- Email: [email protected]
Retroperitoneal Aortoiliac Reconstruction
LOWER EXTREMITY ARTERIAL OCCLUSIVE DISEASE
0039-6109/95 $0.00
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.20
RETROPERITONEAL AORTOILIAC RECONSTRUCTION Jeffrey M. Reilly, MO, and Gregorio A. Sicard, MO
The retroperitoneal approach to the infrarenal aorta was the approach used by Dubost et al4 for the first aortic reconstruction in a patient with an infrarenal abdominal aortic aneurysm. Despite this fact, this approach has never gained widespread acceptance for routine infrarenal aortic reconstruction. 20 Most surgeons reserve this approach for patients who have had multiple previous abdominal surgeries, who have horseshoe kidneys, who are obese, who have had previous aortic surgery, who require concomitant left renal artery revascularization, or who have ostomies, abdominal wall excoriation or infection, a history of abdominal and/or pelvic irradiation, peritoneal dialysis catheters, and ascites2, 15-19,22,26,27,29 (Table 1). In these instances the retroperitoneal exposure of the aorta offers well-recognized and clear-cut advantages over the transabdominal approach to the aorta. Over three decades ago the report by Rob 18 revived interest in the retroperitoneal approach for routine infrarenal aortic reconstruction, and since then numerous reports have demonstrated a clear superiority of the retroperitoneal approach in terms of intraoperative fluid replacement, postoperative pulmonary complications, length of ileus, and length of stay in the intensive care unit and in the hospital.5-10, 12-14, 21, 23, 25 These reports essentially corroborate our experience at the Washington University Medical Center. In both a retrospective analysis of our patients and a recently reported randomized prospective study, we have found that the retroperitoneal approach for routine aortoiliac reconstruction is associated with decreased length of ileus, fewer complications, a shorter length of stay, and lower hospital costs23,24 (Tables 2 and 3). Also, because this approach does not violate the peritoneal cavity, postoperative intra-abdominal adhesions with their attendant risk of early and late small bowel obstruction are avoided. Even more importantly, aortoenteric fistulas are an unheard of complication of aortic revascularization performed via the retroperitoneal approach. For these reasons, even in the absence of the relative indications listed above, we believe that the
From the Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine; The Jewish Hospital of St. Louis (JMR); and Barnes Hospital, St. Louis, Missouri
SURGICAL CLINICS OF NORTH AMERICA VOLUME 75 • NUMBER 4 • AUGUST 1995
679
680
REILLY & SICARD
Table 1. RELATIVE INDICATIONS FOR LEFT RETROPERITONEAL APPROACH (PATIENT FACTORS) Multiple previous abdominal surgeries (hostile abdomen) Abdominal wall osteomies Abdominal wall excoriation or infection Previous abdominal and/or pelvic irradiation Patients with peritoneal dialysis catheters Ascites Massive obesity Horseshoe kidney
retroperitoneal approach offers specific advantages over midline transabdominal exposure of the aorta. In the following sections we discuss the technical aspects of the procedures for aortoiliac revascularization which can be performed via the left and right retroperitoneal approaches to the infrarenal aorta and iliac arteries. Because this article deals primarily with lower extremity arterial occlusive disease, we limit our technical description to the use of the retroperitoneal approach for aortoiliac occlusive disease, although because of the usual distribution of aortic pathology, the largest experience with this approach has been with aneurysmal disease. LEFT RETROPERITONEAL APPROACH FOR AORTOILIAC RECONSTRUCTION
For patients with aortoiliac occlusive disease undergoing aortobifemoral bypass grafting or aortoiliac endarterectomy, the patient is pOSitioned with hips nearly parallel to the table with the left shoulder and trunk elevated to 45 deg using a self-molding, vacuum-operated, plastic foam bean bag (Olympic Medical, Seattle, W A) for maintenance of this position. The left arm is extended anteriorly and supported on a Mayo stand or secured to a table-mounted screen (Fig. 1). Correct positioning of the patient is critical for this exposure, and one of the common pitfalls is inattention to this detail. The most frequently made error is failing to rotate the torso far enough anteriorly, thereby compromising posterior exposure. For aortoiliac exposure, either a right- or left-sided incision is begun at a point just medial to the lateral border of the left rectus muscle midway between the symphysis pubis and the umbilicus. It is continued in a curvilinear fashion to 6 to 8 cm medial and superior to the anterior iliac spine and then posterolaterally to the tip of the 12th rib or the 11th interspace, depending on the size and habitus of the patient (Fig. 1). The retroperitoneal space is most easily entered at the junction of the rectus and lateral abdominal wall muscles by dividing the transversalis fascia. Then using blunt dissection through this opening, the peritoneum is mobilized away from the anterior and lateral abdominal wall, which allows the musculature to be divided using electrocautery. Excellent exposure can usually be achieved by division of the oblique and the transversus abdominis muscles without dividing the rectus muscle. In obese patients or in patients in whom it appears that exposure will be difficult, more extensive exposure can be obtained by dividing the rectus muscle or by extending the incision into the 11th or 12th interspace. As the
Table 2. RETROPERITONEAL VERSUS TRANSPERITONEAL APPROACH TO AORTIC SURGERY Number of Patients Author Sicard et ai, 198723 Johnson et ai, 19867 Peck et ai, 198614 Leather et ai, 1989'0 Gregory et ai, 19895 Cambria et ai, 1990't Darling et ai, 19923 Sicard et ai, 199424t
0'1
"""
Survival
Length of Stay
Retro
Trans
Retro
Trans
PValue
Retro
Trans
PValue
Retro
Trans
PValue
54 298 200 193 53 54 15 70
50 161 70 106 119 59 12 75
0 1% 18% 0.5% 3.3% 3.7% 2.1· 0%
6% 6% 96% 10.4% 4.9% 6.7% 4.0· 11%
<0.001 <0.05 <0.001 <0.02 <0.01
10 12 7 7 9 10.3 6.7 9.9
14 17 10 12 13 12.5 9.0 12.9
<0.02 <0.05
2% 4% 1.5% 3.6% 0% 0% 0 0%
1.9% 3.7% 2.8% 3.8% 4.2% 1.7% 0 3%
NS NS NS NS NS NS NS NS
'Number of days before resuming regular diet tProspective, randomized trials
co
Ileus
NS
<0.05 0.005
NS
<0.02 <0.01 NS
0.157 0.10
682
REILLY & SICARD
Table 3. WASHINGTON UNIVERSITY RANDOMIZED PROSPECTIVE TRIALTRANSABDOMINAL VERSUS RETROPERITONEAL INCISION IN ELECTIVE AORTIC SURGERY24
Retroperitoneal Transabdominal
Number of Patients
ICU Stay
70 75
2.3 3.5*
Hospital Stay
Total Postoperative Complications
Hospital Cost
9.9 12.9t
24% 51%*
$16,350 $21,023*
*P <0.05
tP
=
0.01
