Sir
The authors strongly recommend the use of a transverse incision for aortic aneurysm surgery to reduce the risk of incisional hernia formation. Not all abdominal aortic aneurysms, however, can easily be approached through a transverse incision. Exposure of the external iliac arteries is extremely difficult, and a bypass extending beyond the common iliac bifurcations, if not feasible, is at least not safe. The same may also be true for juxta-renal aneurysms that need suprarenal clamping, aneurysms in patients with previous major abdominal surgery, plus overweight patients with an acute sternal angle.
The authors state that consecutive patients were randomized, something that raises the question whether the patients were pre-selected; the authors did not report exclusion criteria for a transverse approach. It is also striking that only 46 per cent (15 of 32) of the patients who had a transverse incision were alive at follow-up, compared to 60 per cent of the patients with a vertical incision (22 of 37). A transverse approach is usually employed in young, fitter and probably thinner patients. If all patients were truly randomized, then the authors should consider the possibility of a higher