Operative Exposure

A xiphoid-to-pubis midline abdominal incision is made for operative repair of atherosclerotic disease of the main renal artery, especially when bilateral lesions are present. The last 1- or 2-cm cephalad incision coursing to one side of the xiphoid is important in obtaining full exposure of the upper abdominal aorta and renal artery origins. Some form of fixed mechanical retraction is also advantageous, particularly when combined aortorenal procedures are required. Otherwise, extended flank and subcostal incisions are reserved for fibrodysplastic lesions, and splanchnorenal bypass and combined mesenteric reconstruction and branch reconstruction require ex vivo techniques.

When left renal bypass is combined with antegrade mesenteric bypass, an extended flank incision is useful. With the left flank elevated, the incision extends from the right semilunar line into the flank, bisecting the abdominal wall between the left costal margin and iliac crest. A left visceral mobilization allows access to the renal and mesenteric vasculature. If necessary, the aortic crus can be divided, and an extrapleural dissection of the descending thoracic aorta can provide access to the T9 to T10 thoracic aorta for proximal control.

When the midline xiphoid-to-pubis incision is used, the posterior peritoneum overlying the aorta is incised longitudinally, and the duodenum is mobilized at the ligament of Treitz (Figure 1). During this maneuver, it is important to identify mesenteric arterial collaterals that course at this level. Finally, the duodenum is reflected to the patient’s right to expose the left renal artery. By extending the posterior peritoneal incision to the left along the inferior border of the pancreas, an avascular plane posterior to the pancreas can be entered (see Figure 1) to expose the entire renal hilum.

This exposure is of special significance when distal renal artery lesions need to be managed (Figure 2A). The left renal artery lies posterior to the left renal vein. In some instances, the vein can be retracted cephalad to expose the artery; in others, caudal retraction of the vein provides better access. Usually, the gonadal and adrenal veins, which enter the left renal vein, must be ligated and divided to facilitate exposure of the distal artery. Often, a lumbar vein enters the posterior wall of the left renal vein and can be easily avulsed unless special care is taken while mobilizing the renal vein (Figure 2B). The proximal portion of the right renal artery is exposed through the base of the mesentery by ligating two or more pairs of lumbar veins and retracting the left renal vein cephalad and the vena cava to the patient’s right (Figure 2C).

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