Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study

Denise M D Özdemir-Van Brunschot,Janneke E E A Mulder,Michiel C Warlé,Michel Van Der Jagt,Frank A D’Ancona,Albert Dahan,Luuk B Hilbrands,Hans Langenhuijsen,Rogier Donders,Gert J Scheffer,Cees J H M Van Laarhoven,Simone Willems

doi:10.1007/s00268-017-4080-x

Abstract

BackgroundThe use of low intra-abdominal pressure (<10 mmHg) reduces postoperative pain scores after laparoscopic surgery.ObjectiveTo investigate whether low-pressure pneumoperitoneum with deep neuromuscular blockade improves the quality of recovery after laparoscopic donor nephrectomy (LDN).Design, setting and participantsIn a single-center randomized controlled trial, 64 live kidney donors were randomly assigned to 6 or 12 mmHg insufflation pressure. A deep neuromuscular block was used in both groups. Surgical conditions were rated by the five-point Leiden-surgical rating scale (L-SRS), ranging from 5 (optimal) to 1 (extremely poor) conditions. If the L-SRS was insufficient, the pressure was increased stepwise.Main outcome measureThe primary outcome measure was the overall score on the quality of recovery-40 (QOR-40) questionnaire at postoperative day 1.ResultsThe difference in the QOR-40 scores on day 1 between the low- and standard-pressure group was not significant (p = .06). Also the overall pain scores and analgesic consumption did not differ. Eight procedures (24%), initially started with low pressure, were converted to a standard pressure (≥10 mmHg). A L-SRS score of 5 was significantly more prevalent in the standard pressure as compared to the low-pressure group at 30 min after insufflation (p < .01).ConclusionsLow-pressure pneumoperitoneum facilitated by deep neuromuscular blockade during LDN does not reduce postoperative pain scores nor improve the quality of recovery in the early postoperative phase. The question whether the use of deep neuromuscular blockade during laparoscopic surgery reduces postoperative pain scores independent of the intra-abdominal pressure should be pursued in future studies.Trial registrationThe trial was registered at clinicaltrial.gov before the start of the trial (NCT02146417).

Highlights

Laparoscopic donor nephrectomy (LDN) has several advantages over open donor nephrectomy, e.g., shorter length of hospital stay, earlier return to normal physical function and reduced use of analgesics [1]
We addressed the hypothesis that the use of low-pressure PNP (\10 mmHg) during laparoscopic donor nephrectomy improves the early quality of recovery as compared to the use of standard-pressure PNP (C10 mmHg)
Patients allocated to the low-pressure PNP group did not show a significantly better quality of recovery at postoperative day 1 which was the primary endpoint of this study

Summary

Introduction

Laparoscopic donor nephrectomy (LDN) has several advantages over open donor nephrectomy, e.g., shorter length of hospital stay, earlier return to normal physical function and reduced use of analgesics [1]. The use of low intra-abdominal insufflation pressure decreases postoperative pain in laparoscopic cholecystectomy [2, 3], and evidence exists that postoperative pain is decreased when low-pressure pneumoperitoneum (PNP) is used during LDN [4]. To optimize the quality of the surgical conditions, Madsen et al [7] used a deep neuromuscular block (NMB) to enhance surgical space, measured as the distance from the sacral promontory to the trocar. Dubois and Staehr-Rye showed that the use of a deep neuromuscular block (NMB) improves surgical conditions during laparoscopic hysterectomy and laparoscopic cholecystectomy, respectively [8, 9]. A deep NMB was used to facilitate the use of the low-pressure PNP. The use of low intra-abdominal pressure (\10 mmHg) reduces postoperative pain scores after laparoscopic surgery

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Results

Conclusion