musculature is divided, the peritoneum is mobilized medially and cephalad using blunt dissection. This provides excellent exposure of the retroperitoneum down to the distal aorta and proximal iliac arteries. Once the retroperitoneal space is entered, the ureter, which is usually swept medially with the peritoneal envelope, is mobilized up to the level of the renal pelvis and is gently retracted laterally (Fig. 2). To avoid ischemic injury to the ureter, this is done leaving the periureteral fat intact. Failure to adequately mobilize the ureter early in the dissection can result in a traction injury to this structure. The gonadal vein is identified and ligated at its junction with the left renal vein. Once again, failure to perform this step early in the dissection can
A
B
Figure 1. Correct positioning of the patient for exposure of the left retroperitoneum. Incisions Band C are used for aortic and renal revascularization. Incision A is used for iliofemoral endarterectomy or bypass. (From Sicard GA, Reilly JM: Left retroperitoneal approach to the aorta and its branches: Part I. Ann Vasc Surg 8:212-219, 1994; with permission.)
RETROPERITONEAL AORTOILIAC RECONSTRUCTION
683
Right
Figure 2. Retroperitoneal exposure in patient with aortoiliac occlusive disease. The top illustration demonstrates the exposure of the infrarenal aorta and vena cava that is obtained via the right retroperitoneal approach. Note that the right gonadal vein has been ligated and the right ureter has been mobilized to the level of the renal pelvis. The bottom illustration shows the exposure obtained for aortobifemoral bypass using either an end-toside (A) or end-to-end (8) graft to aortic anastomosis. (From Sicard GA, Reilly JM: Left retroperitoneal approach to the aorta and its branches: Part I. Ann Vasc Surg 8:212-219, 1994; with permission.)
684
REILLY & SICARD
result in its subsequent avulsion from the renal vein, which may cause significant hemorrhage. The left kidney is left to lie posteriorly by dissecting in the avascular plane between Gerota's fascia and the peritoneum. At this point it is usually helpful to put in place a self-retaining retractor system. Use of such a system (we prefer the Omni) helps to minimize trauma by providing controlled, constant retraction and eliminates the frequent readjustments that are necessary with hand-held retractors, This helps to eliminate too forceful or vigorous retraction in the left upper quadrant, which can result in injury to intraperitoneal organs (usually the spleen). The exposure provided by such a system is also usually far superior to that provided by handheld retractors. Once adequate exposure of the operative field has been established, the aorta is dissected just below the left renal vein so that a proximal cross-clamp can be applied. For placement of an aortobifemoral bypass graft, there is no need for exposure of the iliac system. An adequate length of the infrarenal aorta is exposed so that another cross-clamp can be applied distally, and the graft to aortic anastomosis is performed between the two clamps. This proximal anastomosis can be performed in an end-to-side or an end-to-end fashion as is dictated by the status of the pelvic circulation (Fig. 2). Ligation of the inferior mesenteric artery can expand the exposure of the right iliac system and can facilitate placement of a bifemoral graft. For aortobifemoral bypass grafting, standard groin incisions are used, and the graft limbs are tunneled in their respective groins. The tunneling of the graft toward the right femoral region must be done bluntly with finger dissection, starting at the proximal right common iliac artery and continuing distally toward the femoral artery so as to displace the right ureter superiorly in order to avoid ureteral injury. This tunnel is then completed by blunt finger dissection, starting in the area of the right femoral artery with the surgeon's right index finger until it meets the surgeon's left index finger. Once the tunnel is complete and free of interposed tissue, a long clamp (e.g., Crawford clamp) is passed from the groin into the retroperitoneum, and the right aortic limb is grasped and brought down to the right femoral region. Passage of the left limb is very simple because the entire left lower retroperitoneum is exposed. Once the graft limbs are tunneled, the distal anastomoses are performed in a standard fashion. If the superficial femoral artery is patent, the femoral anastomosis is performed opposite the profunda femoris origin. If the superficial femoral artery is occluded, the anastomosis is carried down onto the first portion of the profunda, thus creating a profundaplasty. For aortoiliac endarterectomy, the incision and aortic exposure are the same as for aortobifemoral bypass grafting; however, exposure of the iliac system is required as well. Exposure of the left iliac system is easily obtained. Exposure of the right iliac system can be more problematic. Several maneuvers are helpful in this situation. Extending the incision medially by transecting a portion of the rectus muscle usually allows adequate exposure of the right common iliac artery. This exposure is also facilitated by ligating the inferior mesenteric artery, which allows further medial mobilization of the peritoneal envelope. This ligation should be performed flush with the aorta in order to avoid injuring any early branches of the inferior mesenteric artery. This maneuver allows the mobilization of the right common iliac to the level of the bifurcation in nonobese patients. If it is necessary to carry the endarterectomy down into the external iliac artery or if control of the iliac bifurcation is difficult, a small counterincision can be made in the right lower quadrant, and the distal right iliac system can be easily exposed through this. When contemplating aortoiliac endarterectomy, it is important to realize
RETROPERITONEAL AORTOILIAC RECONSTRUCTION
685
that two patterns of atherosclerosis are typically seen in aortoiliac occlusive disease. Type I disease involves the infrarenal aorta, the common iliac artery, and often the orifices of the internal iliac arteries with sparing of the external iliac arteries. Type II disease involves these vessels as well as the external iliac and common femoral arteries. 