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Arumugaswamy PR, Chumber S, Rathore YS, Maitra S, Bhattacharjee HK, Bansal VK, Aggarwal S, Dhar A, Asuri K, Kataria K, Ranjan P. Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial. Surg Endosc 2024; 38:449-459. [PMID: 38012441 DOI: 10.1007/s00464-023-10558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.
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Affiliation(s)
- Prasanna Ramana Arumugaswamy
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sunil Chumber
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Yashwant Singh Rathore
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Souvik Maitra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Hemanga Kumar Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Anita Dhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Krishna Asuri
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Piyush Ranjan
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Low Intra-Abdominal Pressure with Complete Neuromuscular Blockage Reduces Post-Operative Complications in Major Laparoscopic Urologic Surgery: A before-after Study. J Clin Med 2022; 11:jcm11237201. [PMID: 36498775 PMCID: PMC9737534 DOI: 10.3390/jcm11237201] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Most urological interventions are now performed with minimally invasive surgery techniques such as laparoscopic surgery. Combining ERAS protocols with minimally invasive surgery techniques may be the best option to reduce hospital length-of-stay and post-operative complications. We designed this study to test the hypothesis that using low intra-abdominal pressures (IAP) during laparoscopy may reduce post-operative complications, especially those related to reduced intra-operative splanchnic perfusion or increased splanchnic congestion. We applied a complete neuromuscular blockade (NMB) to maintain an optimal space and surgical view. We compared 115 patients treated with standard IAP and moderate NMB with 148 patients treated with low IAP and complete NMB undergoing major urologic surgery. Low IAP in combination with complete NMB was associated with fewer total post-operative complications than standard IAP with moderate NMB (22.3% vs. 41.2%, p < 0.001), with a reduction in all medical post-operative complications (17 vs. 34, p < 0.001). The post-operative complications mostly reduced were acute kidney injury (15.5% vs. 30.4%, p = 0.004), anemia (6.8% vs. 16.5%, p = 0.049) and reoperation (2% vs. 7.8%, p = 0.035). The intra-operative management of laparoscopic interventions for major urologic surgeries with low IAP and complete NMB is feasible without hindering surgical conditions and might reduce most medical post-operative complications.
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Murphy GS. Pro: Deep neuromuscular blockade should be maintained during laparoscopic surgery. Anaesth Crit Care Pain Med 2021; 40:100918. [PMID: 34182167 DOI: 10.1016/j.accpm.2021.100918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Glenn S Murphy
- Illinois Masonic Hospital, 836 West Wellington Avenue; Suite 4815, Chicago, IL 60657, United States.
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Richebé P, Bousette N, Fortier LP. A narrative review on the potential benefits and limitations of deep neuromuscular blockade. Anaesth Crit Care Pain Med 2021; 40:100915. [PMID: 34174460 DOI: 10.1016/j.accpm.2021.100915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neuromuscular blockade was shown to improve surgical conditions. However, the risk of residual neuromuscular blockade upon extubation prevents anaesthesiologists from maintaining complete paralysis. For this reason, deep NMB is still underused in anaesthesia. This review focused on answering six questions revolving around the use of deep NMB versus moderate NMB. METHODS This was a non-exhaustive narrative review based on 6 selected relevant questions: does deep NMB 1) improve surgical conditions? 2) reduce surgical complications? 3) facilitate a reduction in intraoperative pneumoperitoneum pressure (PnP)? 4) does a reduction in intraoperative PnP impact clinical outcomes? 5) does the combination of deep NMB and lower PnP improve respiratory parameters? 6) improve OR efficiency or readmission rates? RESULTS This review highlights some of the key studies that have demonstrated potential benefits of deep NMB, but it also included reports showing no benefit, highlighting that the evidence is not unequivocal. Deep NMB does in fact improve surgical conditions, but whether this improvement translates into improved clinical outcomes is far from concluded. Indeed, there is an increased risk or residual curarisation, especially if patients are not monitored and reversed appropriately. The most important benefit of deep NMB may be the prevention of unacceptable surgical working conditions. The other potential major benefits are the reduction in PnP and reduction in pain. Deep NMB must be used with appropriate monitoring. CONCLUSION Deep NMB was associated with an improvement in surgical conditions, reduction in PnP, pain, and complications; but further research is needed to definitively prove this relationship.
