An abdominal aortic aneurysm is a bulge in the section of the aorta that travels down through the abdomen. It occurs because of a weakness in the wall of the aorta. If the aneurysm bursts (ruptures), it causes internal bleeding, and this can be rapidly fatal. The damaged section of the aorta can be repaired preventatively with a synthetic tube stitched into the artery using video keyhole surgery.

The National Institute for Health and Clinical Excellence is examining laparoscopic repair of abdominal aortic aneurysm and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about laparoscopic repair of abdominal aortic aneurysm.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the preliminary recommendations
  
• the identification of factual inaccuracies
  
• additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
  
• The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales, Scotland and Northern Ireland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 22 May 2007
Target date for publication of guidance: August 2007

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

There is adequate evidence of the safety and efficacy of laparoscopic repair of abdominal aortic aneurysm, but the technical demands are such that this procedure should not be used without special arrangements for consent and for audit or research.

Clinicians wishing to undertake laparoscopic repair of abdominal aortic aneurysm should take the following actions.

• Inform the clinical governance leads in their Trusts.
• Ensure that patients understand the procedure and its place in the elective treatment of abdominal aortic aneurysms, and provide them with clear written information. In addition, the patient should be informed of other available techniques, and told that conversion to open surgery may be necessary. Use of the Institute’s information for patients (‘Understanding NICE guidance’) is recommended (available from www.nice.org.uk/IPG XXX publicinfo). [[details to be completed at publication]]
• Audit and review clinical outcomes of all patients having laparoscopic repair of abdominal aortic aneurysm (see section 3.1).

Selection of patients should be performed by a multidisciplinary team experienced in the management of aortic aneurysms and able to offer alternative treatment options.

Dilatation of the aorta to form an aneurysm occurs in about 2% of men over the age of 65 (it is less common in women). Small aneurysms may present no problems, but some continue to grow, and larger aneurysms may leak or rupture. This carries a high risk of mortality, even when it is possible to offer emergency surgery. Preventative treatment is often advised for patients with aneurysms that represent an appreciable rupture risk.

The traditional treatment for abdominal aortic aneurysm is open surgical repair. The aneurysm is opened and a graft is then sewn in above and below the weakened area to allow normal blood flow. A less invasive approach is now commonly used, involving endovascular stent graft placement via the femoral arteries, but not all aneurysms are suitable for endovascular treatment.

In three non-randomised controlled trials that compared laparoscopic aneurysm repair with open surgery, the mean operative time was longer in the laparoscopic groups (181 minutes using HALS, 468 minutes and 7.7 hours) than in the open surgery groups (136 minutes, 301 minutes and 5.0 hours, respectively). Statistical significance levels were not stated in any of these three studies. A fourth non-randomised controlled study comparing HALS with endovascular stenting reported that operative time was again longer in the laparoscopic repair group (198 minutes and 149 minutes, respectively; not a statistically significant difference).

In one case series the mean operative time was 257 minutes (for HALS) and in a second case series operative time was 265 minutes for a totally laparoscopic aneurysm repair procedure, and 175 minutes for HALS.

Rates of postoperative death following laparoscopic aneurysm repair have been reported at 3% (1/29) (HALS), 4% (1/24) (HALS), 5% (3/60) and 10% (2/20) of patients.

It was noted that there is more than one technique in use and that safety and efficacy may vary.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

• ' Interventional procedure overview of laparoscopic repair of abdominal aortic aneurysm', January 2007.