2B In order to perform an endarterectomy, it is helpful to isolate the lumbar vessels so that backbleeding can be controlled and mandatory to circumferentially dissect the iliac arteries. The aortoiliac endarterectomy is performed once adequate vascular control has been obtained. For type I disease, this means that the internal and external iliacs have been controlled just beyond the iliac bifurcation. For type II disease, the proximal internal iliac is controlled, the external iliac arteries are circumferentially dissected, and the common femoral arteries are fully mobilized through separate groin incisions. We do not favor extensive aortoiliac endarterectomy for patients with type II disease and prefer an aortobifemoral bypass graft. On the other hand, in young patients (mostly young women) with disease limited to the aortoiliac bifurcation, we believe that open aortoiliac endarterectomy is still a good operation in selected cases, and this procedure can be easily performed through a left retroperitoneal approach. One advantage of the left retroperitoneal approach is that it allows easy access to the juxtarenal aorta, and this is sometimes required if the occlusive plaque extends nearly to the level of the renal arteries. The only additional step required to expose the juxtarenal aorta is full mobilization of the left renal vein with ligation of the adrenal and lumbar veins. If a suprarenal clamp is required for the initial portion of the endarterectomy, the origins of both renal arteries should be controlled to prevent embolization of atherosclerotic debris. The aorta can be opened infrarenally and the endarterectomy can be performed to the juxtarenal level from below or the longitudinal arteriotomy can be carried cephalad. After cross-clamping, the infrarenal aorta is opened longitudinally down to the bifurcation. An endarterectomy plane is established, and the plaque is removed en bloc after it is transected proximally. If a suprarenal cross-clamp has been used, it can be moved infrarenally as soon as the proximal portion of the endarterectomy is complete. The iliac portion of the endarterectomy can be done either open or semiclosed. If the open technique is used, the iliac arteries need to be opened down to the level of the iliac bifurcation. These arteriotomies can be continuous or discontinuous with the aortic endarterectomy. The plaque is then removed in the standard fashion. The endpoint of the endarterectomy needs to be at or proximal to the iliac bifurcation (Fig. 3). If necessary, tacking sutures are used to secure the distal endpoint. If primary closure of the iliac artery and/or the aorta will result in stenosis, the arteriotomy can be closed with a patch (either Dacron or polytetrafluoroethylene can be used). THE RIGHT RETROPERITONEAL APPROACH FOR AORTOILIAC RECONSTRUCTION
The right retroperitoneal approach to the aorta is not as versatile as the left retroperitoneal approach, but it is quite useful in specific situations. It can be used for aortobifemoral bypass for occlusive disease and is particularly useful if a concomitant right renal artery revascularization is to be performed. It also serves as an alternative exposure for patients who have had previous surgery in the left retroperitoneum, e.g., a nephrectomy or sigmoid colectomy. The positioning of the patient and the incision are the mirror images of those for the left retroperitoneal approach (Fig. 4). The major technical differences between
686
REILLY & SICARD
Figure 3. A-D, An aortoiliac endarterectomy for type I aortoiliac occlusive disease using the open technique.
the two approaches relate to the differences in venous anatomy between the left and right retroperitoneums. The right gonadal vein drains directly into the vena cava and should be ligated flush with its origin. There is no need to expose the right renal vein, but the left renal vein must be identified. Obviously, the vena cava is interposed between the surgeon and the aorta, and care must be taken in dissecting out the aorta not to injure the fragile lumbar veins. These may be ligated if necessary. When approaching the aorta from the right, ligating the inferior mesenteric artery can greatly facilitate the exposure and is thus done more frequently than on the left side, where exposure is usually not a problem. Once the aorta is exposed, the technical aspects of the procedures are the same as for the left retroperitoneal approach. UNILATERAL ILIAC REVASCULARIZATION
For unilateral iliac revascularization, the patient does not need to be rotated to the extent required for more proximal aortic exposure. In fact, placing a pillow or the bean bag beneath the ipsilateral hip usually provides enough rotation without rotating the upper torso. For exposure of either the right or left iliac system, an incision is made in a curvilinear fashion beginning at a level
RETROPERITONEAL AORTOILIAC RECONSTRUCTION
687
Figure 4. The position of the patient undergoing either a right aortobifemoral bypass (incision A) or right iliac or iliofemoral endarterectomy or bypass (incision B). (From Reilly JM, Sicard GA: Right retroperitoneal approach to the aorta and its branches: Part II. Ann Vasc Surg 8:318-323, 1994; with permission.)
approximately 4 cm above the symphysis pubis at the rectus border and extended laterally to a point just medial to the tip of the 12th rib (Fig. 1B). The peritoneal envelope is swept medially and superiorly, thus exposing the iliac system and the distal aorta. The common iliac artery is then dissected circumferentially from the aorta down to its bifurcation. The distal aorta and the origins of the internal and external iliac arteries are then controlled. Proximal control is obtained by using a curved vascular clamp placed so that the distal aorta is clamped just above the orifice of the common iliac artery. For a common iliac endarterectomy either an open or a semiclosed technique can be used. For the open technique, a longitudinal arteriotomy is made, and a standard endarterectomy is performed as described above. In the semiclosed technique, the plaque is fractured proximally without opening the artery using either a vascular clamp or the LeVeen plaque crackerY For unilateral iliofemoral endarterectomy, we favor the LeVeen plaque cracker because it establishes a perfect endarterectomy plane at the sites where it is used. An arteriotomy is then made at the common femoral artery, and a wire loop or stripper is used to perform the endarterectomy. Before the wire loop is passed, the proximal plaque is milked digitally as far down the iliac as possible. The wire loop is then passed from the elevated femoral plaque, and the whole plaque is removed (Fig. 5). If an iliofemoral endarterectomy is to be performed, the external iliac and femoral artery must be completely mobilized to avoid perforation of the external iliac artery at the inguinal ligament when passing the wire endarterectomy loop as previously outlined. If a unilateral bypass is to be performed, it is first necessary to expose the femoral vessels through a groin incision. The bypass can then be performed from the proximal common iliac artery to the femoral artery. The proximal
688
REILLY & SICARD
Figure 5. Closed iliofemoral endarterectomy using the LeVeen plaque cracker technique. The plaque cracker is deployed in the most proximal common iliac artery (1) and just at the take-off of the hypogastric artery (2). With digital pressure, the separated plaque is mobilized distally (3). A ring endarterectomy loop mobilizes the remainder of the plaque (4) and the plaque is removed (5). A patch angioplasty in the femoral artery or extending to the deep femoral artery is performed if required (6).
