Randomized Clinical Trial of Moderate Versus Deep Neuromuscular Block for Low-Pressure Pneumoperitoneum During Laparoscopic Cholecystectomy

Abstract

Background: The beneficial effects of deep blockade are not fully known. In this study, we evaluated the effect of deep neuromuscular blockade on surgical conditions during laparoscopic cholecystectomy under low-pressure pneumoperitoneum.

Methods: Patients undergoing elective laparoscopic cholecystectomy were randomized to either the moderate group (train-of-four count of 1 or 2) or deep group (posttetanic count of 1 or 2). Neuromuscular blockade was induced and maintained with rocuronium; it was reversed with sugammadex in the deep group and with neostigmine in the moderate group. At the beginning of surgery, the intra-abdominal pressure was set at 8 mmHg. The surgeon rated the surgical condition on a 4-point scale (1 = excellent, 2 = good, 3 = acceptable, 4 = poor) and was allowed to increase the pressure to 12 mmHg if it was determined that the surgical conditions were inadequate for the operation.

Results: A total of 64 patients completed the study. The rate of increasing intra-abdominal pressure to maintain optimal surgical conditions was 34.4 % in the moderate group and 12.5 % in the deep group (P = 0.039). The proportion of patients with a surgical condition score of 1 or 2 (excellent or good) was 34.4 % in the moderate group and 68.8 % in the deep group (P = 0.006).

Conclusion: The maintenance of intraoperative deep neuromuscular blockade was associated with a lower rate of conversion to standard pressure and higher surgeon satisfaction with the surgical conditions than was moderate blockade in patients undergoing low-pressure pneumoperitoneum laparoscopic cholecystectomy.