Commentary on ‘Systematic Review and Meta-analysis of the Retroperitoneal Versus the Transperitoneal Approach to the Abdominal Aorta’

Abstract

In the last few decades the classical open surgical approach for infra-renal aneurysm repair has not undergone major changes. The principle of exposing the aorta, clamping it, and sewing in a vascular graft has not changed significantly. In this meta-analysis, the auteurs claim there may be clinical benefits to performing this surgery via a retroperitoneal (RP) approach. 1 The reduction in mortality of elective infrarenal repairs has been substantial since it was developed. 2 However, this reduction is a result of several factors, such as patient selection, medical treatment, aesthetic techniques, and improved care in intensive care units, and not the surgical technique per se.Traditionally, the RP approach has been reserved for selective cases as many surgeons feel it is technically more demanding and provides limited access to the aortic side branches. 3 However, several comparative studies demonstrated some advantages over the RP approach. 4,5 In clinical practice the RP approach was used for supra-renal and thoraco-abdominal aneurysms, and usually not for infra-renal aneurysms.In the last 20 years endovascular repair (EVAR) has had a major effect on clinical practice. It not only reduced the operative morbidity and mortality but it also changed open surgical repair. The expanding group of patients undergoing EVAR because of an abdominal aortic aneurysm leaves a more challenging group for open repair. The patients who are going to undergo open repair often have more aneurysms expanding cranially and involving the renal arteries and visceral vessels, and more often have anatomical variants, such as accessory renal arteries. This group of patients, who are unsuitable for EVAR, can be treated by an RP approach far more easily than by a transperitoneal approach. 4 As demonstrated in the review 1 an RP approach has some advantages over a classical transperitoneal approach in terms of morbidity. 4,5 Therefore, the indication for an RP approach expands with the increasing role of EVAR.The data presented in the review 1 support the view that an RP approach is one to be considered if open surgical repair is indicated. As the indication for open surgery has changed with the introduction of EVAR, the RP approach is likely to become increasingly important. As pointed out by Twine et al. 1 the reduced number of open surgical repairs is a point of concern from a training point of view. Future vascular surgeons should be familiar with this approach and should consider it when open surgical repair is indicated. REFERENCES 1 Twine CP, Humphreys AK, Williams IM. Systematic review and meta-analysis of the retroperitoneal versus the transperitoneal approach to the abdominal aorta. Eur J Vasc Endovasc Surg 2013. 2 DeBakey ME, Crawford ES, Cooley DA, Morris Jr GC, Royster TS, Abbott WP. Aneurysm of abdominal aorta analysis of results of graft replacement therapy one to eleven years after operation. Ann Surg 1964;160:622e39. 3 Twine CP, Lane IF, Williams IM. The retroperitoneal approach to the aorta in the endovascular era. J Vasc S...