to high risk abdominal aneurysms. Archives of Surgery, 1986, 121, 444–449. Hudoson, J. C., Wurm, W. H., O’Donnel, T. F. Jr. et al, Hemodynamics and prostacyclin release in the early phases of aortic surgery: comparison of transabdominal and retroperitoneal approaches. Journal of Vascular Surgery, 1988, 7, 190–198. Cambia, R. P., Brewste, D. C., Abbott, W. M. et al, Transperitoneal versus retoroperitoneal approach for aortic reconstruction: a randomized prospective study. Journal of Vascular Surgery, 1990, 11, 314–325. Peck, J. J., McReynolds, D. G., Baker, D. H. et al, Extraperitoneal approach for aortoiliac reconstruction of the abdominal aorta. American Journal of Surgery, 1986, 151, 620–623. Schadt, M., Uribe, A. and Schleifer, C., Retroperitoneal approach for repairs of abdominal aortic aneurysms. Journal of Vascular Surgery, 1989, 10, 595–596. Honig, M. P., Mason, R. A. and Giron, F., Wound complications of the retroperitoneal approach to the aorta and iliac vessels. Journal of Vascular Surgery, 1992, 15, 28–34. Chang B. B., Aha D. M., Paty P. S. K., Kaufman J. L. and Leather R. P., Can the retroperitoneal approach to be used for ruptured abdominal aneurysms? Journal of Vascular Surgery 1990, 11, 326–330.
Paper accepted 5 October 2000
253
PII: S0967-2109(00)00134-4
www.elsevier.com/locate/cardiosur
Results of 256 consecutive abdominal aortic aneurysm repairs using extraperitoneal approach T. Igari, S. Hoshino, F. Iwaya, H. Satokawa, H. Midorikawa, S. Takase and Y. Hoshino Fukushima Medical University School of Medicine, Department of Cardiovascular Surgery, 1 Hikarigaoka, Fukushima City, 960-1295, Japan Two hundred and fifty-six consecutive abdominal aortic aneurysms were repaired using three approaches for extraperitoneal exposure of the aorta and iliac vessels from February 1990 through September 1998. The perioperative mortality rate was 3.1% in 228 elective repairs and 14.3% in 28 ruptured cases. The initial 23 cases were repaired using Sicard’s method. The duration of endotracheal intubation was 1.0±2.8 h, alimentation initiation was 2.7±1.6 days, and narcotic requirements were 1.2±1.1 times. Following these initial cases, we employed Williams’ method for 192 abdominal aneurysms, however; repeated incisional pain and three cases of deforming bulge led us to avoid dividing muscles. In the last 13 cases, our approach was performed without muscle dividing. The narcotic requirements decreased to 0.3±0.7 times. As for postoperative complications, the larger skin incision approach had no shower embolism. However, the shorter skin incision had four cases of shower embolisms, one lymphorrhea and one vascular trauma by the aortic clamp. The extraperitoneal approach offers certain physiologic advantages with minimal disturbance of gastrointestinal and respiratory function. We believe that this method is useful for rapid approach to the proximal aorta in case of emergency. Postoperative wound complications could be prevented via an oblique incision without muscle dividing. 2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved Keywords: abdominal aortic aneurysm; extraperitoneal approach; rupture
The advantages of the extraperitoneal approach in aortoiliac reconstruction have been recognized since 1963 [1]. The extraperitoneal approach offers a smoother, faster, and less complicated postoperative course with low incidence of pulmonary complications and ileus [2]. The purpose of this paper is to review the advantage of the extraperitoneal approach to the infrarenal abdominal aneurysm.
