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. 2017 May 4;5(5):CD012302.
doi: 10.1002/14651858.CD012302.pub2.

Laparoscopic surgery for elective abdominal aortic aneurysm repair

Lindsay Robertson  1 , Sandip Nandhra  2
Affiliations

Laparoscopic surgery for elective abdominal aortic aneurysm repair

Lindsay Robertson et al. Cochrane Database Syst Rev. .

Abstract

Background: Abdominal aortic aneurysm (AAA) is an abnormal dilatation of the infradiaphragmatic aorta that is equal to or greater than 30 mm or a local dilatation of equal to or greater than 50% compared to the expected normal diameter of the artery. AAAs rarely occur in individuals under 50 years of age, but thereafter the prevalence dramatically increases with age, with men at a six-fold greater risk of developing an AAA than women. Prevalence of AAA has been reported to range from 1.3% in women aged 65 to 80 years to between 4% and 7.7% in men aged 65 to 80 years.There is evidence that the risk of rupture increases as the aneurysm diameter increases from 50 mm to 60 mm. People with AAAs over 55 mm in diameter are therefore generally referred for consideration of repair, as the risk of rupture exceeds the risk of repair. The traditional treatment for AAA is open surgical repair (OSR) which involves a large abdominal incision and is associated with a significant risk of complications. Two less invasive procedures have recently become more widely used: endovascular aneurysm repair (EVAR) and laparoscopic repair. EVAR is carried out through sheaths inserted in the femoral artery in the groin: thereafter, a stent graft is placed within the aneurysm sac under radiological image guidance and anchored in place to form a new channel for blood flow. Laparoscopic repair involves the use of a laparoscope which is inserted through small cuts in the abdomen and the synthetic graft is sewn in place to replace the weakened area of the aorta. Laparoscopic AAA repair falls into two categories: hand-assisted laparoscopic surgery (HALS), where an incision is made to allow the surgeon's hand to assist in the repair; and total laparoscopic surgery (TLS). Both EVAR and laparoscopic repair are favourable over OSR as they are minimally invasive, less painful, associated with fewer complications and lower mortality rate and have a shorter duration of hospital stay.Current evidence suggests that elective laparoscopic AAA repair has a favourable safety profile comparable with that of EVAR, with low conversion rates as well as similar mortality and morbidity rates. As a result, it has been suggested that elective laparoscopic AAA repair may have a role in treating those patients for whom EVAR is unsuitable.

Objectives: To assess the effects of laparoscopic surgery for elective abdominal aortic aneurysm repair.The primary objective of this review was to assess the perioperative mortality and operative time of laparoscopic (total and hand-assisted) surgical repair of abdominal aortic aneurysms (AAA) compared to traditional open surgical repair or EVAR. The secondary objective was to assess complication rates, all-cause mortality (> 30 days), hospital and intensive care unit (ICU) length of stay, conversion and re-intervention rates, and quality of life associated with laparoscopic (total and hand-assisted) surgical repair compared to traditional open surgical repair or EVAR.

Search methods: The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched August 2016) and CENTRAL (2016, Issue 7). In addition the CIS searched trials registries for details of ongoing or unpublished studies. We searched the reference lists of relevant articles retrieved by electronic searches for additional citations.

Selection criteria: Randomised controlled trials and controlled clinical trials in which patients with an AAA underwent elective laparoscopic repair (total laparoscopic repair or hand-assisted laparoscopic repair) compared with either open surgical repair or EVAR.

Data collection and analysis: Studies identified for potential inclusion were independently assessed for inclusion by at least two review authors.

Main results: One randomised controlled trial with a total of 100 male participants was included in the review. The trial compared hand-assisted laparoscopic repair with EVAR and provided results for in-hospital mortality, operative time, length of hospital stay and lower limb ischaemia. The included study did not report on the other pre-planned outcomes of this review. No in-hospital deaths occurred in the study. Hand-associated laparoscopic repair was associated with a longer operative time (MD 53.00 minutes, 95% CI 36.49 to 69.51) than EVAR. The incidence of lower limb ischaemia was similar between the two treatment groups (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.05 to 5.34). The mean length of hospital stay was 4.2 days and 3.4 days in the hand-assisted laparoscopic repair and EVAR groups respectively but standard deviations were not reported and therefore it was not possible to independently test the statistical significance of this result. The quality of evidence was downgraded for imprecision due to the inclusion of one small study; and wide confidence intervals and indirectness due to the study including male participants only. No study compared laparoscopic repair (total or hand-assisted) with open surgical repair or total laparoscopic surgical repair with EVAR.

Authors' conclusions: There is insufficient evidence to draw any conclusions about effectiveness and safety of laparoscopic (total and hand-assisted) surgical repair of AAA versus open surgical repair or EVAR, because only one small randomised trial was eligible for inclusion in this review. High-quality randomised controlled trials are needed.

