Eur J Vasc Surg 6, 639-641 (1992)
Simultaneous Resection of Abdominal Aortic Aneurysms and Early Gastric Cancer by Retroperitoneal and Transperitoneal Approach Kimihiro Komori, Kenichiro Okadome, Takuya Odashiro, Tetsuro Ishii, Hiroyuki Itoh, Satoru Funahashi and Keizo Sugimachi Department of Surgery II, Faculty of Medicine, Kyushu University, Fukuoka, Japan The surgical approach to patients with abdominal aortic aneurysm and gastrointestinal malignancy remains controversial. We experienced two cases with abdominal aortic aneurysm and gastric cancer, which were treated by a one-stage operation using a different approach. At first, the operation for the aneurysm was done through a retroperitoneal approach and then, a partial gastrectomy for gastric cancer was done through a transperitoneal approach. The postoperative course of both cases was uneventful. The patients were discharged on the 19th and 21st postoperative days, respectively. This one-stage operation using different isolated approaches, such as the retroperitoneaI approachfor abdominal aortic aneurysm and transperitoneal approach for gastric cancer, was useful for the patients with abdominal aortic aneurysm and particularly early gastric cancer in terms of preventing an infection of the prosthetic graft. Key Words: Abdominal aortic aneurysm; Gastric cancer; Graft infection; retroperitoneal approach.
Introduction
Material and Methods
The m a n a g e m e n t of concomitant abdominal aortic a n e u r y s m and gastrointestinal malignancy is still controversial, in that it is difficult to decide which is the first indication for surgery. 1-3 In addition, a one-stage operation is usually not r e c o m m e n d e d because of the fear of a graft infection, since it m a y lead to death. 4 In Japan, due to the increased average life span and changes in eating habits, the n u m b e r of patients with atherosclerotic arterial disease, including abdominal aortic aneurysm, has been increasing. In addition, the incidence of cases of coincident abdominal malignancy has also increased. 5 It is a most difficult choice to decide whether to operate first on the abdominal arotic a n e u r y s m or on the malignancy. We have experienced two cases of a simultaneous resection of abdominal aortic a n e u r y s m and early gastric cancer without any danger of graft infection through retroperitoneal and transperitoneal approaches, respectively. In this report, we present these cases and discuss the advantages of using isolated approaches.
In our department, 214 abdominal aortic aneurysms u n d e r w e n t resection from 1975 to 1990 and 10 cases (4.7%) were accompanied by cancer of the abdominal viscera, with four of these being gastric cancer. Two cases were treated by a one-stage operation t h r o u g h retroperitoneal and transperitoneal approaches. We present the cases as follows.
Please actdress all corresp~ondence to: K. Komori, Depar~t-mentof Surgery II, Faculty of Medicine, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka 812, Japan. 0950-821X/92/060639+03 $08.00/0© 1992Grune & Stratton Ltd.
Case Report Case 1 In A u g u s t of 1990, a 66-year-old Japanese m a n underw e n t an upper gastrointestinal roentogenogram, which disclosed an abnormality of the gastric angle. An upper gastrointestinal endoscopic examination d e m o n s t r a t e d a t u m o u r with a central ulceration and bridging folds of the surroundings mucosa in the anterior wall of the gastric angle. On admission, physical examination revealed a pulsatile mass 5 cm in diameter at the umbilicus. Routine laboratory examination revealed: haematocrit 41.0%, white blood cell count 8300/txl,
640
K. Komori et aL
platelets 27.6 (xl000/ixl), BUN 11mg/100ml, serum creatinine 1.0mg/100ml and creatinine clearance 70 ml/min. ECG showed no abnormality, although he had suffered a myocardial infarction the previous year. A spirogram revealed that the % VC and FEV 1.0% were 72% and 77%, respectively. Blood gas showed a pH of 7.410, PO2 96.5mmHg, PCO2 39.5 mmHg and BE 0.3. Computed tomography (CT) demonstrated an abdominal aortic aneurysm 4.5 cm in diameter, while no liver metastasis or lymphadenopathy were observed. An upper gastrointestinal rentgenogram disclosed a tumour with a central ulceration and bridging folds of the surrounding mucosa in the anterior wall of the gastric angle. Endoscopic examination revealed a superficially ulcerated irregular tumour located at the gastric angle, which was thought to be a depressed type of early gastric cancer. Histological examination of the biopsy specimens from main lesion confirmed poorly differentiated adenocarcinoma.
