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1084	www.anesthesia-analgesia.org	 November 2014 • Volume 119 • Number 5
Copyright © 2014 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000316
T
he number of laparoscopic procedures is increasing
with laparoscopic cholecystectomy being one of the
most common procedures. Laparoscopic cholecystec-
tomy is normally performed with an intraabdominal pres-
sure of 12 to 15 mm Hg, but a pneumoperitoneum <12 to
15 mm Hg is associated with less postoperative pain1
and
fewer adverse effects on pulmonary function2
and hemo-
dynamics.3
However, the impact of decreasing the intraab-
dominal pressure on surgical space conditions and safety
has not been well established.
Neuromuscular blocking drugs are used during laparo-
scopic surgery to improve surgical exposure. The degree of
neuromuscular blockade is measured at the adductor pol-
licis muscle.4
However, this muscle may show no response
to train-of-four (TOF) stimulation, while the diaphragm and
muscles in the abdominal wall have partly recovered from
the neuromuscular blockade,5–7
resulting in inadequate
BACKGROUND: Laparoscopic cholecystectomy performed during low intraabdominal pressure
(<12 mm Hg) is associated with significantly less postoperative pain than standard pressure
(≥12 mm Hg). The impact on surgical space conditions and safety of operating at lower pres-
sures has not been adequately described, but deep neuromuscular blockade may be beneficial.
We investigated if deep muscle relaxation would be associated with a higher proportion of
procedures with “optimal” surgical space conditions compared with moderate relaxation during
low-pressure (8 mm Hg) laparoscopic cholecystectomy.
METHODS: In this assessor-blinded study, 48 patients undergoing elective laparoscopic cho-
lecystectomy were administered rocuronium for neuromuscular blockade and randomized to
either deep neuromuscular blockade (rocuronium bolus plus infusion maintaining a posttetanic
count 0–1) or moderate neuromuscular blockade (rocuronium repeat bolus only for inadequate
surgical conditions with spontaneous recovery of neuromuscular function). Patients received
anesthesia with propofol, remifentanil, and rocuronium. The primary outcome was the propor-
tion of procedures with optimal surgical space conditions (assessed by the surgeon as 1 on a
4-point scale). Secondary outcomes included the proportion of procedures completed at pneu-
moperitoneum 8 mm Hg and surgical space conditions on dissection of the gallbladder (numeric
rating scale 0–100; 0 = optimal surgical space conditions; 100 = unacceptable surgical space
conditions).
RESULTS: Optimal surgical space conditions during the entire procedure were observed in 7
of 25 patients allocated to deep neuromuscular blockade and in 1 of 23 patients allocated to
moderate blockade (P = 0.05) with an absolute difference of 24% between the groups (95%
confidence interval, 4%–43%). Laparoscopic cholecystectomy was completed at pneumoperito-
neum 8 mm Hg in 15 of 25 and 8 of 23 patients in the deep and moderate group, respectively
(95% confidence interval, −2% to 53%; P = 0.08). Surgical space conditions during dissection
of the gallbladder assessed by use of the numeric rating scale were 20 (10–50) (median [25%–
75% range]) in the deep neuromuscular blockade group and 30 (10–50) in the moderate group
(P = 0.58; Wilcoxon-Mann-Whitney odds, 1.2; 95% confidence interval, 0.6–2.5). No operations
were converted to laparotomy.
CONCLUSIONS: Deep neuromuscular blockade was associated with surgical space conditions
that were marginally better than with moderate muscle relaxation during low-pressure laparo-
scopic cholecystectomy.  (Anesth Analg 2014;119:1084–92)
Surgical Space Conditions During Low-Pressure
Laparoscopic Cholecystectomy with Deep Versus
Moderate Neuromuscular Blockade: A Randomized
Clinical Study
Anne K. Staehr-Rye, MD,* Lars S. Rasmussen, MD, PhD, DMSc,† Jacob Rosenberg, MD, DMSc,‡
Poul Juul, MD,§ Astrid L. Lindekaer, MD,|| Claus Riber, MD,§ and Mona R. Gätke, MD, PhD*
From the *Department of Anesthesiology, University of Copenhagen,
Herlev Hospital, Herlev; †Department of Anesthesia, Centre of Head and
Orthopedics, University of Copenhagen, Rigshospitalet, Copenhagen;
‡Department of Surgery, University of Copenhagen, Herlev Hospital,
Herlev; and Departments of §Surgery and ||Anesthesia, Aleris-Hamlet
Hospital, Soeborg, Denmark.
Accepted for publication April 21, 2014.
Funding: Supported by the University of Copenhagen, Denmark (to ­AKS-R),
The Sophus Johansens Foundation of 1981, Copenhagen, Denmark (to AKS-R),
Tryg Foundation, Lyngby, Denmark (to LSR), and The Lippmann Foundation,
Copenhagen, Denmark (to AKS-R). This work was also supported in part by a
research grant from the Investigator Initiated Studies Program of Merck Sharp
& Dohme Corp (to MRG). The opinions expressed in this paper are those of the
authors and do not necessarily represent those of Merck Sharp & Dohme Corp.
Conflict of Interest: See Disclosures at the end of the article.
