Maintaining Optimal Surgical Conditions With Low Insufflation Pressures is Possible With Deep Neuromuscular Blockade During Laparoscopic Colorectal Surgery

Abstract

Carbon dioxide (CO2) absorption and increased intra-abdominal pressure can adversely affect perioperative physiology and postoperative recovery. Deep muscle relaxation is known to improve the surgical conditions during laparoscopic surgery. We aimed to compare the effects of deep and moderate neuromuscular block in laparoscopic colorectal surgery, including intra-abdominal pressure.In this prospective, double-blind, parallel-group trial, 72 adult patients undergoing laparoscopic colorectal surgery were randomized using an online randomization generator to achieve either moderate (1–2 train-of-four response, n = 36) or deep (1–2 post-tetanic count, n = 36) neuromuscular block by receiving a continuous infusion of rocuronium. Adjusted intra-abdominal pressure, which was titrated by a surgeon with maintaining the operative field during pneumoperitoneum, was recorded at 5-minute intervals. Perioperative hemodynamic parameters and postoperative outcomes were assessed.Six patients from the deep and 5 from the moderate neuromuscular block group were excluded, leaving 61 for analysis. The average adjusted IAP was lower in the deep compared to the moderate neuromuscular block group (9.3 vs 12 mm Hg, P < 0.001). The postoperative pain scores (P < 0.001) and incidence of postoperative shoulder tip pain were lower, whereas gas passing time (P = 0.002) and sips of water time (P = 0.005) were shorter in the deep neuromuscular block than in the moderate neuromuscular block group.Deep neuromuscular blocking showed several benefits compared to conventional moderate neuromuscular block, including a greater intra-abdominal pressure lowering effect, whereas surgical conditions are maintained, less severe postoperative pain and faster bowel function recovery.

Effects of depth of neuromuscular block on surgical conditions during laparoscopic colorectal surgery: a randomised controlled trial

“…We could find only one study evaluating deep neuromuscular block in colorectal laparoscopic surgery, which is thought to represent a different surgical environment from upper abdominal or pelvic organ surgeries . Mean IAP during pneumoperitoneum, which was titrated by the operating surgeon, was lower with deep (PTC 1‐2) compared with moderate neuromuscular blockade (TOF 1‐2) during laparoscopic colorectal surgery.…”

Reversal with sugammadex for rocuronium-induced deep neuromuscular block after pretreatment of magnesium sulfate in rabbits

“…A deep NMB has various advantages. It can provide a better surgical field with lower intra-abdominal pressure than a moderate NMB (1–2 train of four [TOF] counts), decrease postoperative pain and induce rapid recovery of bowel function [5]. It also improves the surgical view in microsurgery [6].…”

Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis

“…When compared with open surgery, laparoscopic procedures provide less postoperative pain, shorter duration of hospital admission, and improved patient satisfaction. 1 However, the elevated intra-abdominal pressure (IAP) during pneumoperitoneum created during laparoscopic procedures can affect several homeostatic systems, causing alterations in cardiovascular, pulmonary, and renal physiology. It is also speculated that the pneumoperitoneum is an important factor in the cause of postoperative shoulder pain.…”