Case 2 In October 1990, a 77-year-old Japanese presented with epigastric pain. Upper gastrointestinal endoscopic examination demonstrated a tumour with a central ulceration and bridging folds of the surroundings mucosa in the antral part of the greater curvature. In addition, an abdominal aortic aneurysm was also detected by echogram. On admission, physical examination revealed a pulsatile abdominal mass 5 cm in diameter. Routine laboratory examination revealed: haematocrit 37.0%, white blood cell count 6980/~xl, platelet 18.9 (xl000/txl), BUN 16mg/100ml, serum creatinine 1.1mg/100ml and creatinine clearance 62 ml/min. ECG showed an abnormal Q wave in II, III and AVf. The ejection fraction was 64% by cardioechogram. A spirogram revealed that the % VC and FEV 1.0% were 64% and 61%, respectively. Blood gas showed a pH of 7.464, /90 2 88.2mmHg, PCO2 39.7mmHg and BE 5.3. Computed tomography demonstrated an abdominal aortic aneurysm 4.5 cm in diameter, while no liver metastases or lymphadenopathy were observed. An upper gastrointestinal rentgenogram disclosed a tumour with central ulceration and bridging folds of the surrounding mucosa on the greater curvature. Endoscopic examination revealed a superficially ulcerated irregular tumour, which was thought to be a depressed type of early gastric cancer. Histological Eur J VascSurg Vol 6, November1992
examination of the biopsy specimens from the main lesion showed well differentiated adenocarcinoma. The operative procedures were as follows.
Surgical procedure First, aneurysmectomy was performed. With the patient placed in the right lateral position, a left pararectal skin incision was made. The abdominal aorta was exposed through an extraperitoneal approach. The aneurysms in the two patients were 4.6 x 6cm and 5 x 5 cm in diameter, respectively. The former was a fusiform type and the latter was saccular. After resection of the aneurysm and insertion of a synthetic Y graft, a drain was inserted into the retroperitoneal space and the operative wound was primarily closed in layers. Next, the patient was placed in the supine position and an upper midline abdominal incision was made for laparotomy. A partial gastrectomy by the Billroth II method (retrocolic) was done. Lymph node dissection was made and no metastases were found macroscopicalty. The stage of both cases were macroscopically stage I. After a penrose drain was inserted into the anastomotic region, the w o u n d was closed in layers. The estimated blood losses were 1000g and 650 g and operation times were 390 and 345 min, respectively. The postoperative courses were uneventful. Discharge from the retroperitoneal space and the intraperitoneal cavity was negative for bacterial culture. From the 5th and 6th postoperative day, respectively, oral intake was started. The patients were discharged from hospital on the 19th and 21st postoperative day, respectively, and they are both doing well at the present time.
Discussion
To our knowledge, we are the first to report on a simultaneous resection of abdominal aortic aneurysm and gastric cancer using an isolated approach, such as the retroperitoneal and transperitoneal approach. The incidence of malignant neoplasms is high in patients with abdominal aortic aneurysm. 1'5 In our department, 214 abdominal aortic aneurysms underwent resection from 1975 to 1990 and 10 cases (4.7%) were accompanied by cancer of the abdominal viscera, with four of those 10 cases being gastric cancer with an abdominal aortic aneurysm. However, the management of the patients with abdominal aortic
Abdominal Aortic Aneurysm with Gastric Cancer
aneurysm and gastrointestinal malignancy is still controversial. 1-3 Szilagyi et al. 1 have reported a classification of abdominal aortic aneurysm with coincident malignancy. They defined group 1 as malignancy treated prior to the diagnosis of aneurysm, group 2 as preoperative diagnosis of both aneurysm and cancer, group 3 as unsuspected aneurysm diagnosed at the time of surgery for carcinoma and group 4 as unsuspected carcinoma diagnosed at the time of surgery for aneurysm. According to their classification, our cases belong to group 2. We expect that the incidence of group 2 cases will increase, particularly the cases with abdominal aortic aneurysm and gastric cancer in Japan, since gastric cancer is the most common surgical malignancy in Japan." The most important and difficult decision to make is whether to operate first on the malignancy, the aneurysm or both simultaneously. In 1967, Szilagyi et al. 1 recommended a two-stage operation, while some other authors have performed a one-stage operation. 