Surgical Access to the Abdominal Aorta and Inferior Vena Cava

Anatomical Overview

Key Relations (Surgical Importance)

Surgical Approaches to the Abdominal Aorta

1. Supraceliac Aortic Exposure (Most Expeditious)

1. Divide the gastrohepatic ligament between clamps (Fig. 13-2A)
2. Mobilize the left lobe of the liver by dividing its diaphragmatic attachments if needed
3. Identify the aorta to the right of the esophagus (NGT/OGT helps distinguish them if unclear)
4. Divide the left crus of the diaphragm completely - this is critical. Fibers are divided at the "2 o'clock" position slightly to the left of midline with scissors or cautery
5. Identify and clip or spare the phrenic arteries
6. Encircle the aorta between thumb and index finger, lift gently off the spine to confirm complete mobilization
7. Apply a straight aortic clamp under direct vision

Pitfall: Incomplete division of crural fibers will cause any applied clamp to slip anteriorly - potentially catastrophic.

2. Infrarenal Aortic Exposure

1. Incise the ligament of Treitz and mobilize the 4th part of the duodenum superiorly and to the right
2. Divide the inferior mesenteric vein between clamps if it impairs exposure (risk of avulsion under tension)
3. The left renal vein marks the superior extent of infrarenal dissection - it almost never requires division. If additional mobilization is needed, ligate gonadal and lumbar tributaries; divide adrenal vein if retracting IVC inferiorly
4. Note: ~1% of patients have a retroaortic left renal vein - at risk during cross-clamping if unrecognized
5. Cauterize or ligate lymphatics anterior to the aorta (large ones ligated to prevent chyle leak)
6. Encircle the aorta digitally (thumb + index finger), raise it off the spine, and apply cross-clamp under direct vision
7. A vessel loop/tape can be placed around the infrarenal aorta for additional control

3. Visceral Aortic Exposure

4. Iliac Artery Exposure

• Proximal common iliac: reflect small bowel mesentery to the right, expose the aortic bifurcation
• External iliac: mobilize right or left colon along Toldt's line, reflect toward midline
• Identify and protect the ureter as it crosses the iliac bifurcation
• Warning: The confluence of iliac veins lies directly behind the right common iliac artery - this is the most common site of iatrogenic vascular injury during aortoiliac surgery. Use blunt dissection to separate artery from vein.

Surgical Exposure of the IVC

1. Mobilize the right colon (along the white line of Toldt)
2. Perform an extended Kocher maneuver - rotate the duodenum and head of the pancreas medially for more proximal (suprarenal/retrohepatic) exposure
3. This exposes the IVC and confluence of the iliac veins

• Avoid circumferential mobilization of the IVC whenever possible - posterior lumbar tributaries are fragile and easily torn
• Compression (sponge sticks) is the primary means of IVC hemorrhage control given its low-pressure nature
• Avoid vascular clamps where possible; use partial-occlusion clamps or Allis clamps for wound coaption
• Posterior IVC injuries require extensive mobilization and ligation of multiple lumbar tributaries

Proximal Arterial Control - Endovascular Options

• Intra-aortic balloon occlusion from a remote access site (e.g., retrograde from femoral artery) can achieve proximal control
• The balloon must be buttressed against a rigid sheath to prevent migration from repetitive arterial pressure
• A Foley catheter balloon can control visceral back bleeding from collaterals (e.g., during ruptured aneurysm repair combined with supraceliac clamping)
• For routine/emergent cases, open exposure remains the fastest and most reliable method

Summary Table

Access to Abdominal Aorta and IVC

Abdominal Aorta

Supraceliac Aorta

• Divide gastrohepatic ligament → enter lesser sac
• Divide left crus of diaphragm at "2 o'clock" position
• Encircle aorta by finger dissection → apply straight clamp

Infrarenal Aorta (most common)

• Divide ligament of Treitz → mobilize 4th part of duodenum upward and to the right
• Left renal vein = superior limit of dissection
• Encircle aorta digitally → apply cross-clamp

Inferior Vena Cava

• Mobilize right colon along white line of Toldt
• Extended Kocher maneuver (reflect duodenum + pancreatic head medially) for proximal exposure
• IVC lies to the right of the aorta

• Avoid circumferential dissection (fragile posterior lumbar tributaries)
• Use compression (sponge sticks) as primary hemostatic method - low-pressure system
• Avoid clamps where possible; use partial-occlusion clamps only when needed