Commentary on 'Systematic Review and Meta-analysis of the Retroperitoneal Versus the Transperitoneal Approach to the Abdominal Aorta'

In the last few decades the classical open surgical approach for infra-renal aneurysm repair has not undergone major changes. The principle of exposing the aorta, clamping it, and sewing in a vascular graft has not changed significantly. In this meta-analysis, the auteurs claim there may be clinical benefits to performing this surgery via a retroperitoneal (RP) approach. 1 The reduction in mortality of elective infrarenal repairs has been substantial since it was developed. 2 However, this reduction is a result of several factors, such as patient selection, medical treatment, aesthetic techniques, and improved care in intensive care units, and not the surgical technique per se. Traditionally,theRPapproachhasbeenreservedforselective cases as many surgeons feel it is technically more demanding and provides limited access to the aortic side branches. 3 However, several comparative studies demonstrated some advantages over the RP approach. 4,5 In clinical practice the RP approach was used for supra-renal and thoraco-abdominal aneurysms, and usually not for infra-renal aneurysms. In the last 20 years endovascular repair (EVAR) has had a major effect on clinical practice. It not only reduced the operative morbidity and mortality but it also changed open surgical repair. The expanding group of patients undergoing EVAR because of an abdominal aortic aneurysm leaves a morechallenging groupforopen repair.The patientswho are going to undergo open repair often have more aneurysms expanding cranially and involving the renal arteries and visceral vessels, and more often have anatomical variants, such as accessory renal arteries.This group of patients, who areunsuitableforEVAR,canbetreatedbyanRPapproachfar more easily than by a transperitoneal approach. 4 As