title: Optimising abdominal space with deep neuromuscular blockade in gynaecologic laparoscopy--a randomised, blinded crossover study.
abstract: BACKGROUND
  Insufflation of the abdomen during laparoscopy improves surgical space, but may cause post-operative shoulder pain. The incidence of shoulder pain is reduced using a lower insufflation pressure, but this may, however, compromise the surgical space. We aimed at investigating whether deep neuromuscular blockade (NMB) would enlarge surgical space, measured as the distance from the sacral promontory to the trocar in patients undergoing gynaecologic laparoscopy.
  
  
  METHODS
  Fourteen patients were randomised in an assessor-blinded crossover design. The distance from the sacral promontory to the trocar was measured during deep NMB and without NMB at pneumoperitoneum 8 and 12 mmHg both. Additionally, we assessed surgical conditions while suturing the abdominal fascia using a 4-point subjective rating scale. Deep NMB was established with rocuronium and reversed with sugammadex.
  
  
  RESULTS
  At 12 mmHg pneumoperitoneum, deep NMB improved surgical space with a mean of 0.33 cm (95% confidence interval 0.07-0.59) (P=0.01, paired t-test) compared with no NMB. At 8 mmHg pneumoperitoneum deep NMB improved surgical space with a mean of 0.3 cm (95% confidence interval, 0.06-0.54) (P=0.005) compared with no NMB. Deep NMB resulted in significantly better ratings of surgical conditions during suturing of the fascia (P=0.03, Mann-Whitney U-test).
  
  
  CONCLUSIONS
  Deep NMB enlarged surgical space measured as the distance from the sacral promontory to the trocar. The enlargement, however, was minor and the clinical significance is unknown. Moreover, deep NMB improved surgical conditions when suturing the abdominal fascia.
authors: Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
authors: M V
authors: MV
authors: Madsen
authors: M R
authors: MR
authors: Gätke
authors: H H
authors: HH
authors: Springborg
authors: J
authors: J
authors: Rosenberg
authors: J
authors: J
authors: Lund
authors: O
authors: O
authors: Istre
mesh_terms: D034841:Abdominal Cavity / Q000033:anatomy & histology* / Q000601:surgery*; D000328:Adult; D000732:Androstanols; D018592:Cross-Over Studies; D004311:Double-Blind Method; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000379:methods*; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D019148:Neuromuscular Blockade / Q000379:methods*; D003473:Neuromuscular Nondepolarizing Agents; D011028:Pneumoperitoneum, Artificial; D000077123:Rocuronium; D000077122:Sugammadex; D013537:Sutures; D047408:gamma-Cyclodextrins
chemical_list: D000732:Androstanols; D003473:Neuromuscular Nondepolarizing Agents; D047408:gamma-Cyclodextrins; D000077122:Sugammadex; D000077123:Rocuronium