INTRODUCTION

The management of Abdominal Aortic Aneurysm (AAA) constitutes a significant part of contemporary vascular surgery practice, as it is a relatively common disorder, affecting up to 8% of the population in Western countries¹. AAA refers to an enlargement of the abdominal aorta more than 1,5 times the diameter of the aorta before the enlargement, and elective treatment is usually considered at a diameter of 5.5cm. Untreated AAAs are likely to increase in size and rupture, eventually causing massive internal bleeding, a severe complication, giving an 80% overall mortality rate.

Since the development of endovascular techniques in the 1990s, the standard of care has shifted from Open Aortic Repair (OAR) to Endovascular Aortic Repair (EVAR), mainly due to decreased perioperative mortality and morbidity. However, limitations like anatomic constrictions for EVAR, the need for continuous radiologic surveillance, and the increased risk of reinterventions after endovascular procedures preserve the need for OAR, which, with proven long-term benefits and decreased aneurysm-related mortality², remains an essential tool for the treatment of AAAs.

Since the first attempts at aortic repair in the 1950s, two techniques of abdominal aortic approach have developed and been widely used, the transperitoneal (TP) and the retroperitoneal (RP) approach, which Rob first best described in 1963³. In 1980, Williams reported an extended RP approach. He claimed that this approach offers better exposure not only of the infrarenal aorta but also of the pararenal and suprarenal aorta⁴.

Despite multiple published studies comparing the two techniques, neither has proven to have significantly more advantages, and both have been employed by vascular surgeons with acceptable results. Both approaches are currently used, and the choice between them is based on anatomic criteria and surgeons’ experience and preferences. However, there is a tendency indicating that the TP approach is more widely adopted, especially for infrarenal AAAs, as it is considered technically less challenging and more surgeon-friendly, and the number of surgeons using the RP approach is declining⁵.

TECHNIQUE

RETROPERITONEAL APPROACH IN MODERN PRACTICE

POSTOPERATIVE RESULTS

Few Randomized Control Trials (RCTs) have been conducted to assess the effectiveness and safety of the retroperitoneal versus transperitoneal approach for elective open abdominal aortic aneurysm repair on mortality, complications, hospital stay, and blood loss. A review published in 2021, including 5 RCTs and 152 patients, concluded that the obtained results are considered low-certainty evidence⁷.

No difference in mortality has been established between the two techniques⁷. Studies have suggested various physiological benefits following an RP approach and better short-term results. The TP approach usually involves intestinal manipulation, mesenteric traction, and blood contamination of the peritoneal cavity – all of which may lead to impaired intestinal motility⁸.

COMPLEX AAAs

Extensive literature has been reported considering the treatment of infrarenal AAAs, concluding that EVAR is the approach of choice in the majority of patients. However, juxtarenal aneurysms unsuitable for standard EVAR, and pararenal aneurysms make up 15% of all abdominal aortic aneurysms needing treatment²⁶. Endovascular solutions for those complex AAAs (cAAA) include fenestrated EVAR (FEVAR), branched EVAR, or chimney-EVAR (ChEVAR).

However, in certain patients with anatomically complex aneurysms, open repair remains the preferred treatment choice as it may be beneficial for younger patients, patients unable to comply with long-term surveillance, or with highly unfavorable anatomy. Both RP and TP approaches have been used to treat cAAAs, and recent retrospective studies have favored the RP approach in terms of early results.

CONCLUSION

It is crucial to highlight the importance of the retroperitoneal approach as an essential and invaluable tool in the armory of vascular surgeons. Both transperitoneal and retroperitoneal techniques have been performed and evolved for decades, but modern endovascular techniques have narrowed their practice, and their indications are limited. The issue of whether either approach confers any advantage has been discussed for decades without a definite resolution.

A concern is that an ever-decreasing number of enthusiasts will use the retroperitoneal approach in the future. We consider the preservation of this technique of utmost importance and emphasize the need for quality training of the younger generations in established, high-volume departments to properly navigate future challenges in the contemporary endovascular-driven era.