Reprints will not be available from the authors.
Address correspondence to Anne K. Staehr-Rye, MD, Department of Anes-
thesiology, University of Copenhagen, Herlev Hospital, Herlev Ringvej 75,
Herlev DK-2730, Denmark. Address e-mail to akstaehr1@hotmail.com.
Section Editor: Peter S. A. Glass
Society for Ambulatory Anesthesiology
01
06/04/2015
Mdl. User
 
November 2014 • Volume 119 • Number 5	 www.anesthesia-analgesia.org	 1085
abdominal muscle relaxation during abdominal surgery. With
the establishment of deep, continuous neuromuscular block-
ade, defined as a posttetanic count (PTC) of 0 to 1, all muscles
will be paralyzed.8
This may optimize surgical space condi-
tions during low-pressure laparoscopic cholecystectomy.
To the authors’ knowledge, no published studies have
investigated the impact of muscle relaxation on surgical con-
ditions during low-pressure laparoscopic surgery, and only
few have investigated this aspect during standard-pressure
laparoscopic surgery.9–14
One study reported a difference in
the proportion of adequate pneumoperitoneum between
muscle relaxation (100%) and no muscle relaxation (72%) in 40
patients undergoing gynecological laparoscopic surgery, but
the degree of neuromuscular blockade was not described.14
We designed this study to assess the effect of deep, con-
tinuous neuromuscular blockade on surgical space condi-
tions during low-pressure laparoscopic cholecystectomy.
We hypothesized that deep, continuous neuromuscular
blockade compared to moderate blockade was associated
with a higher proportion of procedures with “optimal”
­surgical space conditions as assessed by the surgeon.
METHODS
This investigator-initiated, randomized, assessor-blinded
study was approved by the Danish Medicines Agency and
the Regional Ethics Committee. The study (NCT01523886)
was registered at ClinicalTrials.gov (January 19, 2013) before
enrollment of the first patient. Written informed consent was
obtained from all patients. Eligible patients were ≥18 years
of age and scheduled for elective laparoscopic cholecystec-
tomy. Women had to be postmenopausal, surgically steril-
ized, or use reliable birth control. Exclusion criteria were
allergy to rocuronium or sugammadex, indication for rapid
sequence induction, pregnancy or breastfeeding, known
neuromuscular disorders that might impair neuromuscular
blockade, and significant liver or renal dysfunction. Female
patients, who were not postmenopausal or surgically steril-
ized, had to provide a negative urine pregnancy test within
24 hours before surgery.
Included patients were randomized immediately before
arrival in the operating room by a computer randomiza-
tion system to ensure adequate allocation concealment.
The computer-generated randomization sequence allocated
patients to either deep, continuous neuromuscular blockade
or moderate neuromuscular blockade with stratification for
body mass index (<30 vs ≥30 kg/m2
).
A standardized protocol emphasized optimal periop-
erative care15
including ventilatory strategy, fluid ther-
apy, antibiotics, adequate temperature control as well as
administration of analgesics and antiemetics. Anesthesia
was induced with propofol 2 mg/kg and remifentanil
0.5 μg/kg/min IV. Anesthesia was maintained with IV infu-
sion of propofol and remifentanil and adjusted under guid-
ance of entropy (Entropy Sensor, GE Healthcare, Hillerød,
Denmark) and arterial blood pressure.
Neuromuscular monitoring was performed with accel-
eromyography (TOF-Watch SX®
, MSD, Ballerup, Denmark)
connected to a computer using the software TOF-Watch
SX (version 2.5 INT 2007, Organon, Oss, The Netherlands)
in accordance with “Good Clinical Research Practice in
Pharmacodynamic Studies of Neuromuscular Blocking
Agents II.”4
The study arm was immobilized and a preload
was placed on the thumb for monitoring acceleration (Hand
Adapter®
, MSD).
After calibration and stabilization of the TOF-Watch,
tracheal intubation was facilitated with rocuronium
0.3 mg/kg IV in both groups, which is the standard practice
at the institution. Moreover, in patients allocated to deep
muscle relaxation, an IV bolus of rocuronium (0.7 mg/kg)
was given 2 minutes after the first dose, which was imme-
diately before tracheal intubation. An IV infusion with
rocuronium (3–4 mg/kg/h) was started when the PTC was
>0, with titration toward PTC 0 to 1. PTC was measured
every 3 to 4 minutes. In patients allocated to the moderate
blockade group, no additional rocuronium was given imme-
diately before intubation, but a similar volume of saline
was given, and an infusion of saline 0.9% (0.3 mL/kg/h)
was started approximately 20 to 30 minutes later. PTC was
measured every 3 to 4 minutes, and TOF measurement was
made every 15 seconds. In the moderate blockade group,
no further rocuronium was administered unless as per pro-
tocol (see below) surgical space conditions were assessed
as inadequate at 12 mm Hg. Neuromuscular function was
therefore allowed to recover spontaneously.
Pneumoperitoneum was obtained with insufflation of
CO2 through a Veress needle to 12 mm Hg, but reduced to 8
mm Hg after the introduction of the 4 trocars. After insuffla-
tion, patients were positioned in 20° reverse Trendelenburg
verified by angle measurement.
