Systematic Review and Meta-analysis of the Retroperitoneal versus the Transperitoneal Approach to the Abdominal Aorta

ObjectivesThe aim was to systematically review and meta-analyse the differences between the retroperitoneal (RP) and the transperitoneal (TP) approach to the infrarenal abdominal aorta.DesignSystematic review and meta-analysis.MethodsPubMed, the Cochrane library, Embase and ClinicalTrials.govwere searched for all studies on differences in clinical outcomes between the RP and TP approach. Outcomes were selected based on inclusion in two or more studies: Operative (length of procedure, intraoperative blood loss); Post operative complications (paralytic ileus, pneumonia, myocardial infarction (MI), renal failure and wound hernia); Mortality (30 day, 1 year); Post-operative changes in respiratory function (forced expiratory volume in 1 second, forced vital capacity); Length of hospital and Intensive care unit (ICU) stay and Cost. The data were pooled by outcome.ResultsEight randomised and 21 cohort studies involving 3035 patients were included. Meta-analysis showed significantly lower rates of postoperative ileus (Odds ratio (OR) 0.17[95% CI 0.10, 0.32] p < 0.00001), pneumonia (OR 0.42[95% CI 0.26, 0.68] p = 0.0004), ICU stay (standardised mean difference (SMD) 0.67[95% CI 1.28, 0.06] p = 0.03), total hospital stay (SMD 0.88[95% CI 1.32, 0.44] p < 0.0001) and cost (SMD 1.15[95% CI 2.11, 0.19] p = 0.02) for patients undergoing a RP approach. Study quality was generally low, with conflicting results and concerns over publication bias in some cohort studies.ConclusionsThe RP approach for open aortic surgery is associated with lower rates of postoperative ileus and pneumonia when compared to the TP approach.