anastomosis can be performed either end to end or end to side. The femoral anastomosis is performed end to side. In the high-risk patient with bilateral iliac occlusive disease, unilateral iliofemoral endarterectomy with a femoral-femoral cross-over graft (Fig. 6) is a means of providing bilateral revascularization without the need for aortic crossclamping, and it can be done under spinal or epidural anesthesia. Although perhaps not quite as durable, this is a much lower risk procedure than aortoiliac endarterectomy or bypass. SUMMARY
The retroperitoneal approach to the aorta and the iliac arteries provides excellent exposure for reconstruction of these vessels for aortoiliac occlusive disease. Furthermore, the weight of evidence in the literature indicates that this approach is associated with fewer complications, a shorter length of stay in the hospital, and lower costs. The major drawback to this approach at present
RETROPERITONEAL AORTOILIAC RECONSTRUCTION
689
Figure 6. Combined unilateral iliofemoral endarterectomy and femorofemoral bypass in high-risk patient with aortoiliac occlusive disease.
appears to be a lack of familiarity with the technical aspects of this exposure. It is our hope that this article helps familiarize surgeons with this exposure and encourages them to use it more frequently for "routine" aortoiliac reconstruction.
References 1. Cambria RP, Brewster OC, Abbott WM, et al: Transperitoneal versus retroperitoneal
2. 3. 4. 5. 6. 7. 8. 9. 10.
approach for aortic reconstruction: A randomized prospective study. J Vase Surg 11:314-325, 1990 Crawford ES, Manning LG, Kelly TF: "Redo" surgery after operation for aneurysm and occlusion of the abdominal aorta. Surgery 81:41-52, 1977 Darling RC ill, Shah DM, McClellan WR, et al: Decreased morbidity associated with retroperitoneal exclusion treatment for abdominal aortic aneurysm. J Cardiovasc Surg 33:65-69, 1992 Dubost C, Allary M, Occonomao N: Resection of an aneurysm of the abdominal aorta: Reestablishment of the continuity by a preserved human arterial homograft, with results after five months. Arch Surg 64:405-408, 1952 Gregory RT, Wheeler JR, Snyder SO, et al: Retroperitoneal approach to aortic surgery. J Cardiovasc Surg 30:185-189, 1989 Helsby R, Moossa AR: Aortoiliac reconstruction with special reference to the extraperitoneal approach. Br J Surg 62:596-600, 1975 Johnson IN, McLouglin GA, Wake PN, et al: Comparison of extraperitoneal and transperitoneal methods of aortoiliac reconstruction. J Cardiovasc Surg 27:561-564, 1986 Johnson IN, McLouglin GA, Wake PN, et al: Comparison of extraperitoneal and transperitoneal methods of aortoiliac reconstruction: 20 year experience [abstract]. J Cardiovase Surg 26:394-395, 1985 Leather RP, Karmody AM, Shah DM, et al: Extraperitoneal aortofemoral bypass with exclusion of the intact infrarenal abdominal aneurysm [abstract]. J Cardiovasc Surg 26:39,1985 Leather RP, Shah DM, Kaufman JL, et al: Comparative analysis of retroperitoneal and
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11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
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transperitoneal aortic replacement for aneurysm. Surg Gynecol Obstet 168:387-393, 1989 LeVeen HH, Diaz C, Ip MW: Extraperitoneal aortoiliac disobliteration with plaque cracker. Am J Surg 136:221-224, 1978 Metz P, Mathiesen FR: Retroperitoneal approach for implantation of aortoiliac and aortofemoral vascular prosthesis. Acta Chir Scand 144:471-473, 1978 Nevelsteen A, Smet G, Weymans M, et al: Transabdominal or retroperitoneal approach to the aortoiliac tract: A pulmonary function study. Eur J Vasc Surg 2:229-232, 1988 Peck JJ, McReynolds DG, Baker DH, et al: Extraperitoneal approach for aortoiliac reconstruction of the abdominal aorta. Am J Surg 151:620-623, 1986 Pennell RC, Hollier LH, Lie JT, et al: Inflammatory abdominal aortic aneurysms: A thirty year review. J Vasc Surg 2:859-869, 1985 Qvarfordt PG, Stoney RJ, Reilly LM, et al: Management of pararenal aneurysm of the abdominal aorta. J Vasc Surg 3:84-92, 1986 Ricotta JJ, Williams GM: Endarterectomy of the upper abdominal aorta and visceral arteries through an extraperitoneal approach. Ann Surg 192:633-638, 1980 Rob C: Extraperitoneal approach to the abdominal aorta. Surgery 53:87-89, 1963 Shepard AD, Tollefson FJ, Reddy DJ, et al: Left flank retroperitoneal exposure: A technical aid to complex aortic reconstruction. J Vase Surg 14:283-291, 1991 Shumacker HB: Little used surgical techniques of value. Am J Surg 144:186--190, 1982 Shumacker HB: Midline extraperitoneal exposure of the abdominal aorta and iliac arteries. Surg Gynecol Obstet 135:791-792, 1972 Shumacker HB Jr: Extraperitoneal approach for vascular operations: Retrospective review. South Med J 75:1499-1516, 1982 Sicard GA, Freeman MB, VanderWoude JC, et al: Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J Vasc Surg 5:19-27, 1987 Sicard GA, Reilly JM, Rubin BG, et al: Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Report of a prospective randomized trial. J Vasc Surg, 1994 Stipa S, Shaw RS: Aortoiliac reconstruction through a retroperitoneal approach. J Cardiovasc Surg 9:224-226,1968 Taheri SA, Gawronski S, Smith D: Paramedian retroperitoneal approach to the abdominal aorta. J Cardiovase Surg 24:529-531, 1983 Taheri SA, Nowakowski PA, Stoesser FG: Retroperitoneal approach for aortic surgery: Experience with 75 consecutive cases. Vasc Surg 3:144-148, 1969 Weinstein ES, Langsfeld M: Aortoiliac endarterectomy. Semin Vasc Surg 7:28-34, 1994 Williams GM, Ricotta J, Zinner M, et al: The extended retroperitoneal approach for treatment of extensive atherosclerosis of the aorta and renal vessels. Surgery 88:846-855,1980
Address reprint requests to Gregorio A. Sicard, MD One Barnes Hospital Plaza Suite 5103 St. Louis, MO 63110
0039-6109/95 $0.00
+
.20
RETROPERITONEAL AORTOILIAC RECONSTRUCTION Jeffrey M. Reilly, MO, and Gregorio A. Sicard, MO
