OPTIMAL EXPOSURE OF THE PROXIMAL ABDOMINAL-AORTA - A CRITICAL-APPRAISAL OF TRANSABDOMINAL MEDIAL VISCERAL ROTATION

Purpose: Adequate exposure of the upper abdominal aorta and its branch es is a necessary prelude to safe and durable reconstruction of this a ortic segment. Although a variety of approaches to this exposure have been described, few outcome data are available to assess the benefits and limitations of the different exposure options. In this series we r eport the results of the transabdominal medal visceral rotation (MVR) approach to exposure of the paramesenteric and pararenal aorta. Method s: One hundred eight operations were performed in 104 patients, repres enting 19.5% of all aortic reconstructions during a 5.5 year interval. Most patients had hypertension (n = 77, 71.3%) or a history of smokin g (n = 83, 76.9%). Heart disease was present in one third of patients (n = 33), and a similar proportion had abnormal renal function (elevat ed creatinine level) before operation (n = 40, 37.0%). One third of pa tients (n = 34) had undergone previous aortic or aortic branch reconst ruction. Eighty percent of procedures were elective (n = 87). Seventy- one patients (65.7%) required renal revascularization, usually for hyp ertension or elevated creatinine levels, whereas 37 patients (34.3%) u nderwent visceral reconstruction, most often for symptoms of chronic m esenteric ischemia. Only 22 patients required isolated infrarenal aort ic repair. Most of the aortic lesions were aneurysmal (n = 42). Eighty percent of procedures (n = 88) required suprarenal or more proximal a ortic clamping. The most frequently used reconstruction techniques wer e bypass (n = 39, 36.1%), endarterectomy (n = 18, 16.7%), or both (n = 23, 21.3%). Results: There were four intraoperative deaths (3.7%) and 15 postoperative deaths (13.9%). Ah intraoperative deaths and four po stoperative deaths were related to hemorrhage and its complications. V isceral infarction was the most frequent cause of postoperative death. The intraoperative complications that were determined to be related t o the medial visceral rotation approach included splenic injury (n = 2 3, 21.3%), one aortic injury, and one adrenal injury. The aortic injur y was associated with substantial intraoperative bleeding and subseque nt death. The postoperative complications resulting from MVR included pancreatitis (n = 5), which contributed to death in two patients, and possibly some of the cases of visceral infarction not associated with visceral reconstruction. The other common postoperative complications, cardiac (n = 25, 24.0%), pulmonary (n = 32, 30.8%), renal (n = 20, 19 .2%), and infectious (n = 17, 16.3%), were attributed to the procedure s performed. Conclusions: TransabdominaI MVR exposure of the upper abd ominal aorta provides unrestricted access to the visceral branch-beari ng segment of the aorta and places no limitations on the choice of art erial reconstruction technique. The associated morbidity and mortality rates are typical of patients undergoing these complex vascular repai rs, but the frequency of splenic injury and postoperative pancreatitis is increased (J VASC SURG 1994;19:375-90.)