PubMed Disclaimer

Conflict of interest statement

LR: none known. SN: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Hand‐assisted laparoscopic repair vs EVAR, Outcome 1 In‐hospital mortality.
1.2
1.2. Analysis
Comparison 1 Hand‐assisted laparoscopic repair vs EVAR, Outcome 2 Operative time (minutes).
1.3
1.3. Analysis
Comparison 1 Hand‐assisted laparoscopic repair vs EVAR, Outcome 3 Major complications.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Veroux 2010 {published data only}
    1. Veroux P, D'Arrigo G, Veroux M, Giaquinta A, Lomeo A. Sexual dysfunction after elective endovascular or hand‐assisted laparoscopic abdominal aneurysm repair. European Journal of Vascular and Endovascular Surgery 2010;40(1):71‐5. - PubMed

References to studies excluded from this review

NCT00821145 {published data only}
    1. NCT00821145. Laparoscopic versus open abdominal aortic aneurysm (AAA) exclusion (LapAorta). Clinicaltrials.gov 2009. [https://clinicaltrials.gov/ct2/show/NCT00821145 (accessed 10 August 2016)]

Additional references

Ahmed 2014
    1. Ahmed N, Gollop ND, Ellis J, Khan OA. How does elective laparoscopic abdominal aortic aneurysm repair compare to endovascular aneurysm repair?. Interactive Cardiovascular and Thoracic Surgery 2014;18(6):814‐20. - PubMed
Anjum 2012
    1. Anjum A, Allmen R, Greenhalgh R, Powell JT. Explaining the decrease in mortality from abdominal aortic aneurysm rupture. British Journal of Surgery 2012;99(5):637‐45. [DOI: 10.1002/bjs.8698] - DOI - PubMed
Ashton 2002
    1. Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA, et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002;360(9345):1531‐9. - PubMed
Ashton 2007
    1. Ashton HA, Gao L, Kim LG, Druce PS, Thompson SG, Scott RA. Fifteen‐year follow‐up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. British Journal of Surgery 2007;94(6):696–701. - PubMed
Atkins 2004
    1. Atkins D, Best D, Briss PA, Eccles M, Falck‐Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328(7454):1490‐4. - PMC - PubMed
Badger 2014
    1. Badger S, Bedenis R, Blair PH, Ellis P, Kee F, Harkin DW. Endovascular treatment for ruptured abdominal aortic aneurysm. Cochrane Database of Systematic Reviews 2014, Issue 7. [DOI: 10.1002/14651858.CD005261.pub3] - DOI - PubMed
Ballard 1999
    1. Ballard DJ, Filardo G, Fowkes FG, Powell JT. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database of Systematic Reviews 1999, Issue 3. [DOI: 10.1002/14651858.CD001835] - DOI - PMC - PubMed
Brewster 2003
    1. Brewster DC, Cronenwett JL, Hallett JW Jr, Krupski WC, Matsumura JS, Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. Guidelines for the treatment of abdominal aortic aneurysms: Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. Journal of Vascular Surgery 2003;37(5):1106‐17. - PubMed
Bush 2006
    1. Bush RL, Johnson ML, Collins TC, Henderson WG, Khuri SF, Yu HJ. Open versus endovascular abdominal aortic aneurysm repair in VA hospitals. Journal of the American College of Surgeons 2006;202(4):577‐87. - PubMed
Ernst 1993
    1. Ernst CB. Abdominal aortic aneurysm. New England Journal of Medicine 1993;328(16):1167‐72. - PubMed
Ferrari 2006
    1. Ferrari M, Adami D, Corso A, Berchiolli R, Pietrabissa A, Romagnani F, et al. Laparoscopy‐assisted abdominal aortic aneurysm repair: early and middle‐term results of a consecutive series of 122 cases. Journal of Vascular Surgery 2006;43(4):695‐700. - PubMed
Filardo 2015
    1. Filardo G, Powell JT, Martinez MAM, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database of Systematic Reviews 2015, Issue 2. [DOI: 10.1002/14651858.CD001835.pub4] - DOI - PMC - PubMed
Forsdahl 2009
    1. Forsdahl SH, Singh K, Solberg S, Jacobsen BK. Risk factors for abdominal aortic aneurysms: a 7‐year prospective study: the Tromsø study, 1994–2001. Circulation 2009;119(16):2202–8. - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Javerliat 2006
    1. Javerliat I, Centa I, Cerceau P, Alfonsi P, Goëau‐Brissonnière O, Coggia M. Totally laparoscopic tube graft bypass for infrarenal aortic aneurysm: a well‐established surgical technique. Acta Chirurgica Belgica 2006;106(2):261‐6. - PubMed
Johnston 1991
    1. Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. Journal of Vascular Surgery 1991;13(3):452‐8. - PubMed
Lederle 1997
