Care is taken to maintain the blood supply to the ureter and avoid excessive dissection of this structure. Injury to the descending colon is also avoided during dissection of the plane over Gerota’s fascia. The dissection is continued further till left renal vein is identified and gonadal vein is ligated at this level to expose the neck of aorta. The aortic neck and the iliac arteries are then clamped, and the repair and sac closure are carried out the same way as described for the transperitoneal approach. In patients with horseshoe kidney or inflammatory aneurysm and in those who likely need a suprarenal or supraceliac clamp, the ureter and the left kidney are retracted medially with the peritoneal cavity.

Absorbable 2-0 sutures are used for the approximation of the wall of aneurysm. Then the peritoneum is reapproximated over the aorta and the small bowel is returned to the abdominal cavity. The duodenum and surrounding structures are carefully inspected, and the peritoneum is placed between the graft and the duodenum to avoid formation of aortoduodenal fistulas. The linea alba is closed with 1-0 polydioxanone. If an aortobifemoral bypass has been performed, the groin incisions are closed in layers using 2-0 absorbable sutures. The skin is closed with skin staples.

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