Most abdominal aortic aneurysms can be resected through a standard transperitoneal approach. In patients with large aneurysms, supra-renal extension of the aneurysm, those requiring renal reconstructive procedures and in patients who have had previous extensive intra-abdominal operations, alternative approaches have been recommended. We exposed the abdominal aorta in ten of these difficult patients using a midline transperitoneal incision and right retroperitoneal dissection that provided excellent exposure of the suprarenal aorta. We recommend this technique for performance of complicated abdominal aortic aneurysm resections.