Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O Canada Canada Retroperitoneal Approach Retroperitoneal Approach to AAA Repair to AAA Repair George E. Hajjar MD. FRCSC Division of Vascular and Endovascular Surgery University of Ottawa Canada
Retroperitoneal Approach to AAA Repair. George E. Hajjar MD. FRCSC Division of Vascular and Endovascular Surgery University of Ottawa Canada. Ottawa Canada The Nations Capital. Pop 990,000. Retroperitoneal AAA Repair. Advantages: Lesser post-op pain, easier respiratory functions. - PowerPoint PPT Presentation
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Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal Approach to AAA Retroperitoneal Approach to AAA RepairRepair
George E. Hajjar MD. FRCSCDivision of Vascular and Endovascular
SurgeryUniversity of Ottawa
Canada
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Ottawa Canada The Nations Capital. Pop 990,000
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
functions.• Less third spacing and fluid shift. • Less hypothermia• Less bowel oedema, and transient ischemia• Less post op ileus and need for NG suction• Better exposure of suprarenal aorta• The Aorta is a retroperitoneal structure
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
and scarring• Prevents development of intra-abdominal
adhesions and scarring• Decreases the chances of duodenal injury, and
intramural haematoma• Decreases the incidence of Aorto-duodenal fistula
development• Possibly decreases length stay.
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair
• Not widely used:Not widely used:• Unfamiliarity with the approach• Reserved for selective difficult cases• Fear of incisional complications : muscle eventration
although it does occur it is well tolerated in this patient population. No incisional hernias or eviscerations.
• Fear of difficulty exposing associated iliac disease: Right iliac aneurysm or femoral exposure if needed.
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair• Procedure of choice InProcedure of choice In• Hostile abdomen• Juxta-renal or supra-renal aneurysms• Horseshoe Kidney• Redo Aortic Surgery• Inflammatory aneurysms
• Avoided:Avoided:• If concurrent right renal repair is needed• Left sided vena cava, other venous anomalies• Ruptured aneurysm with large left sided haematoma
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA RepairHorseshoe kidney
• Requires Re-implanting renal branches to the isthmus
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Ruptured AAA
• Avoid left sided ruptures. Unless low down and neck is accessible
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Right iliac aneurysms
• Mobilization of the retroperitoneum low down in the left pelvis• Relaxing the upper incisional retractors• Ligating and transecting the IMA , allows further aneurysm mobilization .
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Draining Lumbar vein
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair venous anomalies
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Suprarenal exposure
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Iliac Exposure
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Retroperitoneal AAA Repair
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• Redo Redo :: 5 patients 5 patients1 pat. 1 yr post REVAR1 pat. 1 yr post REVAR2 pats. Secondary ADF, in a Type IV AAA post remote 2 pats. Secondary ADF, in a Type IV AAA post remote aortic Sx.aortic Sx.1 pat. IAAs post ruptured AAA repair 4 years earlier1 pat. IAAs post ruptured AAA repair 4 years earlier1 pat. Had an AAA 10 years post ABF end to side graft1 pat. Had an AAA 10 years post ABF end to side graft
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
• Late incisional complications:Late incisional complications:1 Intercostal neuralgia(tip of 111 Intercostal neuralgia(tip of 11thth rib was excised rib was excised for higher exposure)for higher exposure)2 excision of Prolene knot2 excision of Prolene knot6 specific complaints about asymmetric bulge 6 specific complaints about asymmetric bulge needed reassuranceneeded reassurance
Vascular and Endovascular Surg U of O Vascular and Endovascular Surg U of O CanadaCanada
Conclusion• Retroperitoneal approach for AAA repair is easily
feasible.• Can be used in a variety of conditions including right
iliac aneurismal disease, aortoiliac disease.• Approach of choice for hostile abdomens, redo aortic