Endovascular repair has changed the treatment of abdominal aortic aneurysms, offering excellent minimally invasive options for many patients. However, open surgical repair remains essential in selected cases, especially when anatomy is unsuitable for EVAR, in complex juxtarenal or pararenal aneurysms, in a hostile abdomen, inflammatory aneurysms, or after failed endovascular treatment.
Among open surgical options, the retroperitoneal approach is a valuable technique. It allows access to the abdominal aorta without entering the peritoneal cavity and offers excellent exposure of the suprarenal and supraceliac aorta when proximal control is required. It may also reduce bowel manipulation and postoperative ileus and is particularly useful in selected complex cases.
This approach is technically demanding and requires careful preoperative planning, precise anatomical knowledge, proper patient positioning, and a trained surgical team. As endovascular techniques continue to dominate modern practice, preservation of open aortic skills — including the retroperitoneal approach — remains crucial for the next generation of vascular surgeons.
This article, published in the Hellenic Journal of Vascular and Endovascular Surgery, describes the technique, anatomical considerations, advantages, limitations, and contemporary role of open retroperitoneal repair for standard and complex abdominal aortic aneurysms.