Transperitoneal Exposure of the Supraceliac Aorta and Celiac Artery

The exposure of the supraceliac aorta and the celiac artery is required for antegrade bypass to the visceral vessels (both SMA and celiac artery) in the setting of mesenteric ischemia and for the more common scenario when proximal control of the abdominal aorta is required as in the case of a ruptured infrarenal or juxtarenal abdominal aortic aneurysm. The origin of the celiac artery and a 5- to 8-cm segment of the aorta caudal to its origin may be exposed using this approach, although a more limited approach and dissection is usually sufficient if the objective is only to apply a proximal aortic clamp. The supraceliac aorta is usually relatively free of atherosclerotic occlusive disease and therefore is a good inflow source for antegrade visceral bypass. The exposure of the segment of aorta caudal to the celiac artery is somewhat limited through this approach given the overlying anatomic structures and should be exposed through an alternative approach.

The procedure can be performed using either a midline or bilateral subcostal incision; the choice is contingent upon the surgeon’s preference and the patient’s body habitus. The midline incision is slightly easier to close, although a bilateral subcostal incision with a midline extension to the xiphoid provides optimal exposure of the upper abdomen. A lumbar bump can augment the aortic exposure for all of the transperitoneal approaches.

After a general exploration of the abdomen, the left triangular ligament of the liver is incised and the left lateral segment of the liver is reflected to the patient’s right side using a self-retaining retractor such as a Bookwalter. Care should be exercised during incision of the triangular ligament to avoid injuring the hepatic veins. The gastrohepatic ligament is then incised, although caution should be exercised during this maneuver because a replaced left hepatic artery, a common anatomic variant, passes through the ligament. The esophagus and stomach are then retracted to the patient’s left, and identification of the esophagus is facilitated by palpation of the nasogastric tube or transesophageal echocardiography probe. The exposure can be facilitated at this point by placing the patient in a significant amount of reverse Trendelenburg, allowing the abdominal structures to retract caudally by gravity.

The median arcuate ligament and the crus of the diaphragm are incised to expose the underlying aorta; this can be facilitated by incising the muscle fibers between the jaws of a large right-angle clamp using electrocautery (Figure 1). The dissection of the aorta cephalad to the celiac artery can be exposed relatively quickly, although care should be exercised in the segment adjacent to the celiac artery to avoid inadvertent injury to the vessel. Additionally, a dense neural plexus, further complicating the dissection, encases the origin of the celiac artery.

The extent of the aortic dissection required is dictated by the clinical situation. It is not usually necessary to dissect the aorta circumferentially, but it can be helpful to place an umbilical tape around the aorta to serve as a handle should difficulties arise. Importantly, the intercostal vessels come off the posterior aspect of the aorta at this location and can be easily injured. Occasionally the pleura of the lung is entered during the dissection. This is usually obvious and of little consequence, although a chest radiograph should be obtained in the immediate postoperative period to confirm that the lungs are fully expanded. Vascular control of the supraceliac aorta can be obtained very expeditiously if necessary (e.g., unstable patient with ruptured aneurysm) by bluntly dissecting the crus of the diaphragm with the index and long fingers and using them as a guide to position an aortic clamp.

Transperitoneal Approach to Superior Mesenteric Artery and Pararenal Aorta

The aorta can be exposed from the origin of the SMA to its first branching through a transperitoneal approach similar to the generic approach used for most open infrarenal abdominal aortic aneurysm repairs. The exposure of the aorta from the origin of the renal arteries to the base of the SMA is complicated by the adjacent anatomic structures including the crus of the diaphragm, the pancreas, and the left renal vein. The following approach is used commonly for aortorenal bypass, retrograde aorta–SMA bypass, juxtarenal aortic aneurysm repair, and aortobifemoral bypass in the setting of an infrarenal aortic occlusion.

A midline or some type of transverse abdominal incision may be used. Our preferred incision is a transverse one, with a bilateral subcostal incision positioned approximately three fingerbreadths below the margin of the ribs. After initial abdominal exposure, the ligament of Treitz is incised and the duodenum is reflected to the right. A self-retaining retractor is placed to facilitate exposure with the transverse colon retracted cephalad. The inferior mesenteric vein is ligated at the base of the mesentery to prevent inadvertent injury during retraction, although it is important to palpate the adjacent tissue to confirm that there is no accompanying meandering artery, which would function as an important collateral for patients with visceral artery occlusive disease. The retroperitoneum over the aorta is incised, with the caudal extension dictated by the underlying pathology and indication for the procedure.

The left renal vein is completely mobilized and retracted using a vessel loop. This is facilitated by ligating and transecting its lumbar, adrenal, and gonadal branches; preferably ligating them with both a suture ligature and a hemostatic clip. Alternatively, the left renal vein itself can be transected at its confluence with the inferior vena cava, although it is important to preserve the three collateral veins in this setting (i.e., adrenal, lumbar, gonadal). Although somewhat inelegant, ligating the left renal vein is likely safe in terms of its impact on kidney function provided that the collaterals are persevered.

The pararenal aorta and the renal arteries themselves may then be exposed by retracting the left renal vein cephalad and caudad as necessary. The suprarenal aorta can then be exposed to the base of the SMA by retracting the pancreas cephalad and incising the investing dense neural plexus. The origin of the SMA and its proximal few centimeters can be exposed with this approach, and it is our preferred approach for retrograde bypasses to this vessel provided that the occlusive disease is limited to its orifice (Figure 2). Alternatively, the SMA may be exposed through the lesser space at the caudal border of the pancreas or at the base of the mesocolon after caudal retraction of the transverse colon.

Stay updated, free articles. Join our Telegram channel

Join