Annals of Vascular Surgery
Volume 21, Issue 2 , Pages 129-132, March 2007

Transperitoneal Approach Should be Considered for Suspected Ruptured Abdominal Aortic Aneurysms

  • Alexander T. Nguyen
    • ,
  • Christian de Virgilio

      Affiliations

    • Corresponding Author InformationCorrespondence to: Christian de Virgilio, MD, Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box #25, Torrance, CA 90509, USA

Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA

Torrance, California

Article Outline

Although transperitoneal surgical repair has been the gold standard for patients with a suspected ruptured abdominal aortic aneurysm (rAAA), the retroperitoneal approach and endovascular aortic repair (EVAR) are increasingly being recommended as preferred approaches due to lower morbidity and mortality. To highlight the importance of considering the transperitoneal approach, we present three cases of suspected rAAA, all with a known AAA, who were found to have other significant intra-abdominal pathology at surgery that would have been missed using the other approaches.

 

Back to Article Outline

Introduction 

Ruptured abdominal aortic aneurysms (rAAAs) account for at least 15,000 deaths annually in the United States.1 The classic triad of shock, abdominal/back pain, and a pulsatile abdominal mass is seen in 45%, 72%, and 83% of patients, respectively, with less than 40% of patients presenting with all three.2, 3 Immediate open transperitoneal surgical repair is the gold standard for patients with a known AAA who present with pain and hypotension.4 Less invasive techniques, specifically the retroperitoneal approach and endovascular aortic repair (EVAR), are now being recommended as the preferred approach for rAAA due to lower morbidity and mortality. We present three patients, treated in the last year, with known AAA, who underwent open transperitoneal exploration for suspected rAAA and were found to have other abdominal pathology that would not have been addressed by retroperitoneal or endovascular approaches.

Case 1 

A 62-year-old Caucasian male with a history of coronary artery disease, hypertension, diabetes, chronic renal insufficiency, gout, and a known 7-cm juxtarenal abdominal aortic aneurysm was admitted for elective repair. On admission, he was noted to have worsening renal insufficiency, which was partially attributed to a recent increase in nonsteroidal anti-inflammatory drug usage for worsening gout symptoms. Thus the surgery was delayed. On hospital day 8, the patient complained of anorexia and sudden severe abdominal pain radiating to his back. Vital signs included a pulse rate of 102 beats/min, a respiratory rate of 26/min, and a sudden drop in systolic blood pressure from 170 to 113 mm Hg. On examination, the patient was agitated and altered. The abdomen was diffusely tender with guarding.

The patient was immediately taken to the operating room for a presumed rAAA using a transperitoneal approach. At laparotomy, the aorta was found to be intact without evidence of retroperitoneal staining. Upon inspection of the right upper quadrant, bile-stained omentum was noted adherent to the gallbladder. A perforated, gangrenous gallbladder was found. Cholecystectomy was performed (cultures revealed Clostridium perfringens), and the AAA was not repaired.

The patient's postoperative course was complicated by wound infection and dehiscence. He was discharged on postoperative day 24 in good condition with the plan to repair the AAA in 6 to 8 weeks; however the patient refused surgery.

Case 2 

An 82-year-old Caucasian female with a known history of chronic obstructive pulmonary disease, atrial fibrillation, heavy tobacco use, and a recently diagnosed 8-cm AAA presented with a 1-day history of severe abdominal pain radiating to the back.

On examination, she was hemodynamically stable with a pulse rate of 62 beats/min, a respiratory rate of 18/min, and a blood pressure of 144/98 mm Hg. The abdomen was diffusely tender, especially over the epigastrium. Because her vitals were stable, an abdominal computed tomography (CT) scan was obtained that revealed an 8-cm juxtarenal AAA with more than 90 degrees of angulation. The left psoas muscle was asymmetric, suggesting extra-aortic fluid. In addition, the mesenteric vessels appeared to have a swirl pattern (Fig. 1) consistent with a possible small bowel volvulus.

At laparotomy, the aorta was noted to be intact without retroperitoneal staining. A small bowel volvulus was found with significant mesenteric thickening and shortening but without evidence of ischemia. The bowel was detorsed and a pexy of the mesentery was performed. The AAA was repaired with a tube graft during the same procedure.