Materials and methods From February 1990 through September 1998, 256 consecutive patients underwent repair of the infrarenal abdominal aortic aneurysm (AAA) at Fukushima Medical University Hospital. Of these 256 cases, 222 Correspondence to: Tsuguo Igari, MD. Tel.: +81-24-548-2111 (ext. 2492); fax: 81-24-548-3926; e-mail: [email protected]
CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
cases were elective operations for non-ruptured AAA (Table 1). This paper focuses primarily on the elective cases. Ruptured cases are briefly described. The nonrupture elective extraperitoneal approach group was divided into three groups. The initial 23 cases were repaired using Sicard’s method [3], dividing bilateral rectus abdominis muscle (S group). After these initial experiences, we changed to original Williams’ method [4], extended oblique incision. 192 infrarenal AAAs were repaired using this method (W group). From April 1998, the last 13 cases were repaired using oblique incision without muscle dividing (O group). In addition to assessing the changing course of patients undergoing aortoiliac reconstruction, 128 infrarenal AAA patients undergoing elective repair via the transperitoneal approach prior to 1990 were compared. All values are expressed as mean±standard deviation of the mean. Statistical analysis of the data was performed using the Student’s t-test. 249
Abdominal aortic aneurysm repairs: T. Igari et al. Table 1
Elective repaired abdominal aortic aneurysmsa
Cases Age (yr) Sex (male/female) Origin Arteriosclerosis Traumatic So called inflammatory Risk Hypertension Smoking Ischemic heart disease Hyperlipidemia Cerebral vascular disease (CVD) Obesity Malignant neoplasama Diabetes mellitus Obstructive pulmonary disease
EP 229
TP 128
71.2±7.0 (50–93) 192/37
66.2±8.6 (40–82) 101/27
225 2 2
128 0 0
141 (61.6%) 107 (46.7%) 49 (21.4%) 35 (15.3%) 26 (11.4%) 20 (8.7%) 20 (8.7%) 14 (6.1%) 11 (4.8%)
69 (53.9%) 53 (41.4%) 6 (4.7%) 5 (3.9%) 11 (8.6%) 6 (4.7%) 7 (5.5%) 9 (7.0%) 3 (2.3%)
a
EP: extraperitoneal approach; TP: transperitoneal approach
Operative technique The patient is positioned with the hips parallel to the table and the left (or right) thorax elevated 30–40°. The incision is begun midway between the umbilicus and symphysis pubis and extended in a curvilinear fashion to the left (or right) lateral portion of the flank, 5-cm medial to the anterior superior iliac spine and extended posteriori to the eleventh intercostal space. Bilateral rectus muscles are divided [3] in the S group. In the cases of W group, the skin incision is started from the outer edge of the rectus muscle and included the distal paramedian line to prevent the division of the rectus muscle. The muscles are divided with electocautery to minimize blood loss. The peritoneum is mobilized medialy and cephalad with exposure of the distal aorta and common and external iliac arteries. A self-retaining retractor system is routinely used. To avoid retraction trauma, as well as to provide better access to the juxtarenal space, the ureter is never mobilized from its position. The kidney and ureter are left in place in a case needed to expose ipsilateral renal artery. The gonadal vein is ligated at the junctional of the renal vein to avoid retraction avulsion, if necessary. Division of the inferior mesenteric artery is only permitted, when exposure of the opposite side of the aorta and right iliac system was difficult. In the last cases, O group, the muscles are not divided and skin incision is about 10–12 cm from the lateral border of the rectus muscle to the 12th rib (Figure 1).
Results Non-ruptured cases The age, operating time, and intraoperative bleeding amount of the TP group and three groups of the 250
Figure 1 Skin incision of three extraperitoneal approaches. S group: from midway between the umbilicus and symphysis pubis to the 11th intercostal space; W group: from the outer edge of the rectus muscle to the 11th intercostal space, earlier cases started from midway between the umbilicus and symphysis and later cases started at the level of the umbilicus (similar as O group); O group: from the outer edge of the rectus muscle at the level of the umbilicus to the 12th rib
extraperitoneal approach are shown in Figure 2. No significant differences were found. The duration of endotracheal intubation, initiation of alimentation, and narcotic requirements after operation are shown in Figure 3. The duration of endotracheal intubation became shorter in extraperitoneal approach, especially in the S group which was 1.0±2.8 h. This was significantly shorter than the TP group. However, the W group and the O group needed more intubation. Also, initiation of alimentation became shorter and narcotic requirement was less necessary in groups of the extraperitoneal approach. Narcotic requirement became significantly less in the O group. As Table 2 shows, surgical outcome of the non-ruptured AAA cases had a mortality rate of 3.1% (7/229 cases). So far, nine late deaths have occurred among 222 patients. Complications are shown in Table 3. In the S group, the largest approach among the extrapeitoneal approach had no complications. Small incision approaches had shower embolism, bulge, lymphorrhea, and vascular injury. Ruptured cases As Table 4 shows, 28 ruptured cases were operated through the extraperitoneal approach, Williams’ method. Hospital death was 4 and mortality rate was 14.3%. Follow-up duration was 60.6±30.8 months in 24 patients walking out from our hospital. Among 24 cases, three patients were lost due to pneumonia and senile death.