The retroperitoneal approach to the infrarenal aorta was the approach used by Dubost et al4 for the first aortic reconstruction in a patient with an infrarenal abdominal aortic aneurysm. Despite this fact, this approach has never gained widespread acceptance for routine infrarenal aortic reconstruction. 20 Most surgeons reserve this approach for patients who have had multiple previous abdominal surgeries, who have horseshoe kidneys, who are obese, who have had previous aortic surgery, who require concomitant left renal artery revascularization, or who have ostomies, abdominal wall excoriation or infection, a history of abdominal and/or pelvic irradiation, peritoneal dialysis catheters, and ascites2, 15-19,22,26,27,29 (Table 1). In these instances the retroperitoneal exposure of the aorta offers well-recognized and clear-cut advantages over the transabdominal approach to the aorta. Over three decades ago the report by Rob 18 revived interest in the retroperitoneal approach for routine infrarenal aortic reconstruction, and since then numerous reports have demonstrated a clear superiority of the retroperitoneal approach in terms of intraoperative fluid replacement, postoperative pulmonary complications, length of ileus, and length of stay in the intensive care unit and in the hospital.5-10, 12-14, 21, 23, 25 These reports essentially corroborate our experience at the Washington University Medical Center. In both a retrospective analysis of our patients and a recently reported randomized prospective study, we have found that the retroperitoneal approach for routine aortoiliac reconstruction is associated with decreased length of ileus, fewer complications, a shorter length of stay, and lower hospital costs23,24 (Tables 2 and 3). Also, because this approach does not violate the peritoneal cavity, postoperative intra-abdominal adhesions with their attendant risk of early and late small bowel obstruction are avoided. Even more importantly, aortoenteric fistulas are an unheard of complication of aortic revascularization performed via the retroperitoneal approach. For these reasons, even in the absence of the relative indications listed above, we believe that the
From the Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine; The Jewish Hospital of St. Louis (JMR); and Barnes Hospital, St. Louis, Missouri
SURGICAL CLINICS OF NORTH AMERICA VOLUME 75 • NUMBER 4 • AUGUST 1995
679
680
REILLY & SICARD
Table 1. RELATIVE INDICATIONS FOR LEFT RETROPERITONEAL APPROACH (PATIENT FACTORS) Multiple previous abdominal surgeries (hostile abdomen) Abdominal wall osteomies Abdominal wall excoriation or infection Previous abdominal and/or pelvic irradiation Patients with peritoneal dialysis catheters Ascites Massive obesity Horseshoe kidney
retroperitoneal approach offers specific advantages over midline transabdominal exposure of the aorta. In the following sections we discuss the technical aspects of the procedures for aortoiliac revascularization which can be performed via the left and right retroperitoneal approaches to the infrarenal aorta and iliac arteries. Because this article deals primarily with lower extremity arterial occlusive disease, we limit our technical description to the use of the retroperitoneal approach for aortoiliac occlusive disease, although because of the usual distribution of aortic pathology, the largest experience with this approach has been with aneurysmal disease. LEFT RETROPERITONEAL APPROACH FOR AORTOILIAC RECONSTRUCTION
For patients with aortoiliac occlusive disease undergoing aortobifemoral bypass grafting or aortoiliac endarterectomy, the patient is pOSitioned with hips nearly parallel to the table with the left shoulder and trunk elevated to 45 deg using a self-molding, vacuum-operated, plastic foam bean bag (Olympic Medical, Seattle, W A) for maintenance of this position. The left arm is extended anteriorly and supported on a Mayo stand or secured to a table-mounted screen (Fig. 1). Correct positioning of the patient is critical for this exposure, and one of the common pitfalls is inattention to this detail. The most frequently made error is failing to rotate the torso far enough anteriorly, thereby compromising posterior exposure. For aortoiliac exposure, either a right- or left-sided incision is begun at a point just medial to the lateral border of the left rectus muscle midway between the symphysis pubis and the umbilicus. It is continued in a curvilinear fashion to 6 to 8 cm medial and superior to the anterior iliac spine and then posterolaterally to the tip of the 12th rib or the 11th interspace, depending on the size and habitus of the patient (Fig. 1). The retroperitoneal space is most easily entered at the junction of the rectus and lateral abdominal wall muscles by dividing the transversalis fascia. Then using blunt dissection through this opening, the peritoneum is mobilized away from the anterior and lateral abdominal wall, which allows the musculature to be divided using electrocautery. Excellent exposure can usually be achieved by division of the oblique and the transversus abdominis muscles without dividing the rectus muscle. In obese patients or in patients in whom it appears that exposure will be difficult, more extensive exposure can be obtained by dividing the rectus muscle or by extending the incision into the 11th or 12th interspace. As the
Table 2. RETROPERITONEAL VERSUS TRANSPERITONEAL APPROACH TO AORTIC SURGERY Number of Patients Author Sicard et ai, 198723 Johnson et ai, 19867 Peck et ai, 198614 Leather et ai, 1989'0 Gregory et ai, 19895 Cambria et ai, 1990't Darling et ai, 19923 Sicard et ai, 199424t
0'1
"""
Survival
Length of Stay
Retro
Trans
Retro
Trans
PValue
Retro
Trans
PValue
Retro
Trans
PValue
54 298 200 193 53 54 15 70
50 161 70 106 119 59 12 75
0 1% 18% 0.5% 3.3% 3.7% 2.1· 0%
6% 6% 96% 10.4% 4.9% 6.7% 4.0· 11%
<0.001 <0.05 <0.001 <0.02 <0.01
10 12 7 7 9 10.3 6.7 9.9
14 17 10 12 13 12.5 9.0 12.9
<0.02 <0.05
2% 4% 1.5% 3.6% 0% 0% 0 0%
1.9% 3.7% 2.8% 3.8% 4.2% 1.7% 0 3%
NS NS NS NS NS NS NS NS
'Number of days before resuming regular diet tProspective, randomized trials