    1. Lederle FA, Johnson GR, Wilson SE, Chute EP, Littooy FN, Bandyk D, Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Prevalence and associations of abdominal aortic aneurysm detected through screening. Annals of Internal Medicine 1997;126(6):441‐9. - PubMed
Lederle 2000a
    1. Lederle FA, Johnson GR, Wilson SE, Chute EP, Hye RJ, Makaroun MS, Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. The aneurysm detection and management study screening program: validation cohort and final results. Archives of Internal Medicine 2000;160(10):1425‐30. - PubMed
Lederle 2000b
    1. Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, Acher CW, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. New England Journal of Medicine 2002;346(19):1437–44. - PubMed
Lederle 2003
    1. Lederle FA, Nelson DB, Joseph AM. Smokers' relative risk for aortic aneurysm compared with other smoking‐related diseases: a systematic review. Journal of Vascular Surgery 2003;38(2):329‐34. - PubMed
Lindholt 2005
    1. Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for abdominal aortic aneurysms: single centre randomised controlled trial. BMJ 2005;330(7494):750. - PMC - PubMed
NICE 2007
    1. National Institute for Health and Clinical Excellence (NICE). Laparoscopic repair of abdominal aortic aneurysm. NICE interventional procedure guidance. www.nice.org.uk/guidance/ipg229 (date accessed 17 June 2015).
Nordon 2011
    1. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nature Reviews Cardiology 2011;8(2):92‐102. - PubMed
Norman 2004
    1. Norman PE, Jamrozik K, Lawrence‐Brown MM, Le MT, Spencer CA, Tuohy RJ, et al. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm. BMJ 2004;329(7477):1259. - PMC - PubMed
Paravastu 2014
    1. Paravastu SCV, Jayarajasingam R, Cottam R, Palfreyman SJ, Michaels JA, Thomas SM. Endovascular repair of abdominal aortic aneurysm. Cochrane Database of Systematic Reviews 2014, Issue 1. [DOI: 10.1002/14651858.CD004178.pub2] - DOI - PMC - PubMed
Parodi 1991
    1. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Annals of Vascular Surgery 1991;5(6):491‐9. - PubMed
Pleumeekers 1995
    1. Pleumeekers HJ, Hoes AW, Does E, Urk H, Hofman A, Jong PT. Aneurysms of the abdominal aorta in older adults. The Rotterdam Study. American Journal of Epidemiology 1995;142(12):1291‐9. - PubMed
Review Manager 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2013.
Sakalihasan 2005
    1. Sakalihasan N, Limet R, Defawe OD. Abdominal aortic aneurysm. Lancet 2005;365(9470):1577‐89. - PubMed
Scott 2002
    1. Scott RAP, Bridgewater S, Ashton HA. Randomised clinical trial of screening for abdominal aortic aneurysm in women. British Journal of Surgery 2002;89(3):283‐5. - PubMed
Shah 1997
    1. Shah PK. Inflammation, metalloproteinases, and increased proteolysis: an emerging pathophysiological paradigm in aortic aneurysm. Circulation 1997;96(7):2115‐7. - PubMed
Sweeting 2015
    1. Sweeting MJ, Ulug P, Powell JT, Desgranges P, Balm R, Ruptured Aneurysm Trialists. Ruptured aneurysm trials: the importance of longer‐term outcomes and meta‐analysis for 1‐year mortality. European Journal of Vascular and Endovascular Surgery 2015;50(3):297‐302. [DOI: 10.1016/j.ejvs.2015.04.015] - DOI - PubMed
TUKSAT 1998
    1. The UK Small Aneurysm Trial Participants. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998;352(9141):1649‐55. - PubMed
Vardulaki 1999
    1. Vardulaki KA, Prevost TC, Walker NM, Day NE, Wilmink AB, Quick CR, et al. Incidence among men of asymptomatic aortic abdominal aneurysms: estimates from 500 screen detected cases. Journal of Medical Screening 1996;6(1):50–4. - PubMed
Veith 2003
    1. Veith FJ, Ohki T, Lipsitz EC, Suggs WD, Cynamon J. Treatment of ruptured abdominal aneurysms with stent grafts: a new gold standard?. Seminars in Vascular Surgery 2003;16(2):171‐5. - PubMed
Wanhainen 2008
    1. Wanhainen A. How to define an abdominal aortic aneurysm ‐ influence on epidemiology and clinical practice. Scandinavian Journal of Surgery 2008;97(2):105‐9. - PubMed

References to other published versions of this review

Robertson 2016
    1. Robertson L, Nandhra S. Laparoscopic surgery for abdominal aortic aneurysm. Cochrane Database of Systematic Reviews 2016, Issue 7. [DOI: 10.1002/14651858.CD012302] - DOI - PMC - PubMed

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