7-9 However, operations which involve contamination, such as gastrectomy, should be theoretically avoided in combination with sterile procedures such as aneurysmectomy, because a graft infection may lead to death. 4 The simultaneous resection by different approaches solved this problem of graft contamination, because the approaches for abdominal aortic aneurysm and gastric cancer were isolated. A retroperitoneal approach to high risk abdominal aortic aneurysm offers significant advantages.l°12 Pulmonary complications, ileus and postoperative pain were reduced and patient mobilisation was rapid. Both of our patients were high risk patients because of past histories of myocardial infarction and pulmonary dysfunction. Therefore, there was a possibility that the patients would not be able to tolerate a two-stage operation, while abdominal aortic aneurysm and gastric cancer were life-threatening diseases and the surgical resection was required. A one-stage operation is helpful because it markedly reduces the risk of intra- and perioperative complications compared to the two-stage operation. We have presented two patients who had an abdominal aortic aneurysm and gastric cancer. They were treated by a one-stage operation by a retroperitoneal approach for abdominal aortic aneurysm and a transperitoneal approach for gastric cancer simultaneously. This procedure utilising isolated approaches is considered to be useful for preventing graft contamination. In addition, it is particularly
641
helpful for the treatment of high risk patients who are unable to tolerate a two-stage operation. This onestage operation is able to solve the dilemma of surgeon, who has to decide on the most appropriate timing of surgical procedures for patients with abdominal aortic aneurysms and gastric cancer.
Acknowledgements The authors are grateful to Mr Brian Quinn for reading the manuscript.
References 1 SZILAGYIDE, ELLIOT JP, BERGUERR. Coincidental malignancy and abdominal aortic aneurysm. Arch Surg 1967; 95: 402-412. 2 ROBBATOVJ, ROTHENBERGRE, LARAJARD, GEORGIOUJ. Coexistence of abdominal aortic aneurysm and carcinoma of the colon: a dilemma. J Vasc Surg 1985; 2: 724-726. 3 NORAJD, PAIROLEROPC, NIVATONGSS, CHERRYKJ, HALLETTJW, GLOVICZKI P. Concomitant abdominal aortic aneurysm and colorectal carcinoma: priority of resection. J Vasc Surg 1989; 9: 630636. 4 BUNT TJ. Synthetic vascular graft infection. I. Graft infections. Surgery 1983; 93: 733-746. 5 NAKANOH, ESATOK, Ot-IARAM, MOHRI H. Surgical approach to the abdominal aortic aneurysm with alimentary tract tumor: report of three cases. Nihon Geka Gakkaishi 1986; 87:803-807 (in Japanese). 6 DEBAKEYME, CRAWEORDES, COOLEYDA, MORRIS GC, ROYSTER TS, ABBOTT WP. Aneurysm of abdominal aorta: analysis of results of graft replacement therapy one to eleven years after operation. Ann Surg 1964; 160: 622-639. 7 WHO. World Health Statistics Annual 1987. Geneva: World Health Organization, 1988; 388-389. 8 SIGLERL, GEARYJE, BODON GR. One-stage resection of abdominal aortic aneurysm and gastrectomy for carcinoma. Arch Surg 1968; 97: 525-526. 9 DEBAKEYME, OCIISNERJ, COOLEYDA. Associatedintra-abdominal lesions encountered during resection of aortic aneurysms surgical considerations. Dis Colon Rectum 1960; 3: 485. 10 HARDYJD, TOMPKINS WC, CHAVEZCM, CONN JH. Combining intra-abdominal arterial grafting with gastrointestinal or biliary tract procedure. Am J Surg 1973; 126: 598-600. 11 SHEPARDAD, SCOTTGR, MACKEYWC, O'DONNELL TF, BUSHHL, CALLOW AD. Retroperitoneal approach to high-risk abdominal aortic aneurysms. Arch Surg 1986; 121: 444-449. 12 SICARDGA, FREEMAN MB, VANDERWONDE JC, ANDERSONCB. Comparison between the transperitoneal and retroperitoneal approach for reconstruction of infrarenal abdominal aorta. J Vasc Surg 1987; 5: 19-27. 13 CAMBRIARP, BREWSTERDC, ABBOTTWM, et al. Transperitoneal versus retriperitoneal approach for aortic reconstruction: a randomized prospective study. J Vasc Surg 1990; 11: 314-325.
