Then an abdominal, self-retaining retractor is placed to maintain and facilitate the exposure which has been created. Increasing the exposure superiorly helps in the identification of left renal vein. The left renal vein crosses the neck of the aneurysm anteriorly.
It is extremely necessary to mobilize left renal vein and ligate its branches (left adrenal vein, left gonadal vein, and lumbar vein) to get proper exposure of suprarenal aorta. Next, infrarenal neck of the aneurysm is dissected and mobilized after identification of renal arteries. The purpose of this is to make space for placing infrarenal clamp. If there is a need of suprarenal clamping, then both the renal arteries are dissected and renal arteries are occluded with soft bulldog clamps or fine vessel loops to prevent embolization. As far as inferior dissection is concerned, it is carried down to the level of the aortic bifurcation to expose both common iliac arteries. It is important to avoid excessive dissection of the aortic bifurcation and the proximal common iliac arteries, especially on the left side, to prevent damage to the parasympathetic nerve plexus, which is important in males to maintain normal erectile and ejaculatory function. The ureters are located near the iliac bifurcations, coursing along the anterior surface of the iliac arteries, and care should be taken to avoid injury during dissection and clamping. Circumferential dissection of the iliac arteries can cause injury to the iliac veins which can result in extensive hemorrhage.