All laparoscopies were performed by 1 of 2 experienced
surgeons, and they were asked to evaluate surgical space
conditions with modification of a 4-point scale previously
used by others9,14,16,17
: grade 1 (optimal) = optimal surgical
space conditions; grade 2 (good) = nonoptimal conditions,
but an intervention was not considered; grade 3 (accept-
able) = an intervention was considered to improve surgical
space; grade 4 (poor) = inadequate conditions and an inter-
vention was necessary to ensure acceptable surgical space.
They also rated surgical space conditions on a numeric
rating scale (NRS), where NRS 0 indicated optimal surgi-
cal space conditions and NRS 100 indicated unacceptable
surgical space conditions and an intervention was needed
to secure acceptable surgical space. The assessments were
made during dissection of the gallbladder and at the end of
the surgery, based on overall space conditions as well as the
time during surgery, when surgical space conditions were
determined as worst.
In case of inadequate surgical space conditions, the fol-
lowing 3-step intervention procedure was used in both
groups:
1.  Increase of preset intraabdominal pressure to 12 mm Hg.
2.  If still inadequate, patients allocated to moderate
muscle relaxation were given a bolus of rocuronium
(0.6 mg/kg) IV. Patients allocated to deep muscle relax-
ation were given an equivalent volume of 0.9% NaCl.
3.  If still not adequate, the surgeon would decide accord-
ing to usual clinical practice.
If any of the above-mentioned interventions were
required, surgical space conditions were automatically
1086   www.anesthesia-analgesia.org anesthesia  analgesia
Optimizing Surgical Space Conditions
rated as 4 (4-point scale) and 100 (NRS) in the assessment,
based on the time of surgery when surgical space conditions
were determined as worst.
Sugammadex 2 to 8 mg/kg IV was given at the end of
surgery, if the TOF ratio was 0.90.15
Endotracheal extubation
was only performed when the patients were fully awake and
had a stable T1 response between 80% and 120%, a TOF ratio
≥0.90 and a variation of the T1 response ≤5% for 2 minutes.
At the end of the surgery, the surgeon was asked if any sur-
gical difficulties had occurred. Moreover, the patients’ charts
were reviewed to assess whether macroscopic cholecystitis,
adhesions, or any other surgical difficulties had been described.
The primary outcome was the proportion of procedures
with optimal surgical space conditions during the entire pro-
cedure (assessed as 1 on the 4-point scale based on the time
of surgery, when surgical space conditions were determined
as worst). The secondary outcomes were surgical space con-
ditions based on the time of surgery, when surgical space
conditions were determined as worst (NRS), on dissection
of the gallbladder (4-point scale and NRS) and overall sur-
gical space conditions as an average of the entire procedure
(4-point scale and NRS), proportion of laparoscopies per-
formed with an intraabdominal pressure of 8 mm Hg, and
duration of surgery and anesthesia. Other outcomes were
pain expressed as the area under the curve from the first
postoperative assessment to 1 week after surgery, pain at
arrival in the postoperative care unit, 2 hours after surgery
and 1 day after surgery, postoperative consumption of anal-
gesics, antiemetics, and incidence of postoperative nausea
and/or vomiting up to 24 hours after surgery, and number
of days after surgery before resumption of normal activity.
Before surgery, all included patients were carefully
instructed by the same investigator in use of a visual analog
scale (VAS). Pain was evaluated as abdominal pain, incisional
pain, shoulder pain, and overall pain using VAS (VAS 0 = no
pain, 100 = worst possible pain). Each assessment was done
at rest and during mobilization. Patients were discharged on
the day of surgery. A questionnaire was given to the patients
to be completed every morning after discharge from hospital
and until they experienced no pain. The same investigator
contacted the patient on the first postoperative day and again
1 week after surgery to ensure that postoperative pain assess-
ment was made and to assess any discomfort. Any adverse
event or reaction developed within the first 21 postoperative
days was recorded. An adverse event or reaction was consid-
ered serious if it was fatal, life threatening, caused permanent
disability, or required prolonged hospitalization.
The surgeons, surgical staff, patients, personnel in the
postoperative care unit as well as the investigator collecting
postoperative data were blinded to group allocation. In a sep-
arate room, syringes containing rocuronium, sugammadex,
and NaCl were prepared. The patient’s hand with the neu-
romuscular monitoring equipment and the connecting neu-
romuscular monitor were covered to keep the surgical team
blinded to group allocation. However, the investigator who
gave rocuronium was able to follow the level of neuromus-
cular blockade via a connected computer using the software
TOF-Watch SX (version 2.5 INT 2007, Organon). Information
about group allocation, administered doses of rocuronium
and sugammadex, and neuromuscular data were recorded
on a separate form and placed in a sealed opaque envelope
when the patient left the operating room. After the end of
surgery, the surgeon was asked which group he/she believed
the patient was allocated to and to indicate why. The patient
was asked the same questions on postoperative day 7.
Thestudywasmonitoredbyanindependentinspectorfrom
the department of Good Clinical Practice, Bispebjerg, Denmark
and conducted according to the International Conference on
Harmonization/Good Clinical Practice guidelines.