co
Ileus
NS
<0.05 0.005
NS
<0.02 <0.01 NS
0.157 0.10
682
REILLY & SICARD
Table 3. WASHINGTON UNIVERSITY RANDOMIZED PROSPECTIVE TRIALTRANSABDOMINAL VERSUS RETROPERITONEAL INCISION IN ELECTIVE AORTIC SURGERY24
Retroperitoneal Transabdominal
Number of Patients
ICU Stay
70 75
2.3 3.5*
Hospital Stay
Total Postoperative Complications
Hospital Cost
9.9 12.9t
24% 51%*
$16,350 $21,023*
*P <0.05
tP
=
0.01
musculature is divided, the peritoneum is mobilized medially and cephalad using blunt dissection. This provides excellent exposure of the retroperitoneum down to the distal aorta and proximal iliac arteries. Once the retroperitoneal space is entered, the ureter, which is usually swept medially with the peritoneal envelope, is mobilized up to the level of the renal pelvis and is gently retracted laterally (Fig. 2). To avoid ischemic injury to the ureter, this is done leaving the periureteral fat intact. Failure to adequately mobilize the ureter early in the dissection can result in a traction injury to this structure. The gonadal vein is identified and ligated at its junction with the left renal vein. Once again, failure to perform this step early in the dissection can
A
B
Figure 1. Correct positioning of the patient for exposure of the left retroperitoneum. Incisions Band C are used for aortic and renal revascularization. Incision A is used for iliofemoral endarterectomy or bypass. (From Sicard GA, Reilly JM: Left retroperitoneal approach to the aorta and its branches: Part I. Ann Vasc Surg 8:212-219, 1994; with permission.)
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Right
Figure 2. Retroperitoneal exposure in patient with aortoiliac occlusive disease. The top illustration demonstrates the exposure of the infrarenal aorta and vena cava that is obtained via the right retroperitoneal approach. Note that the right gonadal vein has been ligated and the right ureter has been mobilized to the level of the renal pelvis. The bottom illustration shows the exposure obtained for aortobifemoral bypass using either an end-toside (A) or end-to-end (8) graft to aortic anastomosis. (From Sicard GA, Reilly JM: Left retroperitoneal approach to the aorta and its branches: Part I. Ann Vasc Surg 8:212-219, 1994; with permission.)
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result in its subsequent avulsion from the renal vein, which may cause significant hemorrhage. The left kidney is left to lie posteriorly by dissecting in the avascular plane between Gerota's fascia and the peritoneum. At this point it is usually helpful to put in place a self-retaining retractor system. Use of such a system (we prefer the Omni) helps to minimize trauma by providing controlled, constant retraction and eliminates the frequent readjustments that are necessary with hand-held retractors, This helps to eliminate too forceful or vigorous retraction in the left upper quadrant, which can result in injury to intraperitoneal organs (usually the spleen). The exposure provided by such a system is also usually far superior to that provided by handheld retractors. Once adequate exposure of the operative field has been established, the aorta is dissected just below the left renal vein so that a proximal cross-clamp can be applied. For placement of an aortobifemoral bypass graft, there is no need for exposure of the iliac system. An adequate length of the infrarenal aorta is exposed so that another cross-clamp can be applied distally, and the graft to aortic anastomosis is performed between the two clamps. This proximal anastomosis can be performed in an end-to-side or an end-to-end fashion as is dictated by the status of the pelvic circulation (Fig. 2). Ligation of the inferior mesenteric artery can expand the exposure of the right iliac system and can facilitate placement of a bifemoral graft. For aortobifemoral bypass grafting, standard groin incisions are used, and the graft limbs are tunneled in their respective groins. The tunneling of the graft toward the right femoral region must be done bluntly with finger dissection, starting at the proximal right common iliac artery and continuing distally toward the femoral artery so as to displace the right ureter superiorly in order to avoid ureteral injury. This tunnel is then completed by blunt finger dissection, starting in the area of the right femoral artery with the surgeon's right index finger until it meets the surgeon's left index finger. Once the tunnel is complete and free of interposed tissue, a long clamp (e.g., Crawford clamp) is passed from the groin into the retroperitoneum, and the right aortic limb is grasped and brought down to the right femoral region. Passage of the left limb is very simple because the entire left lower retroperitoneum is exposed. Once the graft limbs are tunneled, the distal anastomoses are performed in a standard fashion. If the superficial femoral artery is patent, the femoral anastomosis is performed opposite the profunda femoris origin. If the superficial femoral artery is occluded, the anastomosis is carried down onto the first portion of the profunda, thus creating a profundaplasty. For aortoiliac endarterectomy, the incision and aortic exposure are the same as for aortobifemoral bypass grafting; however, exposure of the iliac system is required as well. Exposure of the left iliac system is easily obtained. Exposure of the right iliac system can be more problematic. Several maneuvers are helpful in this situation. Extending the incision medially by transecting a portion of the rectus muscle usually allows adequate exposure of the right common iliac artery. This exposure is also facilitated by ligating the inferior mesenteric artery, which allows further medial mobilization of the peritoneal envelope. This ligation should be performed flush with the aorta in order to avoid injuring any early branches of the inferior mesenteric artery. This maneuver allows the mobilization of the right common iliac to the level of the bifurcation in nonobese patients. If it is necessary to carry the endarterectomy down into the external iliac artery or if control of the iliac bifurcation is difficult, a small counterincision can be made in the right lower quadrant, and the distal right iliac system can be easily exposed through this. When contemplating aortoiliac endarterectomy, it is important to realize