The patient's hospital course was uneventful, and she was discharged to home in stable condition on postoperative day 10 after therapeutic anticoagulation for atrial fibrillation.

Case 3 

An 82-year-old Caucasian male with a past medical history of hypertension, myocardial infarction, tobacco dependence, and a known large AAA, for which he refused elective repair, presented with severe abdominal pain radiating to the right groin, bloody stools, and hypotension. Vital signs included a temperature of 98.0° F, pulse rate of 113 beats/min, a respiratory rate of 24/min, and a blood pressure of 82/55 mm Hg. The patient's abdomen was diffusely tender with rebound, guarding, and a tender pulsatile mass.

Because of hemodynamic instability, he was taken directly to the operating room. At laparotomy, there was left retroperitoneal staining consistent with a contained rupture. The AAA was juxtarenal and inflammatory with adherent left renal vein and duodenum. In addition, a gangrenous gallbladder was found as well as a segment of ischemic but viable distal small bowel, measuring several feet. Due to hemodynamic instability and the inflammatory nature of the AAA, the aorta was initially clamped just below the diaphragm then repositioned to a suprarenal position. The aorta was repaired with a bifurcated graft. Following closure of the retroperitoneum, a cholecystectomy was performed. After resuscitation, the small bowel appeared viable with doppler interrogation and inspection with a Wood's lamp after fluorescein dye injection. However, the following day he developed bloody diarrhea. The patient underwent immediate re-exploration. The area of ischemic bowel was now gangrenous and thus resected.

The patient had a prolonged hospital course complicated by multiple problems including renal failure requiring temporary hemodialysis, pulmonary failure requiring long-term ventilator dependence, pseudomembranous colitis, and fungal sepsis.

Back to Article Outline

Discussion 

Mortality from rAAA remains high, ranging from 40%-90% in most series.5, 6, 7 With improved emergency medical service transportation and advances in critical care, mortality has slightly improved over the last several decades, from 55% in 1960 to 41% in 2000.8 However, the gold standard technique for rAAA, via an immediate laparotomy, has changed little since its first description in 1951 by Dubost.9

Efforts to further improve mortality for rAAA have prompted investigators to advocate the retroperitoneal approach. Advantages of the retroperitoneal approach include a decrease in perioperative fluid requirements, cardiac work, incidence of postoperative ileus, blood loss, length of intubation, intensive care unit stay, and total hospital stay.10 In a review of 63 patients with rAAA, Chang and colleagues11 reported a 12% mortality using the retroperitoneal approach, as compared to 34% with transperitoneal surgery. Additional advantages of the retroperitoneal approach included less ventilatory support and gastrointestinal disturbances, and a reduced hospital stay. In a follow-up study, using the retroperitoneal approach routinely, the same authors reported an overall mortality of 29% in 107 patients.12, 13

Since the first publication of successful endovascular repair of a rAAA by Yusuf in 1994,14 several other reports have surfaced as experience with this technique and device availability has increased. For rAAA, EVAR appears to decrease the anesthesia requirements, blood loss, transfusion requirement, and ICU/hospital stay. The operative mortality ranges from 9%-45% with an average of 24%.15 One potential concern is the time delay necessary to obtain a CT scan so as to determine suitability for EVAR. Another concern is that the percentage of patients deemed suitable for EVAR may be as low 40%.16, 17 One must be cautious in comparing mortality results for EVAR with open AAA as to date many EVAR studies report on a selective group of rAAA with stable vital signs.15, 18, 19

Several previous studies have reported the frequency of finding unexpected pathology at the time of open exploration for suspected rAAA. Valentine et al20 reported that 16 of 160 (10%) patients undergoing laparotomy for suspected rAAA had other etiologies. Similarly, Kvilekval et al21 found 17 (18%) of 95 patients with suspected rAAA to have other pathology, the majority of which needed immediate surgical treatement. Of the 17, 10 (59%) needed operative management. Significant findings included perforated viscus, strangulated bowel, ruptured visceral artery aneurysm, acute or gangrenous cholecystitis, hemorrhagic pancreatitis, hemorrhagic/necrotic cancer, diverticulitis, intra-abdominal abscess, and postsurgical bleed.20, 21

The encouraging results of retroperitoneal and EVAR techniques for rAAA have created hope that major strides are being made in the management of this highly lethal condition. As we progress, however, it is important to keep in mind that patients presenting with suspected rAAA may have other pathology frequently needing open transperitoneal operative intervention, especially if a patient continues to deteriorate after a presumed successful retroperitoneal or endovascular repair. We presented three cases treated last year to highlight that the transperitoneal approach for suspected symptomatic/rAAA should be considered, because other significant abdominal pathology may be found at surgery.

