With refinement of surgical and anesthetic techniques, mortality and morbidity of AAA have been significantly reduced and the surgeons have continued to search a more physiological, less invasive techniques causing less discomfort for the patient. RPA popularized in recent years is deemed to transform into a minimal invasive RPA and laparascopic surgery has already begun to cover AAA surgery. Endovascular approach is another alternative in AAA. Besides above-mentioned modalities requiring skilled technicians and delicate tools, cost-effectiveness has become more of concern. Centers have turned to less procedural costs and more successful results; thus, an open procedure with rapid recovery of the patient and short ICU/hospital stay is usually the choice of surgeon. RPA gains importance in this regard being less invasive and as shown in the results of our study it enables quicker gastrointestinal recovery with shorter dismissal.[
13-
16] RPA may also be preferable in the presence of repeat abdominal surgery, inflammatory aneurysms, suprarenal aneurysms, obesity and horse-shoe kidney.[
12,
17,
18] This technique is on the other hand may serve difficulties in the presence of right iliac artery aneurysm or the close neighborhood of the right renal artery.
In the modern era of elective AAA surgery, mortality has decreased below 5%; it was 2.5% in our study. Overall mortality was, however, higher principally due to high mortality rate of ruptured cases which constituted 22.5% of our series. It must be noted that most comparative studies regarding the surgical approach have excluded emergent ruptured aneurysm repair. Several centers reported mortality of 35-50% in ruptured AAA repair.[19,20] We found 45.7% mortality in this latter group. Acute myocardial infarction has been cited as the most common cause for mortality in AAA repair. In our series, acute myocardial infarction constituted 19% of 21 fatal cases. Impact of acute MI on mortality was more significant on elective cases (9.4% of all deaths). In our series, excessive bleeding was responsible for most of the mortality in the ruptured cases (42.8% of all mortality). This, in part, may be due to hemodynamic instability and rapidly deteriorating states of bleeding patient. Among the non-fatal complications seen in 2.5% of the patients, only one patient had a non-fatal infarction; arrhythmias and cardiac ischemia were among the other non-fatal cardiac complications. Acute renal failure has been responsible for 3-12% of mortality in AAA surgery. In our study, acute renal failure seen was held responsible in 23.8% of the 21 fatal cases. This may be in part due to the fact that 22.5% of the series is constituted of ruptured cases with 45.7% overall mortality. Gastrointestinal complications and bowel ischemia are particular interest to the surgeon due to anatomical relationships. Colonic ischemia has been reported to occur in 0.2-10% of the patients;[19] in our series, 4 patients such a dismal complication with 3 of them succumbed to death. In accordance with the classical data, 3 of 4 patients with colonic ischemia were operated in emergency settings with rupture.
Anomalous origin of Adamkiewch artery and/or perioperative hypotension have been blamed for para- plegia and spinal chord ischemia which are notably rare post-AAA repair. We found one case with paraplegia and another case with paraparesia indicative of spinal chord ischemia. Both cases were noted to have had severe hypotensive episodes perioperatively. It is noteworthy that the cross clamp times in the RPA group were significantly shorter than in the TPA group. This was attributed to the fact that TPA group included ruptured cases with friable tissues. This, somewhat, contradicts the similar need for allogeneic blood transfusion in either group depicted on Tablo 4 (1.3±1.4 vs. 0.9±0.4 units; p=0.401).
As mentioned before, cost-effectiveness is a major drive for hospital management in our era. Besides various aforementioned advantages that RPA serves for the surgeons and the patients, it may well serve for significant financial savings. Ballard et al.[21] indicated a mean cost difference of $5,527 between TPA and RPA. Although an endovascular approach is as attractive causing significantly less hospital stay and possibly no ICU stay at all, this modality is still applied to selected cases in many centers and the potential complications that necessitate continuous surveillance and presence of limited long-term data raise doubts about its applicability in every day practice.[22] Financial burden of endovascular versus open retroperitoneal AAA repair has also been assessed by some authors. Endovascular procedures were found to be more expensive with a mean difference of $11.662 in comparison to RPA in selected cases.[23] It was also noted that neither quality of life nor perioperative complication rate was significantly different for endovascular approach than TPA despite its minimal invasiveness.
This study aims to summarize a single-operating surgeon experience with either surgical strategy over a period of 10 years. Results of the current review show beneficial effects of RPA, but randomized studies with long-term results are required to establish solid data. It must be reminded that the review comprises the authors’ experience with RPA. Inclusion of all infrarenal AAA’s after 2000 in the RPA group may be an eliminating factor for patient-selection bias. Significantly quicker restoration of bowel motility and shorter ICU and hospital stay in spite of initial stages of learning curve support the idea that RPA should be preferred when applicable. Inclusion of more detailed data as the actual need for analgesia in ICU and the perioperative hematocrit drop would have made the review more comprehensive and would have enabled us to comment more on the impact of various factors on the postoperative outcome.
Retroperitoneal approach to abdominal aortic aneurysms is a reliable technique for repair. It causes less fluid-electrolyte imbalance with rapid restoration of gastrointestinal physiology. It causes less discomfort to patients with reduced need for analgesia. Rapid weaning from mechanical ventilation and less hemodynamic instability due to less blood loss are benefits for patients with co-morbid states. Shorter ICU and hospital stay may substantially reduce costs for the patient, hospital and the health insurance system.
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