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Affiliation(s)
- Philippe Richebé
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montréal, Montréal, QC, Canada.
| | - Nicolas Bousette
- Merck Canada Inc., 16750 Trans Canada Hwy, Kirkland, QC, H9H 4M7, Canada
| | - Louis-Philippe Fortier
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montréal, Montréal, QC, Canada
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Balayssac D, Selvy M, Martelin A, Giroudon C, Cabelguenne D, Armoiry X. Clinical and Organizational Impact of the AIRSEAL ® Insufflation System During Laparoscopic Surgery: A Systematic Review. World J Surg 2020; 45:705-718. [PMID: 33258023 DOI: 10.1007/s00268-020-05869-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2020] [Indexed: 01/01/2023]
Abstract
Several low-impact laparoscopic strategies have been developed to improve the safety of pneumoperitoneum. We conducted a systematic review to establish the current evidence base for the use of the AIRSEAL® insufflation device for low-pressure pneumoperitoneum in laparoscopic surgery. We searched the literature using several electronic databases, for studies with comparative design published in the English language from January 2010 to April 2020. The population of interest included patients with any type of health condition who underwent laparoscopic surgery using the AIRSEAL® insufflation system or a standard CO2 insufflator. Ten studies (four randomized clinical trials/six non-randomized clinical trials), that enrolled 1394 participants in total who underwent urology, gynaecology or abdominal surgeries, were included. Total complication rates were similar between groups. Only three studies evaluated the impact of the insufflation system on post-operative pain, and showed inconsistent benefit of AIRSEAL® (significant decrease in pain in two studies, no difference in one). The same was observed in the two sole studies in which pain killers consumption was measured (significant decrease in morphine consumption 24 h after surgery in one study, no difference in the other). Operative duration was significantly shorter with AIRSEAL® in three studies. For both post-operative room and total length of stay, there was no difference between groups. No studies reported economic outcomes. Current literature supports the feasibility of the AIRSEAL® system during laparoscopic surgery but more studies are required to establish the added clinical benefit and to explore the preferences of physicians and patients.
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Affiliation(s)
- David Balayssac
- INSERM, U1107, NEURO-DOL, Université Clermont Auvergne, 63000, Clermont-Ferrand, France. .,Délégation à la Recheche Clinique et à l'Innovation, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France.
| | - Marie Selvy
- INSERM, U1107, NEURO-DOL, Université Clermont Auvergne, 63000, Clermont-Ferrand, France.,Service de Chirurgie Digestive, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Anthony Martelin
- Service Pharmacie, Unité des dispositifs médicaux, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69000, Lyon, France
| | - Caroline Giroudon
- Service de Documentation Centrale, Hospices Civils de Lyon, 69000, Lyon, France
| | - Delphine Cabelguenne
- Service Pharmacie, Unité des dispositifs médicaux, Hospices Civils de Lyon, Hôpital Lyon Sud, 69000, Lyon, France
| | - Xavier Armoiry
- Délégation à la Recheche Clinique et à l'Innovation, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France.,Faculté de Pharmacie (ISPB), UMR CNRS 5510 MATEIS, Université de Lyon, 69000, Lyon, France.,Division of Health Sciences, University of Warwick, Coventry, UK
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Chadi SA, Guidolin K, Caycedo-Marulanda A, Sharkawy A, Spinelli A, Quereshy FA, Okrainec A. Current Evidence for Minimally Invasive Surgery During the COVID-19 Pandemic and Risk Mitigation Strategies: A Narrative Review. Ann Surg 2020; 272:e118-e124. [PMID: 32675513 PMCID: PMC7268822 DOI: 10.1097/sla.0000000000004010] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks. SUMMARY BACKGROUND DATA The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action. METHODS We conducted a narrative review of the existing literature surrounding the risks of viral transmission during laparoscopic surgery and balance these risks against the benefits of minimally invasive approaches. We also propose mitigation measures to address these risks that we have adopted in our institution. RESULTS AND CONCLUSION While it is currently assumed that open surgery minimizes operating room staff exposure to the virus, our findings reveal that this may not be the case. A well-informed, evidence-based opinion is critical when making decisions regarding which operative approach to pursue, for the safety and well-being of the patient, the operating room staff, and the healthcare system at large. Minimally invasive surgical approaches offer significant advantages with respect to both patient care, and the mitigation of the risk of viral transmission during surgery, provided the appropriate equipment and expertise are present.
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Affiliation(s)
- Sami A Chadi
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Keegan Guidolin
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | | | - Abdu Sharkawy
- Department of Medicine, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milano, Italy
| | - Fayez A Quereshy
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
| | - Allan Okrainec
- Department of Surgery, Faculty of Medicine, University of Toronto and University Health Network, Toronto, Canada
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