Deep versus Moderate Neuromuscular Blockade in Gynecologic Laparoscopic Operations: Randomized Controlled Trial

Abstract

Background: To investigate whether deep neuromuscular blockade (NMB) improves surgical conditions and postoperative pain compared to moderate block, in patients undergoing gynecologic laparoscopic surgery. Methods: A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients, who were randomly assigned to one of the following two groups: patients in the first group received deep NMB (PTC 0-1) and in the other, moderate NMB (TOF 0-1). Primary outcomes included assessing the surgical conditions using a four-grade scale, ranging from 0 (extremely poor) to 3 (optimal), and patients’ postoperative pain was evaluated with a five-grade Likert scale and the analgesic consumption. Results: 144 patients were analyzed as follows: 73 patients received deep NMB and 71 moderate NMB. Mean surgical field scores were comparable between the two groups (2.44 for moderate vs. 2.68 for deep NMB). Regarding postoperative pain scores, the patients in the deep NMB experienced significantly less pain than in the group of moderate NMB (0.79 vs. 1.58, p < 0.001). Moreover, when the consumption of analgesic drugs was compared, the moderate NMB group needed more extra opioid analgesia than the deep NMB group (18.3% vs. 4.1%, p = 0.007). From the secondary endpoints, an interesting finding of the study was that patients on deep NMB had significantly fewer incidents of subcutaneous emphysema. Conclusions: Our data show that, during the performance of gynecologic laparoscopic surgery, deep NMB offers no advantage of operating filed conditions compared with moderate NMB. Patients may benefit from the deep block as it may reduce postoperative pain.

Evaluation of surgical condition during laparoscopic gynaecological surgery in patients with moderate vs. deep neuromuscular block in low-pressure pneumoperitoneum

“…Recent study in 2022 by Nikolaos et al . [ 16 ] also showed that there is no statistically significant improvement in operative visual field and handling of small and large bowel between moderate and deep NMB. Surgical rating scales enable the surgeon to quantify the surgical space condition, especially during research works in laparoscopic surgery.…”

Laparoscopic management of a second trimester ruptured spontaneous heterotopic tubal pregnancy mimicking ovarian tumour, a case report

“…Direct vision of the ureter when applying thermal energy and cutting the retroperitoneal structures when previously dissected are some of the principles the laparoscopic surgeon should follow to avoid ureteral damage. Finally, anaesthesia modifications such as applying deep neuromuscular blockade during the operation may improve the operating field visualisation and reduce post-operative pain and analgesic consumption ( Kathopoulis et al, 2022 ).…”