[Approach to aortic aneurysms including the renal arteries: intra-abdominal method]

Transperitoneal incision is the usual way to approach the abdominal aorta, either electively or in emergent cases. Supine position of the patient is more comfortable for him, for the anaesthesiologists and for the surgical team. The exploration of the intra-peritoneal organs which is the first stage of the operation, may find pathological processes such as infectious diseases or cancer which contraindicate the vascular procedure. The right tributaries of the aorta, the hepatic artery, the renal artery and the common iliac artery, are only easily approached by a transperitoneal route. In order to control the upper part of pararenal aneurysms, four manoeuvres may be used:--mobilization of the left renal vein with ligation of the left genital and suprarenal veins--dissection of the coeliac aorta through the crux of the diaphragm,--dextro-rotation of the spleen, the tail of the pancreas, and the left part of the colon which enables the supra-renal aorta and the visceral arteries to be approached,--mobilization of the duodeno-pancreas to approach the origin of the superior mesenteric artery, and the full length of the right renal artery. The closure of the abdominal incision is easy. No prospective randomized study has proved, up to now, the superiority on the extra-peritoneal route compared to the transperitoneal approach in terms of post-operative respiratory or general complications.