Discussion The extraperitoneal approach to the iliac arteries was originally performed in 1796 [2]. The first successful repair of an infrarenal aortic aneurysm was performed through the extraperitoneal approach in 1951 [5]. Since that time, a few articles have been published on the use of this technique for reoperative aortoiliac surgery, the treatment of juxtarenal or suprarenal abdominal aortic aneurysms, and in other CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
Abdominal aortic aneurysm repairs: T. Igari et al.
Figure 2 Age, operating time, and bleeding amount during surgery
Figure 3 Duration of endotracheal intubation, initiation of alimentation, and narcotic requirements after surgery
selected elective cases. Several reports have mentioned the advantages of the extraperitoneal approach for aortic surgery in patients with morbid obesity, multiple previous intraperitoneal operations and in high-risk patients [6,7]. These reports, irrespective of the exact approach, have commented on the uneventful postoperative course as demonstrated by a decrease in postoperative ileus, less respiratory CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
complications, better tolerance of incisional pain, and shortened hospitalization [2]. Even though, our transperitoneal results were historical controls, our experience corroborates the findings of other authors. To date, only one prospective randomized study comparing the extraperitoneal and transperitoneal approach has been reported [8]. They were unable 251
Abdominal aortic aneurysm repairs: T. Igari et al. Table 2 Deaths of elective repaired abdominal aortic aneurysms through extraperitoneal approach 229 cases Hospital death ⱕ30 days >30 days Late death Malignant neoplasm Other surgery Ruptured TAA CVD Pneumonia Unknown
7 2a 5b 9 2 2 1 1 1 1
a
Acute myocardial infarction;1, CVD;1 Respiratory failure;4, sepsis;1
b
Table 3
Complication of three extraperitoneal approaches
Cases Elective Rupture Complications Shower embolism Bulge Lymphorrhea Vascular injury
S group
W group
O group
23 23 0 0 (0%) 0 0 0 0
220 192 28 8 (3.6%) 3a 3b 1 1
13 13 0 1 (7.7%) 1 0 0 0
a
Major amputation (1), minor amputation (1) Operation (1)
b
Table 4
Ruptured cases repaired extraperitoneal approach
Cases
28
Age (yr) Sex (male/female) Shock Hospital death
70.8±10.2 (45–83) 23/5 23/28 (82.2%) 4/28 (14.3%) Blood loss (1) MOF (1) CHF (1) MRSA pneumonia (1) 3/24 Pneumonia (2) Senile death (1)
Late death Follow-up period 60.6±30.8 mo.(19–115 mo.)
to demonstrate any statistical difference between the two approaches. However, they observed a trend towards reduced mortality, morbidity, postoperative ileus and hospitalization in the extraperitoneal group [2]. The data presented in this series verify the advantage of the extraperitoneal approach in improving the postoperative course in patients with abdominal aortic aneurysm. Earlier reports have observed decreased operating time [6,9] while recent reports have found the same operating time [3,8]. Our 252
results demonstrate same operating time. The protective effect of the peritoneal cavity accounts for less operative trauma to the small bowel, as well as decreased insensible fluid loss. This was reflected in the decreased intraoperative crystaloid requirements and the decrease in postoperative ileus. Moreover, the extraperitoneal approach would isolate the graft from peritoneal dialysate and allow for the postoperative use of peritoneal dialysis [10]. At first, we chose Sicard’s method [3], a more extended modification of Williams’ method [4], because it is easier for a beginner to do surgery through an extraperitoneal approach. The duration of endotracheal intubation and initiation of alimentation became shorter and the narcotic requirements after surgery became decreasingly significant compared with the transperitoneal approach. After 23 initial experiences, we moved up to the original Williams’ method for preventing dividing rectus muscle and epigastric vessels. With some modification of the technique described by Williams et al. [4], we were able to obtain access to the entire aortoiliac system, thereby making this technique useful for repair of routine abdominal aortic aneurysms. An important application of this technique includes patients with juxtarenal aneurysms or severely calcified aortas since the aorta can be controlled at the supraceliac level [6]. Making incisions shorter did not increase the operating time and the amount of bleeding during surgery. The tendency of shortened initiation of alimentation and decreased narcotic requirements was also apparent. Our earlier experiences to make shorter incisions in the W group resulted in shower embolism due to manipulation in a smaller operating field. Repeated complaints of postoperative wound pain, lumbosacral neuritic pain, incisional hernia, and deforming abdominal bulge were the disadvantages of the extraperitoneal approach. For preventing these disadvantages, incisions without muscle dividing were recommended [11]. In the last 13 cases, we tried without muscle dividing for decreasing the wound complication. This change also did not increase the operating time or amount of bleeding during surgery and it showed the shortened the initiation of alimentation and the narcotic requirements. Narcotic requirement showed significant decrease compared, particularly, with the S group. So far, results are satisfying. Ligation of the inferior mesenteric artery and mobilization of the aorta from the overlying peritoneum has permitted us to reach the juxtarenal vena cava and the proximal renal arteries in unusual circumstances. The extraperitoneal approach provides easy access to the incisional side renal artery if concomitant ipsilateral renal revascularization is warranted. If the contralateral renal artery requires CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
Abdominal aortic aneurysm repairs: T. Igari et al.
