Incision: In the transperitoneal approach, a midline abdominal incision is made and it extends from the level of xiphoid process to the pubis.
In the retroperitoneal approach, the incision is made infraumbilically. It starts at the lateral border of the rectus sheath and goes up to the 11th or 12th rib.
Surgery: As defined earlier, there are two main surgical approaches which are used: transperitoneal and retroperitoneal approach. There are differences in both the approaches and therefore, these procedures are explained separately.
Transperitoneal approach: After the midline incision is made, the abdomen is explored carefully and all the abdominal contents are inspected. The confirmation of proper insertion of urinary catheter and nasogastric tube is done. The omentum and transverse colon are retracted superiorly whereas the small intestine is eviscerated to the right of the patient. This helps in the visualization of mesenteries and left colon. Small intestines are not manipulated vigorously and are not taken out of the abdominal cavity. This reduces the occurrence of postoperative ileus.
After this, effort is made to expose infrarenal abdominal aorta. This is done by incising the posterior peritoneum from the ligament of Treitz to the aortic bifurcation. The posterior peritoneum is located between the inferior mesenteric vein and the fourth portion of the duodenum. It is important to dissect on the right side of the inferior mesenteric vein and this should be done cautiously. This is because there are chances of damaging inferior mesenteric artery at it origin from the left anterolateral aspect of the aorta halfway between the renal arteries and the aortic bifurcation. The dissection of this area becomes difficult in inflammatory AAA. Ureteral stents can also be placed to avoid ureteral damage in inflammatory AAA or in the presence of pelvic infection.
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