TO THE EDITORS:Since Starzl et al. 1 first published on organ recovery techniques, the field has changed in substantial ways. Organs are often recovered by different centers, and this requires more in situ dissection in a setting of competing interests and unfamiliarity among different surgical teams and local operating room staff. These challenges are compounded by a donor population of advanced age and with a higher prevalence of obesity; this makes reoperative fields more common and the difficulties associated with a larger body habitus more relevant. The imbalance between supply and demand makes organ damage even less excusable in modernday recovery operations.It is well recognized that any reoperative field is more complicated than a virgin abdomen. Two specific operations occurring with increasing frequency have the potential to affect the ability to safely perfuse and recover abdominal organs. Approximately 50,000 persons per year undergo elective or urgent abdominal aortic aneurysm repair. Endovascular repair is increasingly considered the first-line treatment for elective repairs, and in each year since 2003, electively performed endovascular repairs have surpassed open approaches. 2 More than 150,000 people per year undergo bariatric operations, including gastric bypass, gastric banding, and sleeve gastrectomy, in the United States. 3 These numbers reflect just 1% of the population eligible for weight-loss surgery.A preoperative plan is critical to a successful operation, and we present 2 techniques for approaching these complex reoperative patients within the normal skill set of a recovering surgeon.
ABDOMINAL ORGAN RECOVERY FOLLOWING ENDOVASCULAR ANEURYSM REPAIRAn endovascular graft is a covered, self-expanding metal framework that intravascularly bridges the infrarenal aorta and iliac arteries through the aneurysm; newer fenestrated grafts may even cross the renal arteries. Traditional tube grafts used during open aneurysm repair lack a metal infrastructure and are sewn directly to the proximal aorta and distal aorta or iliacs. This is done after the aneurysm is opened, so there is no false lumen. These structural and technical contrasts are the basis for potential harm to organ perfusion.The radial strength provided by the metal framework allows proper fixation. In contrast to standard grafts, clamping or finger pinching during cannulation results in crimping and flattening of the endovascular graft (Fig. 1A). This may result in high resistance, no flow of the preservation fluid, or even inability to properly insert the aortic flush cannula. Moreover, the cannula may be inadvertently placed in the native aortic lumen outside the covered endovascular stent (Fig. 1B). Both errors risk poor graft perfusion and loss and require an alternative, safe, and easily reproducible technique in any environment without special equipment.We have used a femoral cutdown with distal ligation, through which a standard 18-Fr nasogastric tube (sump-tied) is passed into the abdominal aorta from the side with the longer...