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Deep neuromuscular blockade and surgical conditions during laparoscopic ventral hernia repair

A randomised, blinded study

Söderström, Carl M.; Borregaard Medici, Roar; Assadzadeh, Sami; Følsgaard, Søren; Rosenberg, Jacob; Gätke, Mona R.; Madsen, Matias V.

European Journal of Anaesthesiology (EJA): November 2018 - Volume 35 - Issue 11 - p 876–882
doi: 10.1097/EJA.0000000000000833
Neuromuscular blocking agents

BACKGROUND Laparoscopic ventral hernia repair is a common surgical procedure. However, muscle contractions and general muscle tension may impair the surgical view and cause difficulties suturing the hernial defect. Deep neuromuscular blockade (NMB) paralyses the abdominal wall muscles and may help to create better surgical conditions.

OBJECTIVES The current study investigated if deep compared with no NMB improved the surgical view during laparoscopic ventral hernia repair.

DESIGN Crossover study.

SETTING The study was carried out at Herlev and Gentofte Hospital, University of Copenhagen, Denmark and conducted from May 2015 until February 2017.

PARTICIPANTS A total of 34 patients were randomised in an investigator-initiated, assessor-blinded crossover design of deep vs. no NMB during laparoscopic ventral hernia repair.

INCLUSION CRITERIA Adults scheduled for elective laparoscopic ventral hernia repair.

EXCLUSION CRITERIA Known allergy to any study medication, known homozygous variants in the butyrylcholinesterase gene, severe renal disease, neuromuscular disease, lactating or pregnant women, any indication for rapid sequence induction.

INTERVENTIONS Deep NMB was established with rocuronium and reversed with sugammadex. Anaesthesia was conducted with propofol and remifentanil.

MAIN OUTCOME MEASURES The primary outcome was evaluation of surgical view assessed on a five-point rating scale. Other outcomes included the surgical conditions during laparoscopic suturing of the hernia defect.

RESULTS We found no difference in ratings for the surgical view when comparing deep with no NMB: mean −0.1 (95% confidence interval −0.4 to 0.2) (P = 0.521, paired t test). However, deep compared with no NMB improved the rating score for surgical conditions while suturing the hernia defect (P = 0.012, Mann–Whitney U test). No differences were found in either total length of surgery (P = 0.76) or hernia suturing time (P = 0.81).

CONCLUSION Deep compared with no NMB did not change the rating score of the surgical view immediately after introduction of trocars during laparoscopic ventral hernia repair, but the surgical condition were improved during suturing of the hernia.

TRIAL REGISTRATION ClinicalTrials.gov, NCT02247466.

From the Department of Anaesthesiology (CMS, RBM, SF, MRG, MVM) and Department of Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (SA, JR)

Correspondence to Matias V. Madsen, Department of Anaesthesiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, Herlev, DK-2730, Denmark E-mail: matias.vested.madsen@regionh.dk

Published online 6 June 2018

© 2018 European Society of Anaesthesiology