An inflammatory AAA may be a very difficult case for an open repair. Because of the inflammation, the duodenum and the initial part of the jejunum is stuck on the posterior peritoneum in front of the abdominal aorta and it is very difficult to expose the aorta with the usual way. Additionally, the inflammation may compress the ureters this being a cause of hydronephrosis.
There are two ways to deal with an inflammatory AAA. The crucial point is the surgical access. Anterior or posterior (retroperitoneal)? Both can be performed.
If one follows the usual approach, he will notice that the jejunum is stuck on the posterior peritoneum and cannot be dissected away. In order to dissect it, the surgeon can use a 15 scalpel and make an incision on the posterior peritoneum, quite deep, I would say at about 0.3-0.5 cm deep. Then, using a pair of forceps he may try to unfold this layer of peritoneum away from the aneurysm, together with the overlying jejunum, as one tears away the layers of an onion. This can be done at various depths until the real aortic wall. Of course, there is always the danger of inadverting insertion into the aneurysm and having an unexpected bleeding. Just for this reason, it is better to have in advance an subdiaphragmatic control of the aorta through the lesser epiploic sac. Thus, if an unexpected bleeding from the aorta occurs, a proximal control at this level may save the case.
The posteriorn (retroperitoneal) approach theroretically offers the benefit of avoiding the inflammatory tissue as it is usually located betweent the duodenum and the aorta. However, the access is often difficult and due to the rigidity of the inflammatory wall it may be difficult to open easily after the aortotomy.