Retroperitoneal approach to the aorta

Most historians feel that history is cyclical and, indeed, circular. The retroperitoneal approach for aortic level surgery emphasizes this phenomenon. Although there has been a great deal of interest in this "new" method, it is truly an old approach. Sir Astley Cooper ligated a high lying iliac artery aneurysm through this approach in the early 1800's, while Dulsost reported resection of an abdominal aortic an aneurysm with a homograft replacement achieved through this approach in 1952. In 1963, Rob reviewed 500 of his patients who underwent the retroperitoneal approach for aortic surgery and enthusiastically advocated this approach, because of its lower morbidity and mortality. Unfortunately little hard data accompanied this paper. Ten years later, a large series of 90 patients who underwent aortoiliac reconstruction was reviewed by Helsby, et a1. 1975. In this series he employed a long left paramedian incision to achieve this retroperitoneal exposure of the aorta. A low, 3%, mortality was reported. More recently, Melvin Williams at Johns Hopkins reawakened interest in the retroperitoneal approach when he described a 4% operative mortality accompanying difficult aortic reconstruction. He favored medial rotation of the left kidney so that the aorta could be approached posteriorly. His seminal report of an exceedingly low mortality and morbidity, despite complex aortic anatomy influenced the readoption of this approach by several surgeons. Influenced by his results we adopted the retroperitoneal approach for high risk AAA while Leather and Sicard subsequently reported large series of aortoiliac reconstruction and aneurysms done through this approach. These series were associated with a relatively low mortality and shortened hospital stay (Table I).