Accepted 30 June 1992
Eur I Vasc Surg Vol 6, November 1992
Simultaneous Resection of Abdominal Aortic Aneurysms and Early Gastric Cancer by Retroperitoneal and Transperitoneal Approach Kimihiro Komori, Kenichiro Okadome, Takuya Odashiro, Tetsuro Ishii, Hiroyuki Itoh, Satoru Funahashi and Keizo Sugimachi Department of Surgery II, Faculty of Medicine, Kyushu University, Fukuoka, Japan The surgical approach to patients with abdominal aortic aneurysm and gastrointestinal malignancy remains controversial. We experienced two cases with abdominal aortic aneurysm and gastric cancer, which were treated by a one-stage operation using a different approach. At first, the operation for the aneurysm was done through a retroperitoneal approach and then, a partial gastrectomy for gastric cancer was done through a transperitoneal approach. The postoperative course of both cases was uneventful. The patients were discharged on the 19th and 21st postoperative days, respectively. This one-stage operation using different isolated approaches, such as the retroperitoneaI approachfor abdominal aortic aneurysm and transperitoneal approach for gastric cancer, was useful for the patients with abdominal aortic aneurysm and particularly early gastric cancer in terms of preventing an infection of the prosthetic graft. Key Words: Abdominal aortic aneurysm; Gastric cancer; Graft infection; retroperitoneal approach.
Introduction
Material and Methods
The m a n a g e m e n t of concomitant abdominal aortic a n e u r y s m and gastrointestinal malignancy is still controversial, in that it is difficult to decide which is the first indication for surgery. 1-3 In addition, a one-stage operation is usually not r e c o m m e n d e d because of the fear of a graft infection, since it m a y lead to death. 4 In Japan, due to the increased average life span and changes in eating habits, the n u m b e r of patients with atherosclerotic arterial disease, including abdominal aortic aneurysm, has been increasing. In addition, the incidence of cases of coincident abdominal malignancy has also increased. 5 It is a most difficult choice to decide whether to operate first on the abdominal arotic a n e u r y s m or on the malignancy. We have experienced two cases of a simultaneous resection of abdominal aortic a n e u r y s m and early gastric cancer without any danger of graft infection through retroperitoneal and transperitoneal approaches, respectively. In this report, we present these cases and discuss the advantages of using isolated approaches.
In our department, 214 abdominal aortic aneurysms u n d e r w e n t resection from 1975 to 1990 and 10 cases (4.7%) were accompanied by cancer of the abdominal viscera, with four of these being gastric cancer. Two cases were treated by a one-stage operation t h r o u g h retroperitoneal and transperitoneal approaches. We present the cases as follows.
Please actdress all corresp~ondence to: K. Komori, Depar~t-mentof Surgery II, Faculty of Medicine, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka 812, Japan. 0950-821X/92/060639+03 $08.00/0© 1992Grune & Stratton Ltd.
Case Report Case 1 In A u g u s t of 1990, a 66-year-old Japanese m a n underw e n t an upper gastrointestinal roentogenogram, which disclosed an abnormality of the gastric angle. An upper gastrointestinal endoscopic examination d e m o n s t r a t e d a t u m o u r with a central ulceration and bridging folds of the surroundings mucosa in the anterior wall of the gastric angle. On admission, physical examination revealed a pulsatile mass 5 cm in diameter at the umbilicus. Routine laboratory examination revealed: haematocrit 41.0%, white blood cell count 8300/txl,
640
K. Komori et aL
platelets 27.6 (xl000/ixl), BUN 11mg/100ml, serum creatinine 1.0mg/100ml and creatinine clearance 70 ml/min. ECG showed no abnormality, although he had suffered a myocardial infarction the previous year. A spirogram revealed that the % VC and FEV 1.0% were 72% and 77%, respectively. Blood gas showed a pH of 7.410, PO2 96.5mmHg, PCO2 39.5 mmHg and BE 0.3. Computed tomography (CT) demonstrated an abdominal aortic aneurysm 4.5 cm in diameter, while no liver metastasis or lymphadenopathy were observed. An upper gastrointestinal rentgenogram disclosed a tumour with a central ulceration and bridging folds of the surrounding mucosa in the anterior wall of the gastric angle. Endoscopic examination revealed a superficially ulcerated irregular tumour located at the gastric angle, which was thought to be a depressed type of early gastric cancer. Histological examination of the biopsy specimens from main lesion confirmed poorly differentiated adenocarcinoma.