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that two patterns of atherosclerosis are typically seen in aortoiliac occlusive disease. Type I disease involves the infrarenal aorta, the common iliac artery, and often the orifices of the internal iliac arteries with sparing of the external iliac arteries. Type II disease involves these vessels as well as the external iliac and common femoral arteries. 2B In order to perform an endarterectomy, it is helpful to isolate the lumbar vessels so that backbleeding can be controlled and mandatory to circumferentially dissect the iliac arteries. The aortoiliac endarterectomy is performed once adequate vascular control has been obtained. For type I disease, this means that the internal and external iliacs have been controlled just beyond the iliac bifurcation. For type II disease, the proximal internal iliac is controlled, the external iliac arteries are circumferentially dissected, and the common femoral arteries are fully mobilized through separate groin incisions. We do not favor extensive aortoiliac endarterectomy for patients with type II disease and prefer an aortobifemoral bypass graft. On the other hand, in young patients (mostly young women) with disease limited to the aortoiliac bifurcation, we believe that open aortoiliac endarterectomy is still a good operation in selected cases, and this procedure can be easily performed through a left retroperitoneal approach. One advantage of the left retroperitoneal approach is that it allows easy access to the juxtarenal aorta, and this is sometimes required if the occlusive plaque extends nearly to the level of the renal arteries. The only additional step required to expose the juxtarenal aorta is full mobilization of the left renal vein with ligation of the adrenal and lumbar veins. If a suprarenal clamp is required for the initial portion of the endarterectomy, the origins of both renal arteries should be controlled to prevent embolization of atherosclerotic debris. The aorta can be opened infrarenally and the endarterectomy can be performed to the juxtarenal level from below or the longitudinal arteriotomy can be carried cephalad. After cross-clamping, the infrarenal aorta is opened longitudinally down to the bifurcation. An endarterectomy plane is established, and the plaque is removed en bloc after it is transected proximally. If a suprarenal cross-clamp has been used, it can be moved infrarenally as soon as the proximal portion of the endarterectomy is complete. The iliac portion of the endarterectomy can be done either open or semiclosed. If the open technique is used, the iliac arteries need to be opened down to the level of the iliac bifurcation. These arteriotomies can be continuous or discontinuous with the aortic endarterectomy. The plaque is then removed in the standard fashion. The endpoint of the endarterectomy needs to be at or proximal to the iliac bifurcation (Fig. 3). If necessary, tacking sutures are used to secure the distal endpoint. If primary closure of the iliac artery and/or the aorta will result in stenosis, the arteriotomy can be closed with a patch (either Dacron or polytetrafluoroethylene can be used). THE RIGHT RETROPERITONEAL APPROACH FOR AORTOILIAC RECONSTRUCTION
The right retroperitoneal approach to the aorta is not as versatile as the left retroperitoneal approach, but it is quite useful in specific situations. It can be used for aortobifemoral bypass for occlusive disease and is particularly useful if a concomitant right renal artery revascularization is to be performed. It also serves as an alternative exposure for patients who have had previous surgery in the left retroperitoneum, e.g., a nephrectomy or sigmoid colectomy. The positioning of the patient and the incision are the mirror images of those for the left retroperitoneal approach (Fig. 4). The major technical differences between
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Figure 3. A-D, An aortoiliac endarterectomy for type I aortoiliac occlusive disease using the open technique.
the two approaches relate to the differences in venous anatomy between the left and right retroperitoneums. The right gonadal vein drains directly into the vena cava and should be ligated flush with its origin. There is no need to expose the right renal vein, but the left renal vein must be identified. Obviously, the vena cava is interposed between the surgeon and the aorta, and care must be taken in dissecting out the aorta not to injure the fragile lumbar veins. These may be ligated if necessary. When approaching the aorta from the right, ligating the inferior mesenteric artery can greatly facilitate the exposure and is thus done more frequently than on the left side, where exposure is usually not a problem. Once the aorta is exposed, the technical aspects of the procedures are the same as for the left retroperitoneal approach. UNILATERAL ILIAC REVASCULARIZATION
For unilateral iliac revascularization, the patient does not need to be rotated to the extent required for more proximal aortic exposure. In fact, placing a pillow or the bean bag beneath the ipsilateral hip usually provides enough rotation without rotating the upper torso. For exposure of either the right or left iliac system, an incision is made in a curvilinear fashion beginning at a level
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Figure 4. The position of the patient undergoing either a right aortobifemoral bypass (incision A) or right iliac or iliofemoral endarterectomy or bypass (incision B). (From Reilly JM, Sicard GA: Right retroperitoneal approach to the aorta and its branches: Part II. Ann Vasc Surg 8:318-323, 1994; with permission.)