Statistical Analysis
All outcomes were reported with median (interquar-
tile range) or number (%) and compared with the Mann-
Whitney U test, the χ2
test, or the Fisher exact test. The
Wilcoxon-Mann-Whitney odds and 95% confidence inter-
vals were calculated for the continuous outcomes.18,19
A
P value of 0.05 was considered statistically significant.
Analyses were performed using SAS statistical software
version 9.2 (SAS Institute Inc., Cary, NC).
A difference in the proportion of adequate pneumo-
peritoneum of 28% was previously found between no
muscle relaxation (72%) and muscle relaxation (100%) in
laparoscopic surgery.14
We calculated that a sample size of
48 patients would allow us to detect a clinically relevant dif-
ference of 28% in the proportion of optimal surgical space
conditions during the entire procedure with a power of 80%
and a type 1 error risk of 5%.
RESULTS
Forty-eight patients were included and received the inter-
vention (Fig. 1). Demographic and perioperative character-
istics were similar in the 2 groups (Table 1, Fig. 2).
The intended depth of neuromuscular blockade was
achieved during 91% (median; range, 70%–100%) of the proce-
dure from surgical incision to administration of sugammadex
in the deep group (PTC, 0–1). In the moderate group, a TOF
count ≥2 was present during 87% (median; range, 67%–100%)
of the procedure. Neuromuscular data are shown in Table 2.
Optimal surgical space conditions during the entire pro-
cedure were found in 7 of 25 (28%) patients allocated to deep
blockade and in 1 of 23 (4%) patients allocated to moderate
blockade (P = 0.05) with an absolute difference of 24% between
the groups (95% confidence interval, 0.04–0.43; Table 3).
Laparoscopic cholecystectomy was completed at pneu-
moperitoneum 8 mm Hg in 15 (60%) patients in the deep
group compared with 8 (35%) patients in the moderate group,
respectively (95% confidence interval, −0.02 to 0.53; P = 0.08).
Twenty-five patients had pneumoperitoneum increased to
12 mm Hg due to inadequate surgical space conditions. PTC
was 0 to 1 in 7 of 8 (88%) of the patients in the deep group
when the pneumoperitoneum was increased and TOF count
was ≥2 in 12 of 13 (92%) of the patients in the moderate group
when the pressure was increased. Data were missing in 4
patients. In the moderate group, 3 patients coughed during
the recruitment maneuvers at the end of surgery, but no other
signs of poor relaxation were seen. The median duration of
anesthesia and postoperative hospitalization was 60 and 230
minutes in patients in the deep group and 58 and 236 minutes
in the moderate group (P = 0.77 and P = 0.60).
We conducted correlation analyses to assess concur-
rent validity of the 4-point scale and the NRS (Table 4). A
 
November 2014 • Volume 119 • Number 5	 www.anesthesia-analgesia.org	 1087
logistic regression analysis showed that none of the fol-
lowing factors was predictive of inferior surgical space
conditions based on the time during surgery, when surgi-
cal space conditions were determined as worst: male, age
60 years, previous intraabdominal surgery and cholecys-
titis (Table 5).
Forty-three of 48 patients had returned the question-
naire by postoperative day 21. There were no significant
differences in postoperative pain between the 2 groups. The
median consumption of oxycodone within 24 hours postop-
eratively was 20 mg in both groups. The median number of
days after surgery before resumption of normal activity was
6 and 5 days in the deep and moderate group, respectively
(P  =  0.29). There were no significant differences in post-
operative nausea, vomiting, or administered ondansetron
within 24 hours postoperatively.
There were no major anesthetic or surgical intraopera-
tive complications, and no procedure was converted to open
surgery. Overall, 48% of the patients experienced an adverse
event in the follow-up period. Serious adverse events were
seen in 4 patients: prolonged hospitalization due to postop-
erative observation (2 patients) and readmission to hospital
because of pain from undiagnosed gallstones in the com-
mon bile duct (2 patients). There were no reported adverse
reactions or serious adverse reactions considered related to
rocuronium or sugammadex by the investigators.
The surgeons correctly identified 20 of 48 patients’ alloca-
tion and 12 of the 48 patients correctly identified their alloca-
tion. There were no indications of unblinding in their answers.
DISCUSSION
Deep, continuous neuromuscular blockade was associated
with surgical space conditions that were marginally better
than with moderate muscle relaxation during low-pressure
laparoscopic cholecystectomy. There tended to be more pro-
cedures completed at 8 mm Hg in the deep muscle relax-
ation group than in the moderate group.
