BACKGROUND: The management of coexisting intra-abdominal disease in aortic surgery is controversial. A staged repair is preferred by many and, in general, the symptomatic lesion is treated first. Twenty-one years ago this vascular unit elected a policy of treating such lesions synchronously. This was on the theoretical premises that the benefits of a single operation in these patients would outweigh the potential risks of graft infection and increased complication rates from a prolonged procedure. METHODS: The case records of 676 patients undergoing aortic grafting for aneurysmal or occlusive disease between 1978 and 1998 were analysed retrospectively. RESULTS: Fifty-five patients (8 per cent) had coexisting intra-abdominal diseases treated at the time of aortic graft surgery. These included biliary disease (26), and gastric (12), intestinal (13), urological (two), hepatic (one) and splenic (one) pathology. The median age at presentation was 72 (range 46-90) years. There were three hospital deaths and five patients required early reoperation, three for lower limb ischaemia and two for intra-abdominal bleeding. One patient developed a subphrenic abscess and there were three superficial wound infections. There were no graft infections in this group of 55 patients. CONCLUSION: This large single-centre experience with synchronous intra-abdominal surgery and aortic grafting demonstrates that it is safe and does not predispose to an increased risk of graft infection or perioperative haemorrhage.