approximately 4 cm above the symphysis pubis at the rectus border and extended laterally to a point just medial to the tip of the 12th rib (Fig. 1B). The peritoneal envelope is swept medially and superiorly, thus exposing the iliac system and the distal aorta. The common iliac artery is then dissected circumferentially from the aorta down to its bifurcation. The distal aorta and the origins of the internal and external iliac arteries are then controlled. Proximal control is obtained by using a curved vascular clamp placed so that the distal aorta is clamped just above the orifice of the common iliac artery. For a common iliac endarterectomy either an open or a semiclosed technique can be used. For the open technique, a longitudinal arteriotomy is made, and a standard endarterectomy is performed as described above. In the semiclosed technique, the plaque is fractured proximally without opening the artery using either a vascular clamp or the LeVeen plaque crackerY For unilateral iliofemoral endarterectomy, we favor the LeVeen plaque cracker because it establishes a perfect endarterectomy plane at the sites where it is used. An arteriotomy is then made at the common femoral artery, and a wire loop or stripper is used to perform the endarterectomy. Before the wire loop is passed, the proximal plaque is milked digitally as far down the iliac as possible. The wire loop is then passed from the elevated femoral plaque, and the whole plaque is removed (Fig. 5). If an iliofemoral endarterectomy is to be performed, the external iliac and femoral artery must be completely mobilized to avoid perforation of the external iliac artery at the inguinal ligament when passing the wire endarterectomy loop as previously outlined. If a unilateral bypass is to be performed, it is first necessary to expose the femoral vessels through a groin incision. The bypass can then be performed from the proximal common iliac artery to the femoral artery. The proximal
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Figure 5. Closed iliofemoral endarterectomy using the LeVeen plaque cracker technique. The plaque cracker is deployed in the most proximal common iliac artery (1) and just at the take-off of the hypogastric artery (2). With digital pressure, the separated plaque is mobilized distally (3). A ring endarterectomy loop mobilizes the remainder of the plaque (4) and the plaque is removed (5). A patch angioplasty in the femoral artery or extending to the deep femoral artery is performed if required (6).
anastomosis can be performed either end to end or end to side. The femoral anastomosis is performed end to side. In the high-risk patient with bilateral iliac occlusive disease, unilateral iliofemoral endarterectomy with a femoral-femoral cross-over graft (Fig. 6) is a means of providing bilateral revascularization without the need for aortic crossclamping, and it can be done under spinal or epidural anesthesia. Although perhaps not quite as durable, this is a much lower risk procedure than aortoiliac endarterectomy or bypass. SUMMARY
The retroperitoneal approach to the aorta and the iliac arteries provides excellent exposure for reconstruction of these vessels for aortoiliac occlusive disease. Furthermore, the weight of evidence in the literature indicates that this approach is associated with fewer complications, a shorter length of stay in the hospital, and lower costs. The major drawback to this approach at present
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Figure 6. Combined unilateral iliofemoral endarterectomy and femorofemoral bypass in high-risk patient with aortoiliac occlusive disease.
appears to be a lack of familiarity with the technical aspects of this exposure. It is our hope that this article helps familiarize surgeons with this exposure and encourages them to use it more frequently for "routine" aortoiliac reconstruction.
References 1. Cambria RP, Brewster OC, Abbott WM, et al: Transperitoneal versus retroperitoneal
2. 3. 4. 5. 6. 7. 8. 9. 10.
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transperitoneal aortic replacement for aneurysm. Surg Gynecol Obstet 168:387-393, 1989 LeVeen HH, Diaz C, Ip MW: Extraperitoneal aortoiliac disobliteration with plaque cracker. Am J Surg 136:221-224, 1978 Metz P, Mathiesen FR: Retroperitoneal approach for implantation of aortoiliac and aortofemoral vascular prosthesis. Acta Chir Scand 144:471-473, 1978 Nevelsteen A, Smet G, Weymans M, et al: Transabdominal or retroperitoneal approach to the aortoiliac tract: A pulmonary function study. Eur J Vasc Surg 2:229-232, 1988 Peck JJ, McReynolds DG, Baker DH, et al: Extraperitoneal approach for aortoiliac reconstruction of the abdominal aorta. Am J Surg 151:620-623, 1986 Pennell RC, Hollier LH, Lie JT, et al: Inflammatory abdominal aortic aneurysms: A thirty year review. J Vasc Surg 2:859-869, 1985 Qvarfordt PG, Stoney RJ, Reilly LM, et al: Management of pararenal aneurysm of the abdominal aorta. J Vasc Surg 3:84-92, 1986 Ricotta JJ, Williams GM: Endarterectomy of the upper abdominal aorta and visceral arteries through an extraperitoneal approach. Ann Surg 192:633-638, 1980 Rob C: Extraperitoneal approach to the abdominal aorta. Surgery 53:87-89, 1963 Shepard AD, Tollefson FJ, Reddy DJ, et al: Left flank retroperitoneal exposure: A technical aid to complex aortic reconstruction. J Vase Surg 14:283-291, 1991 Shumacker HB: Little used surgical techniques of value. Am J Surg 144:186--190, 1982 Shumacker HB: Midline extraperitoneal exposure of the abdominal aorta and iliac arteries. Surg Gynecol Obstet 135:791-792, 1972 Shumacker HB Jr: Extraperitoneal approach for vascular operations: Retrospective review. South Med J 75:1499-1516, 1982 Sicard GA, Freeman MB, VanderWoude JC, et al: Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J Vasc Surg 5:19-27, 1987 Sicard GA, Reilly JM, Rubin BG, et al: Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Report of a prospective randomized trial. J Vasc Surg, 1994 Stipa S, Shaw RS: Aortoiliac reconstruction through a retroperitoneal approach. J Cardiovasc Surg 9:224-226,1968 Taheri SA, Gawronski S, Smith D: Paramedian retroperitoneal approach to the abdominal aorta. J Cardiovase Surg 24:529-531, 1983 Taheri SA, Nowakowski PA, Stoesser FG: Retroperitoneal approach for aortic surgery: Experience with 75 consecutive cases. Vasc Surg 3:144-148, 1969 Weinstein ES, Langsfeld M: Aortoiliac endarterectomy. Semin Vasc Surg 7:28-34, 1994 Williams GM, Ricotta J, Zinner M, et al: The extended retroperitoneal approach for treatment of extensive atherosclerosis of the aorta and renal vessels. Surgery 88:846-855,1980
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