Forty-eight percent of laparoscopies were successfully
completed at 8 mm Hg, which is less than the success rates
of approximately 70% to 100% previously reported in stud-
ies comparing pain after low- and standard-pressure laparo-
scopic cholecystectomy.20–23
However, in the present study,
the proportion of patients having acute or chronic inflam-
mation of the gallbladder was relatively high (50%) com-
pared with previous studies (18%),20
which may explain the
need for better exposure. The lower completion rate at 8 mm
Hg in our study may also have been caused by a less restric-
tive inclusion of patients. Some of the previous studies only
included patients with uncomplicated symptomatic gall-
stones and excluded patients with previous upper abdomi-
nal surgery.20,21
Also, the level of neuromuscular blockade
was not described uniformly in the previous studies. Other
Patients planned for elective laparoscopic
cholecystectomy and assessed for eligibility
(n=87)
Not enrolled (n=38)
Refusal (n=15)
Unable to informed consent (n=1)
Indication for rapid sequence induction (n=9)
No available investigators (n=13)
Other reasons (n=0)
Randomized (n=49)
BMI 30 kg/m2
(n=13)
Allocated to moderate neuromuscular blockade (n=24)
Received intervention (n=23)
Did not receive intervention (n=1)
Reason
- Surgery cancelled
Allocated to deep neuromuscular blockade (n=25)
Received intervention (n=25)
Included in the intention-to-treat analysis (n=23)
of
- surgical space conditions when they were worst
- overall surgical space conditions
- surgical space conditions during dissection
- proportion of procedures performed
at PnP 8 mmHg
Procedures completed at PnP 8 mmHg (n=8)
PnP increased to 12 mmHg (n=15)
Before dissection of GB (n=7)
After dissection of GB (n=7)
Missing data (n=1)
Required deep NMB (n=3)
PnP increased to 12 mmHg (n=1)
Procedures completed at PnP 8 mmHg (n=15)
PnP increased to 12 mmHg (n=10)
Before dissection of GB (n=7)
During dissection of GB (n=1)
After dissection of GB (n=2)
Required deep NMB (n=2)
PnP increased to 12 mmHg (n=2)
Included in the intention-to-treat analysis (n=25)
of
- surgical space conditions when they were worst
- overall surgical space conditions
- surgical space conditions during dissection
- proportion of procedures performed
at PnP 8 mmHg
Figure 1. Trial profile. BMI = body mass index;
PnP = pneumoperitoneum; GB = gallbladder.
1088   www.anesthesia-analgesia.org anesthesia  analgesia
Optimizing Surgical Space Conditions
influential factors could have been administration of total
IV anesthesia instead of inhaled anesthesia, blinding of the
surgeons, and other surgical difficulties experienced intra-
operatively including adhesions and increased amount of
intraabdominal fat. Moreover, the surgeons in our study
were not familiar with low-pressure laparoscopic surgery
before beginning the study. However, we found no signifi-
cant difference between the first 24 and the last 24 proce-
dures or between the 2 surgeons with respect to successfully
completed procedures at low-pressure pneumoperitoneum.
Many factors contribute to pain after laparoscopic cho-
lecystectomy with pain coming from the incision sites, the
dissected viscera, and from the pneumoperitoneum. The
exact mechanism of pain related to pneumoperitoneum
has not been clarified. Low-pressure pneumoperitoneum
has been associated with significantly less postoperative
pain,1,20,21,24
including shoulder tip pain.20,22,24,25
We found no
difference in postoperative pain characteristics or incidence
of postoperative nausea or vomiting between patients, who
had received a deep or a moderate neuromuscular blockade
during laparoscopic cholecystectomy, but the results may
have been impacted by the need to increase the intraab-
dominal pressure when exposure was inadequate.
Neuromuscular blockade is often used during lapa-
roscopic surgery to improve surgical space conditions,
but only few studies have focused on defining optimal or
necessary muscle relaxation in the context of abdominal
surgical space conditions. To our knowledge, only 7 stud-
ies have described the association between neuromuscu-
lar blockade and surgical conditions during laparoscopic
surgery,9–14,26
and only 3 reported the actual degree of mus-
cle relaxation.9,13,26
Traditionally, a TOF count of the adduc-
tor pollicis muscle between 1 and 2 has been associated with
adequate surgical relaxation.27
However, the clinical situa-
tion in which abdominal muscle and diaphragmatic relax-
ation seems inadequate despite minimal response of the
adductor pollicis to ulnar nerve stimulation is frequently
encountered. This may primarily be explained by the effects
of neuromuscular blocking drugs being muscle dependent6
;
the diaphragm shows a lower peak effect5,7,28
and a more
rapid recovery5,7,28–31
of a given dose of a neuromuscular
blocking drug than the adductor pollicis muscle. The lateral
abdominal muscles have a time course somewhere between
the diaphragm and the adductor pollicis regarding sen-
sitivity and time to recovery.7
Therefore, there may be no
response of the adductor pollicis muscle to TOF stimulation,
while the diaphragm and the muscles in the abdominal wall
have recovered partly from the neuromuscular blockade. To
ensure total paralysis of the diaphragm, the neuromuscular
blockade measured at the adductor pollicis muscle should
be intense, that is, PTC = 0. The results of our study indi-
cate that deep, continuous muscle relaxation optimizes the
surgical space conditions compared with moderate muscle
relaxation during low-pressure laparoscopic cholecystec-
tomy, although it is not effective in all patients. Thus, 60% of
patients in the deep group had optimal to acceptable condi-
tions compared with 35% in the moderate group.