Case 2 In October 1990, a 77-year-old Japanese presented with epigastric pain. Upper gastrointestinal endoscopic examination demonstrated a tumour with a central ulceration and bridging folds of the surroundings mucosa in the antral part of the greater curvature. In addition, an abdominal aortic aneurysm was also detected by echogram. On admission, physical examination revealed a pulsatile abdominal mass 5 cm in diameter. Routine laboratory examination revealed: haematocrit 37.0%, white blood cell count 6980/~xl, platelet 18.9 (xl000/txl), BUN 16mg/100ml, serum creatinine 1.1mg/100ml and creatinine clearance 62 ml/min. ECG showed an abnormal Q wave in II, III and AVf. The ejection fraction was 64% by cardioechogram. A spirogram revealed that the % VC and FEV 1.0% were 64% and 61%, respectively. Blood gas showed a pH of 7.464, /90 2 88.2mmHg, PCO2 39.7mmHg and BE 5.3. Computed tomography demonstrated an abdominal aortic aneurysm 4.5 cm in diameter, while no liver metastases or lymphadenopathy were observed. An upper gastrointestinal rentgenogram disclosed a tumour with central ulceration and bridging folds of the surrounding mucosa on the greater curvature. Endoscopic examination revealed a superficially ulcerated irregular tumour, which was thought to be a depressed type of early gastric cancer. Histological Eur J VascSurg Vol 6, November1992
examination of the biopsy specimens from the main lesion showed well differentiated adenocarcinoma. The operative procedures were as follows.
Surgical procedure First, aneurysmectomy was performed. With the patient placed in the right lateral position, a left pararectal skin incision was made. The abdominal aorta was exposed through an extraperitoneal approach. The aneurysms in the two patients were 4.6 x 6cm and 5 x 5 cm in diameter, respectively. The former was a fusiform type and the latter was saccular. After resection of the aneurysm and insertion of a synthetic Y graft, a drain was inserted into the retroperitoneal space and the operative wound was primarily closed in layers. Next, the patient was placed in the supine position and an upper midline abdominal incision was made for laparotomy. A partial gastrectomy by the Billroth II method (retrocolic) was done. Lymph node dissection was made and no metastases were found macroscopicalty. The stage of both cases were macroscopically stage I. After a penrose drain was inserted into the anastomotic region, the w o u n d was closed in layers. The estimated blood losses were 1000g and 650 g and operation times were 390 and 345 min, respectively. The postoperative courses were uneventful. Discharge from the retroperitoneal space and the intraperitoneal cavity was negative for bacterial culture. From the 5th and 6th postoperative day, respectively, oral intake was started. The patients were discharged from hospital on the 19th and 21st postoperative day, respectively, and they are both doing well at the present time.
Discussion
To our knowledge, we are the first to report on a simultaneous resection of abdominal aortic aneurysm and gastric cancer using an isolated approach, such as the retroperitoneal and transperitoneal approach. The incidence of malignant neoplasms is high in patients with abdominal aortic aneurysm. 1'5 In our department, 214 abdominal aortic aneurysms underwent resection from 1975 to 1990 and 10 cases (4.7%) were accompanied by cancer of the abdominal viscera, with four of those 10 cases being gastric cancer with an abdominal aortic aneurysm. However, the management of the patients with abdominal aortic
Abdominal Aortic Aneurysm with Gastric Cancer
aneurysm and gastrointestinal malignancy is still controversial. 1-3 Szilagyi et al. 1 have reported a classification of abdominal aortic aneurysm with coincident malignancy. They defined group 1 as malignancy treated prior to the diagnosis of aneurysm, group 2 as preoperative diagnosis of both aneurysm and cancer, group 3 as unsuspected aneurysm diagnosed at the time of surgery for carcinoma and group 4 as unsuspected carcinoma diagnosed at the time of surgery for aneurysm. According to their classification, our cases belong to group 2. We expect that the incidence of group 2 cases will increase, particularly the cases with abdominal aortic aneurysm and gastric cancer in Japan, since gastric cancer is the most common surgical malignancy in Japan." The most important and difficult decision to make is whether to operate first on the malignancy, the aneurysm or both simultaneously. In 1967, Szilagyi et al. 1 recommended a two-stage operation, while some other authors have performed a one-stage operation. 