revascularization, the kidney and ureter are left in place. A disadvantage of the extraperitoneal exposure is the inability to detect lesions of the intraperitoneal viscera. In any case, routine use of fecal occult blood testing, computed tomographic scanning, sonography, and barium studies has decreased the incidence of unexpected findings. The extraperitoneal approach for ruptured abdominal aneurysms has similar physiologic benefits. Studies of 63 cases of ruptured abdominal aneurysms (transperitoneal 38, extraperitoneal 25) showed a lower operative mortality in the extraperitoneal group (12%) as compared to the transperitoneal group (34.2%) [12]. Our results displayed this same trend. On the basis of the experience reported herein, we believe that the extraperitoneal approach should be the standard approach for elective surgery of infrarenal abdominal aneurysms, and should be considered in emergency procedures.
4. 5.
6. 7.
8.
9.
10.
11.
References 1. Rob, C., Extraperitoneal approach to the abdominal aorta. Surgery, 1963, 53, 87–89. 2. Grace, P. A. and Bouchier-Hayes, D., Infrarenal abdominal aortic disease: a review of the retroperitoneal approach. British Journal of Surgery, 1991, 78, 6–9. 3. Sicard, G. A., Freeman, M. B., VanderWunde, J. C. et al, Com-
CARDIOVASCULAR SURGERY
JUNE 2001 VOL 9 NO 3
12.
parison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. Journal of Vascular Surgery, 1987, 5, 19–27. Williams, G. M., Ricotta, T., Zinner, M. et al, The extended retroperitoneal approach for treatment of extensive atherosclerosis of the aorta and renal vessels. Surgery, 1980, 88, 846–855. Dubost, C., Allary, M. and Oeconomos, N., Resection of an aneurysm of the abdominal aorta. Archives of Surgery, 1952, 64, 405–408. Shepaed, A. D., Scott, G. R., Mackey, W. C. et al, Retroperitoneal approach to high risk abdominal aneurysms. Archives of Surgery, 1986, 121, 444–449. Hudoson, J. C., Wurm, W. H., O’Donnel, T. F. Jr. et al, Hemodynamics and prostacyclin release in the early phases of aortic surgery: comparison of transabdominal and retroperitoneal approaches. Journal of Vascular Surgery, 1988, 7, 190–198. Cambia, R. P., Brewste, D. C., Abbott, W. M. et al, Transperitoneal versus retoroperitoneal approach for aortic reconstruction: a randomized prospective study. Journal of Vascular Surgery, 1990, 11, 314–325. Peck, J. J., McReynolds, D. G., Baker, D. H. et al, Extraperitoneal approach for aortoiliac reconstruction of the abdominal aorta. American Journal of Surgery, 1986, 151, 620–623. Schadt, M., Uribe, A. and Schleifer, C., Retroperitoneal approach for repairs of abdominal aortic aneurysms. Journal of Vascular Surgery, 1989, 10, 595–596. Honig, M. P., Mason, R. A. and Giron, F., Wound complications of the retroperitoneal approach to the aorta and iliac vessels. Journal of Vascular Surgery, 1992, 15, 28–34. Chang B. B., Aha D. M., Paty P. S. K., Kaufman J. L. and Leather R. P., Can the retroperitoneal approach to be used for ruptured abdominal aneurysms? Journal of Vascular Surgery 1990, 11, 326–330.
Paper accepted 5 October 2000
253