To evaluate surgical space conditions, we used the
4-point scale as well as a NRS. It is, however, a limitation
that these scales have not been validated for assessment
Table 1.  Characteristics of 48 Patients Who Underwent Laparoscopic Cholecystectomy
Deep NMB
(n = 25)
Moderate NMB neuromuscular block group
(n = 23)
Age (y) 45 (42–49) 48 (35–59)
Gender (male:female) 10:15 6:17
BMI (kg/m2
) 27 (24–29) 26 (22–31)
BMI ≥30.0 kg/m2
6 (24%) 7 (30%)
ASA physical status category (I:II:III) 22:3:0 20:3:0
Coexisting disease 5 (20%) 8 (35%)
Previous intraabdominal surgery 10 (40%) 9 (39%)
Previous upper abdominal surgery 0 1 (4%)
Crystalloid infused (mL) 500 (350–690) 500 (350–700)
Estimated blood loss (mL) 10 (5–18) 10 (5–20)
Acute cholecystitis 5 (20%) 2 (9%)
Chronic cholecystitis 12 (48%) 10 (43%)
Surgical difficulties due to
 Adhesions 3 (12%) 5 (22%)
 Intraabdominal obesity 4 (16%) 2 (9%)
 Other reasons 5 (20%)a
9 (43%)
  Anatomic abnormalities 2 3
  Poor placement of the trocars 1 2
  Serosa lesion 0 1
  Bleeding from liver bed 0 2
  Diffuse bleeding 1 0
  Big/multiple gall stones 2 1
Bile leak into the peritoneal cavity 5 (20%) 5 (22%)
Rocuronium dose (mg) 80 (71–91) 21 (18–23)
Sugammadex dose (mg) 380 (330–440) 120 (0–170)
Propofol dose (mg) 474 (446–566) 430 (410–570)
Remifentanil dose (μg) 3390 (2736–4290) 2940 (2544–4200)
Data are median (interquartile range) or number of patients (%).
NMB = neuromuscular blockade; BMI = body mass index.
a
Two types of surgical difficulties in 1 subject.
 
November 2014 • Volume 119 • Number 5	 www.anesthesia-analgesia.org	 1089
of surgical space conditions. The correlation analyses
indicated concurrent validity of the 4-point scale and
the NRS, even though the evaluation of surgical space
conditions could be influenced by other factors. There
were more patients with cholecystitis and of male gen-
der in the deep relaxation group, which together with
previous upper abdominal surgery, advanced age (60
years), and higher body weight (65 kg) has been asso-
ciated with increased risk of converting laparoscopic
cholecystectomy to open surgery.32,33
However, a logis-
tic regression analysis showed no significant impact of
sex, cholecystitis, previous abdominal surgery, or age
on the primary outcome. All patients received a small
dose of rocuronium (0.3 mg/kg) to facilitate tracheal
intubation. This was the only dose given to the moder-
ate group, because it is the standard regime for lapa-
roscopic cholecystectomy at the institution. Completely
omitting giving rocuronium to patients in the control
group could have allowed a better separation regarding
surgical space conditions but could also have impaired
tracheal intubation conditions. Most importantly, there
was a clear separation in the degree of neuromuscular
blockade between the 2 groups during dissection of the
gallbladder as well as in the situations where the pneu-
moperitoneum was increased.
We assessed the effect of deep, continuous muscle
relaxation compared with moderate neuromuscular
blockade on abdominal surgical space conditions during
low-pressure laparoscopic cholecystectomy, for which
surgical conditions and safety have not been adequately
described. All laparoscopies were performed by only
2 surgeons, each with 10 years of surgical experience
and 1000 performed laparoscopic cholecystectomies,
which reduces the variability in assessment of surgical
space conditions. Two experts conducted neuromuscular
monitoring in accordance with “Good Clinical Research
Practice in Pharmacodynamic Studies of Neuromuscular
Blocking Agents II.”4
All patients scheduled for laparo-
scopic cholecystectomy during the study period were
consecutively evaluated for fulfillment of inclusion and
exclusion criteria regardless of age, gender, or body mass
index. All randomized, evaluable patients had a thorough
follow-up with assessment of adverse intra- and post-
operative events. We therefore believe that the results of
this study are applicable to a general surgical population
undergoing low-pressure laparoscopic cholecystectomy
performed by experienced surgeons; however, the results
may not be generalizable to standard-pressure laparo-
scopic cholecystectomy, other laparoscopic procedures, or
other types of anesthesia.
In conclusion, we found that the proportion of opti-
mal surgical space conditions with deep neuromuscular
blockade was marginally greater than with moderate
muscle relaxation during low-pressure laparoscopic cho-
lecystectomy. However, intraabdominal pressure was
increased from 8 to 12 mm Hg in approximately half of
the procedures to secure acceptable surgical space condi-
tions. E
Blood pressure
0
20
40
60
80
100
120
140
160
mmHg
Heart rate
0
10
20
30
40
50
60
70
80
90
beatsprmin
Deep neuromuscular blockade
Systolic pressure
Diastolic pressure
Heart rate
Moderate neuromuscular blockade
Systolic pressure
Diastolic pressure
Heart rate
Tpre
Tinc
T25%
T50%
T75%
Tend
Tpre
Tinc
T25%
T50%
T75%
Tend
Figure 2. Hemodynamic changes in patients
undergoing low-pressure laparoscopic cholecys-
tectomy with deep or moderate neuromuscular
blockade. Values are medians and interquar-
tile range (error bars). Time measurements:
Tpre = preoperatively; Tinc = at surgical incision;
T25% = at 25% of surgical duration; T50% = at
50% of surgical duration; T75% = at 75% of surgi-
cal duration; Tend = at end of surgery.