Back to Article Outline

References 

  1. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328:167–172
  2. Wakefield TW, Whitehouse WM, Wu SC, et al. Abdominal aortic aneurysm rupture: statistical analysis of factors affecting outcome of surgical treatment. Surgery. 1982;91:586–596
  3. Martin RS, Edwards WH, Mulherin JL, et al. Ruptured abdominal aortic aneurysm: a 25-year experience and analysis of recent cases. Am Surg. 1988;54:539–543
  4. Adam DJ, Bradbury AW, Stuart WP, et al. The value of computed tomography in the assessment of suspected ruptured abdominal aortic aneurysm. J Vasc Surg. 1988;27:431–437
  5. Ottinger LW. Ruptured arteriosclerotic aneurysms of the abdominal aorta. reducing mortality. JAMA. 1975;233:147–150
  6. Bengtsson H, Bergqvist D. Ruptured abdominal aortic aneurysm: a population-based study. J Vasc Surg. 1993;18:74–80
  7. Farooq MM, Freischlag JA, Towne JB, et al. Effect of the duration of symptoms, transport time, and length of emergency room stay on morbidity and mortality in patients with ruptured abdominal aortic aneurysms. Surgery. 1996;119:9–14
  8. Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg. 2002;89:714–730
  9. Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months. AMA Arch Surg. 1952;64:405–408
  10. Chang BB, Paty PK, Shah DM, Leather RP. Selective use of retroperitoneal aortic exposure in the emergency treatment of ruptured and symptomatic abdominal aortic aneurysms. Am J Surg. 1988;156:108–110
  11. Chang BB, Shah DM, Paty PS, et al. Can the retroperitoneal approach be used for ruptured abdominal aortic aneurysms?. J Vasc Surg. 1990;11:326–330
  12. Darling RC, Shah DM, Leather RP, et al. Current status of the use of retroperitoneal approach for reconstructions of the aorta and its branches. Ann of Surg. 1996;224:501–508
  13. Darling RC, Cordero JA, Leather RP, et al. Advances in the surgical repair of ruptured abdominal aortic aneurysms. Cardiovasc Surg. 1996;4:720–723
  14. Yusuf SW, Whitaker SC, Chuter TA, et al. Emergency endovascular repair of leaking aortic aneurysm. Lancet. 1994;344:1645
  15. Alsac JM, Kobeiter H, Becquemin JP, Desgranges P. Endovascular repair for ruptured AAA: a literature review. Acta Chir Belg. 2005;105:134–139
  16. Wilson WR, Fishwick G, Bell PR, Thompson MM. Suitability of ruptured AAA for endovascular repair. J Endovasc Ther. 2004;11:635–640
  17. Lee WA, Hirneise CM, Tayyarah M, et al. Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg. 2004;40:211–215
  18. Franks S, Lloyd G, Fishwick G, et al. Endovascular treatment of ruptured and symptomatic abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2006;31:345–350
  19. Hechelhammer L, Lachat ML, Wildermuth S, et al. Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg. 2005;41:752–757
  20. Valentine RJ, Barth MJ, Myers SI, Clagett GP. Nonvascular emergencies presenting as ruptured abdominal aortic aneurysms. Surgery. 1993;113:286–289
  21. Kvilekval KH, Best IM, Mason RA, et al. The value of computed tomography in the management of symptomatic abdominal aortic aneurysms. J Vasc Surg. 1990;12:28–33

 Presented at the 24th Annual Meeting of the Southern California Vascular Surgical Society, Temecula, CA, May 5-7, 2006.

PII: S0890-5096(07)00074-X

doi:10.1016/j.avsg.2006.10.019

Annals of Vascular Surgery
Volume 21, Issue 2 , Pages 129-132, March 2007

Article Tools

* Image Usage & Resolution