7-9 However, operations which involve contamination, such as gastrectomy, should be theoretically avoided in combination with sterile procedures such as aneurysmectomy, because a graft infection may lead to death. 4 The simultaneous resection by different approaches solved this problem of graft contamination, because the approaches for abdominal aortic aneurysm and gastric cancer were isolated. A retroperitoneal approach to high risk abdominal aortic aneurysm offers significant advantages.l°12 Pulmonary complications, ileus and postoperative pain were reduced and patient mobilisation was rapid. Both of our patients were high risk patients because of past histories of myocardial infarction and pulmonary dysfunction. Therefore, there was a possibility that the patients would not be able to tolerate a two-stage operation, while abdominal aortic aneurysm and gastric cancer were life-threatening diseases and the surgical resection was required. A one-stage operation is helpful because it markedly reduces the risk of intra- and perioperative complications compared to the two-stage operation. We have presented two patients who had an abdominal aortic aneurysm and gastric cancer. They were treated by a one-stage operation by a retroperitoneal approach for abdominal aortic aneurysm and a transperitoneal approach for gastric cancer simultaneously. This procedure utilising isolated approaches is considered to be useful for preventing graft contamination. In addition, it is particularly
641
helpful for the treatment of high risk patients who are unable to tolerate a two-stage operation. This onestage operation is able to solve the dilemma of surgeon, who has to decide on the most appropriate timing of surgical procedures for patients with abdominal aortic aneurysms and gastric cancer.
Acknowledgements The authors are grateful to Mr Brian Quinn for reading the manuscript.
References 1 SZILAGYIDE, ELLIOT JP, BERGUERR. Coincidental malignancy and abdominal aortic aneurysm. Arch Surg 1967; 95: 402-412. 2 ROBBATOVJ, ROTHENBERGRE, LARAJARD, GEORGIOUJ. Coexistence of abdominal aortic aneurysm and carcinoma of the colon: a dilemma. J Vasc Surg 1985; 2: 724-726. 3 NORAJD, PAIROLEROPC, NIVATONGSS, CHERRYKJ, HALLETTJW, GLOVICZKI P. Concomitant abdominal aortic aneurysm and colorectal carcinoma: priority of resection. J Vasc Surg 1989; 9: 630636. 4 BUNT TJ. Synthetic vascular graft infection. I. Graft infections. Surgery 1983; 93: 733-746. 5 NAKANOH, ESATOK, Ot-IARAM, MOHRI H. Surgical approach to the abdominal aortic aneurysm with alimentary tract tumor: report of three cases. Nihon Geka Gakkaishi 1986; 87:803-807 (in Japanese). 6 DEBAKEYME, CRAWEORDES, COOLEYDA, MORRIS GC, ROYSTER TS, ABBOTT WP. Aneurysm of abdominal aorta: analysis of results of graft replacement therapy one to eleven years after operation. Ann Surg 1964; 160: 622-639. 7 WHO. World Health Statistics Annual 1987. Geneva: World Health Organization, 1988; 388-389. 8 SIGLERL, GEARYJE, BODON GR. One-stage resection of abdominal aortic aneurysm and gastrectomy for carcinoma. Arch Surg 1968; 97: 525-526. 9 DEBAKEYME, OCIISNERJ, COOLEYDA. Associatedintra-abdominal lesions encountered during resection of aortic aneurysms surgical considerations. Dis Colon Rectum 1960; 3: 485. 10 HARDYJD, TOMPKINS WC, CHAVEZCM, CONN JH. Combining intra-abdominal arterial grafting with gastrointestinal or biliary tract procedure. Am J Surg 1973; 126: 598-600. 11 SHEPARDAD, SCOTTGR, MACKEYWC, O'DONNELL TF, BUSHHL, CALLOW AD. Retroperitoneal approach to high-risk abdominal aortic aneurysms. Arch Surg 1986; 121: 444-449. 12 SICARDGA, FREEMAN MB, VANDERWONDE JC, ANDERSONCB. Comparison between the transperitoneal and retroperitoneal approach for reconstruction of infrarenal abdominal aorta. J Vasc Surg 1987; 5: 19-27. 13 CAMBRIARP, BREWSTERDC, ABBOTTWM, et al. Transperitoneal versus retriperitoneal approach for aortic reconstruction: a randomized prospective study. J Vasc Surg 1990; 11: 314-325.
Accepted 30 June 1992
Eur I Vasc Surg Vol 6, November 1992