Table 2.  Neuromuscular Data for 45 Patients Who
Underwent Laparoscopic Cholecystectomy
Time point
Deep NMB
(n = 25)
Moderate NMB
(n = 20)
At surgical incision PTC0 (PTC0–TOF4) T1 0 (0–8)
At 25% of duration of surgery PTC0 (PTC0–PTC1) T1 10 (0–76)
At 50% of duration of surgery PTC0 (PTC0–PTC4) T1 47 (17–103)
At 75% of duration of surgery PTC1 (PTC0–PTC10) T1 89 (61–108)
At end of surgery T1 93 (0–103) T1 99 (96–103)
Data are median (range). Three patients are missing in the moderate group
because they received a deep neuromuscular blockade due to unacceptable
surgical space conditions at pneumoperitoneum 12 mm Hg.
NMB = neuromuscular blockade; PTC = posttetanic count; T1 = normalized
T1 response in %.
1090   www.anesthesia-analgesia.org anesthesia  analgesia
Optimizing Surgical Space Conditions
DISCLOSURES
Name: Anne K. Staehr-Rye, MD.
Contribution: This author helped in study design, patient
recruitment, data collection, data analysis, and writing of the
first draft of the manuscript.
Attestation: Anne K. Staehr-Rye approved the final manuscript
and is the archival author.
Conflicts of Interest: The author has no conflicts of interest to
declare.
Name: Lars S. Rasmussen, MD, PhD, DMSc.
Contribution: This author helped in study design, data analy-
sis, and critical revision.
Attestation: Lars S. Rasmussen approved the final manuscript.
Conflicts of Interest: Spouse has received payments and travel
funding for lectures from MSD. Total funding was approxi-
mately €8700. Spouse has received investigator-initiated
research funding of €93,800 from MSD.
Table 4.  Rank Correlation of Surgical Space Conditions in Patients Who Underwent Laparoscopic
Cholecystectomy
Surgical space conditions
when they were worst on 4-point
scale in all patients (n = 48)
Surgical space conditions when they were worst
on 4-point scale in patients, who had their whole
procedure undertaken at 8 mm Hg (n = 23)
Surgical space conditions when less view on NRS r = 0.985 (P  0.0001) r = 0.878 (P  0.0001)
Pneumoperitoneum completed at 8 mm Hg r = 0.914 (P  0.0001)
Overall surgical space conditions on 4-point scale r = 0.561 (P  0.0001) r = 0.890 (P  0.0001)
Overall surgical space conditions on NRS r = 0.613 (P  0.0001) r = 0.813 (P  0.0001)
Surgical space conditions during dissection of the
GB on 4-point scale
r = 0.527 (P  0.0001) r = 0.771 (P  0.001)
Surgical space conditions during dissection of the
GB on NRS
r = 0.457 (P = 0.0011) r = 0.688 (P = 0.0003)
Duration of surgery r = 0.383 (P = 0.0073) r = 0.507 (P = 0.0097)
Data are Spearman correlation. First column includes all patients. Second column includes only patients, who had their whole procedure performed at 8 mm Hg.
Four-point scale: 0 = “optimal” surgical space conditions; 4 = poor surgical space conditions.
NRS = numeric rating scale (0 = “optimal” surgical space conditions; 100 = unacceptable surgical space conditions); GB = gallbladder.
Table 5.  A Logistic Regression Analysis of Inferior Surgical Space Conditions, Assessed at the Time During
Surgery When They Were Worst as the Dependent Variable in Patients Who Underwent Laparoscopic
Cholecystectomy
Variable Regression coefficient SE Wald χ2
P value Odds ratio (95% CI)
Sex (male) 0.091 0.50 0.032 0.86 1.20 (0.17–8.57)
Age (60 y) 0.191 0.59 0.104 0.74 1.47 (0.14–15.05)
Previous intraabdominal
surgery
0.230 0.44 0.277 0.60 1.58 (0.29–8.79)
Cholecystitis 0.650 0.47 1.883 0.17 3.67 (0.57–23.46)
The table shows a logistic regression analysis of inferior surgical space conditions assessed at the time during surgery when they were worst (1 on the 4-point
scale) as the dependent value and sex (male), age (60 y), previous intraabdominal surgery (yes) and cholecystitis, acute or chronic (yes) as the independent values.
CI = confidence interval.
