From the Guidelines
Open abdominal aortic aneurysm (AAA) repair should be performed through a mid-line laparotomy with a Dacron graft, while considering the high risk of incisional hernia, particularly in obese patients, and the potential benefits of prophylactic mesh use in high-risk cases, as well as the recommendation to use endovascular repair to reduce peri-operative morbidity and mortality 1. The procedure begins with general anesthesia administration and endotracheal intubation. After proper positioning, the surgeon makes a midline laparotomy incision from the xiphoid process to the pubic symphysis.
- Key steps in the procedure include:
- Achieving vascular control by placing clamps proximal and distal to the aneurysm, as well as on the iliac arteries if needed
- Administering systemic heparin (typically 100 units/kg) before clamping to prevent thrombosis
- Opening the aneurysm sac longitudinally and removing any intraluminal thrombus
- Selecting a synthetic graft (typically Dacron or PTFE) of appropriate size and anastomosing it to the proximal aorta using continuous polypropylene sutures
- Performing the distal anastomosis to either the distal aorta (tube graft) or iliac arteries (bifurcated graft)
- It is essential to consider the potential risks and complications associated with open AAA repair, including bleeding, organ ischemia, and cardiopulmonary complications, as well as the risk of incisional hernia, particularly in obese patients 1.
- The use of endovascular repair is recommended to reduce peri-operative morbidity and mortality, especially in ruptured AAA cases, where open repair results are worse than those of elective surgery 1.
From the Research
Step-by-Step Open AAA Repair
The following steps are a general outline of the open AAA repair process:
- Preoperative preparation: Patient evaluation, medical optimization, and anesthesia planning 2
- Surgical approach: Midline laparotomy incision to access the abdominal aorta 3
- Aortic cross-clamping: Clamping the aorta above and below the aneurysm to control blood flow 2
- Aneurysm repair: Resection of the aneurysm and replacement with a graft 3
- Graft implantation: Suturing the graft to the aortic wall 2
- Aortic cross-clamp removal: Removing the clamps to restore blood flow 2
- Hemostasis: Controlling bleeding and achieving hemostasis 2
- Closure: Closing the incision and completing the surgery 3
Key Considerations
- Patient selection: Open repair is often reserved for patients with ruptured AAAs or those who are not candidates for endovascular repair 3, 2
- Anesthetic management: General anesthesia is commonly used, but local anesthesia may be considered in certain cases 4
- Perioperative care: Close monitoring and management of blood pressure, fluid status, and coagulation are crucial 2
- Postoperative surveillance: Regular follow-up with imaging studies to monitor the graft and detect potential complications 5, 2