Commentary: The Untaught Midline Retroperitoneal Approach to Repair Complex Abdominal Aortic Diseases

With increasing endovascular technology and skills, treatment of the aneurysmal and atherosclerotic occlusive aortic diseases is shifting towards a minimally invasive approach. Several prospective, randomized trials have shown decreased morbidity and mortality with the endovascular aneurysm repair (EVAR), compared to open surgery, for the treatment of infrarenal aortic aneurysms [1-4]. For aortic atherosclerotic occlusive disease, the preferred method of treatment is still controversial, with open surgical repair being considered the optimal approach in standard risk patients [5]. Endovascular treatment (kissing stents, covered endovascular reconstruction of the aortic bifurcation (CERAB), chimney-CERAB, and aorto-uni-iliac stent grafts) has been more commonly utilized in high-risk patients, but the mid and long-term patencies remain unknown [6-9]. As a result of the incessant transformation of the treatment of the aortic diseases, the vascular surgeons are becoming less comfortable performing open surgery, facing fewer but more complex open aortic repairs that require a supra renal or supra mesenteric clamp, such as for failed EVAR (“resilient”, high-pressure, endoleaks or graft infection) and for diseases involving the para visceral aorta. There are two techniques, well-illustrated in surgical books and atlas, which are taught during the surgical training to expose the abdominal aorta: The Midline Transperitoneal Approach (MTA) and the Lateral Retroperitoneal Approach (LRA). An “eternal fight” on the best modality exists between the two, with the MTA being the most familiar to the surgeons. Several retrospective studies highlighted the pros and cons of each approach, sometimes with opposite conclusions [10-12]. Historically, LRA has been utilized in patients with horseshoe kidney, inflammatory aneurysm, or history of multiple intraperitoneal procedures (hostile abdomen). Besides, LRA has been preferred for the exposure of the para visceral aorta. However, the LRA requires division of the lateral abdominal wall muscles with frequent muscular and/or flank bulging from muscle denervation and significant postoperative pain [13]. Furthermore, the LRA does not allow the exposure of the right iliac bifurcation and provides limited visualization of the right renal artery.