So, the aorta is clamped. Proximally, at the diaphragm, and distally at both common iliacs. Get ready! Go! 

Make an incision along the aortic sac, ending above the proximal end of the aneurysm. Remove the thrombus. Put a stay suture (silk No 1) on the right side of the aortic sac, grab it with a clip, and let it hanging outside the wound. This is a better way than a self-retractor. Now, it is just you and the aneurysm.

Are there any lumbar arteries leaking? Ligate them quickly using a Silk 0 suture or even better a Polypropylene 3/0. Remember always to ask for a big size needle. Get the graft and trim it on a long oblique fashion. It is better the cut to be rather long than short.

Get a 3/0 Polypropylene stitch with a long 31mm, 1/2 circle needle and start the anastomosis. Where will you start from? The easy answer is from the heel with a tacking down suture. No!!! Try the other way around. Tack down the top corner of the graft and the anastomosis. It will be much easier. Then, take the long part of the suture and start sewing on your side (left side) aiming that the heel of the graft will be just after the orifice of the right renal artery. Remember to make big bites on the aorta and short steps one to the next. After you have completed the 3/4 of the anastomosis, get the other end of the suture and complete the anastomosis.

In most of the times, the left renal artery will remain outside the anastomosis. Either a reimplantation of the left renal artery on the graft or a bypass using a synthetic graft (PTFE 6 mm) from the aortic graft to the left renal artery will be adequate. My first choice is always a reimplantation.

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