Deep neuromuscular blockade improves surgical conditions during low-pressure pneumoperitoneum laparoscopic donor nephrectomy

D M D Özdemir-Van Brunschot,D Lam,F C D’Ancona,J F Langenhuijsen,V A Huurman,A E Braat,R E Dam,A Dahan,C H Martini,M F P Van Der Jagt,M C Warlé,G J Scheffer

doi:10.1007/s00464-017-5670-2

Abstract

BackgroundEvidence indicates that low-pressure pneumoperitoneum (PNP) reduces postoperative pain and analgesic consumption. A lower insufflation pressure may hamper visibility and working space. The aim of the study is to investigate whether deep neuromuscular blockade (NMB) improves surgical conditions during low-pressure PNP.MethodsThis study was a blinded randomized controlled multicenter trial. 34 kidney donors scheduled for laparoscopic donor nephrectomy randomly received low-pressure PNP (6 mmHg) with either deep (PTC 1–5) or moderate NMB (TOF 0–1). In case of insufficient surgical conditions, the insufflation pressure was increased stepwise. Surgical conditions were rated by the Leiden-Surgical Rating Scale (L-SRS) ranging from 1 (extremely poor) to 5 (optimal).ResultsMean surgical conditions were significantly better for patients allocated to a deep NMB (SRS 4.5 versus 4.0; p < 0.01). The final insufflation pressure was 7.7 mmHg in patients with deep NMB as compared to 9.1 mmHg with moderate NMB (p = 0.19). The cumulative opiate consumption during the first 48 h was significantly lower in patients receiving deep NMB, while postoperative pain scores were similar. In four patients allocated to a moderate NMB, a significant intraoperative complication occurred, and in two of these patients a conversion to an open procedure was required.ConclusionsOur data show that deep NMB facilitates the use of low-pressure PNP during laparoscopic donor nephrectomy by improving the quality of the surgical field. The relatively high incidence of intraoperative complications indicates that the use of low pressure with moderate NMB may compromise safety during LDN. Clinicaltrials.gov identifier: NCT 02602964.

Highlights

MethodsLaparoscopic donor nephrectomy (LDN), in most countries the ‘‘gold standard’’ for live kidney donation, is associated with an improved quality of life, earlier return to work, and improved cosmetics [1,2,3]
Background Evidence indicates that low-pressure pneumoperitoneum (PNP) reduces postoperative pain and analgesic consumption
In a recent study by Kim et al, it was shown that the intra-abdominal pressure could be titrated from 12 mmHg to 9.3 mmHg in patients receiving a deep neuromuscular block (NMB) during laparoscopic colorectal surgery, while intra-abdominal pressure was kept at 12 mmHg in patients allocated to a moderate NMB to maintain adequate surgical conditions [13]

Summary

Introduction

MethodsLaparoscopic donor nephrectomy (LDN), in most countries the ‘‘gold standard’’ for live kidney donation, is associated with an improved quality of life, earlier return to work, and improved cosmetics [1,2,3]. A lower intra-abdominal pressure during laparoscopy comes at a cost It may compromise surgical conditions, such as working space and sight at the surgical field. This study showed that the surgical conditions were significantly better in patients receiving a deep NMB despite the use of a lower mean intra-abdominal pressure. Staehr-Rye et al concluded that deep NMB only marginally improved surgical conditions during low-pressure laparoscopic cholecystectomy [14]. The question whether deep NMB facilitates the use of lowpressure PNP during laparoscopy remains controversial To address this issue, we perform a study in which we hypothesize that deep NMB improves surgical conditions during laparoscopic donor nephrectomy with low-pressure PNP. The aim of the study is to investigate whether deep neuromuscular blockade (NMB) improves surgical conditions during low-pressure PNP

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