A helpful modification of the standard midline abdominal incision that can be used to expose the proximal abdominal aorta without entering the chest is illustrated in Figure 8.8. An inverted hockey-stick incision is employed beginning at the left midcostal margin. The left rectus muscle is transected and the oblique and transversus muscles are divided in the direction of the skin incision. The incision is continued down the linea alba to the symphysis pubis. The left colon is mobilized by incising the peritoneum along the white line of Toldt from the pelvis to the lateral peritoneal attachments of the spleen. The spleen is gently mobilized and brought forward toward the midline by incising the splenorenal and splenophrenic ligaments.
Dissection is continued by forward mobilization of the spleen, pancreatic tail and splenic flexure of the colon between the mesocolon and Gerota's fascia taking care not to damage the adrenal gland medially or the adrenal vein at its junction with the left renal vein. This left-to-right transperitoneal medial visceral rotation affords excellent exposure of the supraceliac and visceral aorta including the renal arteries (Fig. 8.9). Division of the median arcuate ligament and diaphragmatic crura exposes the distal thoracic aorta without entering the left chest. The left kidney can be brought forward with the rest of mobilized viscera or left in situ.
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