Roof-top approach is a totally abdominal approach to the suprarenal aorta. This means that the incision is an abdominal incision. And as the title says, it is like a roof-top on the abdominal wall. Or in other words, a bilateral subcostal incision.
On the right side is an incision just above the right abdominal muscle. On the left side it extends all the left side arch down to the left anterior axillary line. The distance from both side arches is just two finger breadths.
First, start with the scalpel for the skin. And then proceed with the electrocautery for the muscles. Just be a bit careful when you enter the peritoneal cavity as the viscera are just underneath. In the midline, there is always the round ligament which needs to be ligated before divided.
After the abdominal incision has been completed the lower flap of the incision is everted and is tacked down on the right lower quadrant. This is done with a heavy suture (ie Vicryl No 1) from the fascia of the flap to the skin of the right lower abdominal wall.