Vascular Surgery Case Study

Temporary abdominal flexion during AAA surgery: A technical report of an Open Transperitoneal Infrarenal Abdominal Aorta Aneurysms Repair using an Inflatable Support for improved Juxta-renal Exposure.

J.M.M. Heyligers, MD, PhD1; J.A.M. de Ridder, MD, PhD2; P.R.A.M. Depauw, MD3. *



Appropriate patient positioning is essential during each step of a surgical procedure. During a transperitoneal approach, the patient is in supine position on the operating table. This is ideal for incision and displacement of the organs. However due to the vascular structures lying deep in the abdomen obtaining good exposure of the abdominal aorta can be challenging. It would be beneficial to apply intra-operatively lumbar extension that brings the vascular structure more anteriorly.

Case Description

A case of infrarenal abdominal aortic aneurysm (AAA), with a diameter of 7.6 cm in a 66-year-old male patient, is presented here. Open surgical repair using a knitted Dacron tube graft was opted for and the patient was discharged successfully on the 6th postoperative day. Past medical history included heart failure, CABG, and pulmonary malignancy. The patients’ weight was 91 kg, and he had a BMI of 30.1. Abdominal US revealed an infrarenal AAA with a diameter of 7.6 cm. The patient underwent thoracoabdominal CT angiography, which revealed an infrarenal AAA, with a diameter of 76 mm, and a significant intra-arterial mural thrombus.

The patient was positioned supine on the rigid operating table with an inflatable support (IXS-R, Ergotrics) positioned underneath the patient at the level of the AAA. A midline laparotomy from the xyphoid to the symphysis pubis was performed.

After the laparotomy, displacement of the omentum, large bowel and small bowel, the peritoneum was divided, and the duodenum mobilized. Once the retroperitoneum had been opened, the clamp sites for proximal and distal vascular control had been exposed.

To facilitate this, an inflatable support (IxS-R, Ergotrics) was inflated using compressed medical air. By inflating the IXS-R abdominal extension was obtained, resulting in an excellent exposure of the abdominal aorta (Figure 1).


Intra-operative lumbar extension could be obtained using an operating table with a table break and positioning the patient with the table break 5 to 10 cm cephalad to the left iliac crest. Intra-operatively, the head and foot end of the operating table are lowered resulting in lumbar flexion. This is not always practically and sometimes time consuming. Also, at a Hybrid OR, the available tables are not all supplied with the breaking feature. 

The inflatable support, provides an easy, safe, and rapid method for providing lumbar extension during abdominal aorta exposure and repair. The inflatable support is positioned underneath the patient prior to incision. Intra-operatively the support is inflated and deflated to the appropriate height. Adjustments can be made at any time during the procedure.

* About the authors

  • J.M.M Heylogers: Department of Surgery, Elisabeth TweeSteden Hospital Tilburg, The Netherlands
  • J.A.M de Ridder: Department of Surgery, Reinier de Graaf Gasthuis Delft, The Netherlands
  • P.R.A.M. Depauw and G.J. Rutten: Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.


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3.Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019 Jan;57(1):8-93. doi: 10.1016/j.ejvs.2018.09.020. Epub 2018 Dec 5. Erratum in: Eur J Vasc Endovasc Surg. 2020 Mar;59(3):494. PMID: 30528142.

4.Schmitz-Rixen T, Böckler D, Vogl TJ, Grundmann RT. Endovascular and Open Repair of Abdominal Aortic Aneurysm. Dtsch Arztebl Int. 2020 Oct 20;117(48):813-819. doi: 10.3238/arztebl.2020.0813. PMID: 33568258.

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