Table 3.  Surgical Space Conditions in 48 Patients Who Underwent Laparoscopic Cholecystectomy
Deep NMB (n = 25) Moderate NMB (n = 23) P value WMWodds
“Optimal” surgical space conditions during the entire procedure 7 (28%) 1 (4%) 0.05  
Surgical space conditions when they were worst on 4-point scale 3 (1–4) 4 (2–4) 0.07 1.9 [1.0–3.8]
The distribution of surgical space conditions when they were
worst on 4-point scale (1/2/3/4)
7/3/5/10 1/5/2/15    
Surgical space conditions when they were worst on NRS 60 (10–100) 100 (40–100) 0.06 1.8 [1.0–3.8]
Procedure completed at 8 mm Hg 15 (60%) 8 (35%) 0.08  
Overall surgical space conditions on 4-point scale 2 (1–3) 2 (2–3) 0.97 1.0 [0.5–1.9]
The distribution of overall surgical space conditions on 4-point
scale (1/2/3/4)
8/7/10/0 4/13/6/0    
Overall surgical space conditions on NRS 40 (10–50) 30 (20–50) 0.7 1.1 [0.6–2.3]
Surgical space conditions during dissection of the GB on
4-point scale
2 (1–3) 2 (1–3) 0.91 1.0 [0.5–2.0]
The distribution of surgical space conditions during dissection
of the GB on 4-point scale (1/2/3/4)
9/7/8/1 6/11/4/2
Surgical space conditions during dissection of the GB on NRS 20 (10–50) 30 (10–50) 0.58 1.2 [0.6–2.5]
Duration of surgery (min) 40 (29–47) 36 (31–54) 0.93
Data are number of patients (%), median (interquartile range) or median [95% confidence interval]. Four-point scale: 0 = “optimal” surgical space conditions;
4 = poor surgical space conditions.
NMB = neuromuscular blockade; WMWodds = Wilcoxon-Mann-Whitney odds; NRS = numeric rating scale (0 = “optimal” surgical space conditions;
100 = unacceptable surgical space conditions); GB = gallbladder.
 
November 2014 • Volume 119 • Number 5	 www.anesthesia-analgesia.org	 1091
Name: Jacob Rosenberg, MD, DMSc.
Contribution: This author helped in study design, data analy-
sis, and critical revision.
Attestation: Jacob Rosenberg approved the final manuscript.
Conflicts of Interest: Jacob Rosenberg has been a member of
the advisory board in MSD.
Name: Poul Juul, MD.
Contribution: This author helped in study design, patient
recruitment, data collection, and critical revision.
Attestation: Poul Juul approved the final manuscript.
Conflicts of Interest: The author has no conflicts of interest to
declare.
Name: Astrid L. Lindekaer, MD.
Contribution: This author helped in study design, data collec-
tion, and critical revision.
Attestation: Astrid L. Lindekaer approved the final manuscript.
Conflicts of Interest: The author has no conflicts of interest to
declare.
Name: Claus Riber, MD.
Contribution: This author helped in patient recruitment, data
collection, and critical revision.
Attestation: Claus Riber approved the final manuscript.
Conflicts of Interest: The author has no conflicts of interest to
declare.
Name: Mona R. Gätke, MD, PhD.
Contribution: This author helped in study design, data collec-
tion, data analysis, and critical revision.
Attestation: Mona R. Gätke approved the final manuscript.
Conflicts of Interest: Mona R. Gätke has received payments
and travel funding for lectures from MSD. Total funding was
approximately €8700. Mona R. Gätke has received investiga-
tor-initiated research funding of €93,800 from MSD.
This manuscript was handled by: Peter S. A. Glass, MB, ChB.
REFERENCES
	1.	Gurusamy KS, Samraj K, Davidson BR. Low pressure versus
standard pressure pneumoperitoneum in laparoscopic chole-
cystectomy. Cochrane Database Syst Rev 2009;2:CD006930
	2.	Strang CM, Freden F, Maripuu E, Ebmeyer U, Hachenberg T,
Hedenstierna G. Improved ventilation-perfusion matching
with increasing abdominal pressure during CO(2) -pneumo-
peritoneum in pigs. Acta Anaesthesiol Scand 2011;55:887–96
	 3.	 Dexter SP, Vucevic M, Gibson J, McMahon MJ. Hemodynamic
consequences of high- and low-pressure capnoperitoneum dur-
ing laparoscopic cholecystectomy. Surg Endosc 1999;13:376–81
	 4.	 Fuchs-BuderT,ClaudiusC,SkovgaardLT,ErikssonLI,Mirakhur
RK, Viby-Mogensen J; 8th
International Neuromuscular
Meeting. Good clinical research practice in pharmacodynamic
studies of neuromuscular blocking agents II: the Stockholm
revision. Acta Anaesthesiol Scand 2007;51:789–808
	5.	Cantineau JP, Porte F, d’Honneur G, Duvaldestin P.
Neuromuscular effects of rocuronium on the diaphragm
and adductor pollicis muscles in anesthetized patients.
Anesthesiology 1994;81:585–90
	6.	Hemmerling TM, Donati F. Neuromuscular blockade at the
larynx, the diaphragm and the corrugator supercilii muscle: a
review. Can J Anaesth 2003;50:779–94
	7.	Kirov K, Motamed C, Dhonneur G. Differential sensitivity of
abdominal muscles and the diaphragm to mivacurium: an elec-
tromyographic study. Anesthesiology 2001;95:1323–8
	8.	Dhonneur G, Kirov K, Motamed C, Amathieu R, Kamoun
W, Slavov V, Ndoko SK. Post-tetanic count at adductor pol-
licis is a better indicator of early diaphragmatic recovery
than train-of-four count at corrugator supercilii. Br J Anaesth
2007;99:376–9
	9.	Chassard D, Bryssine B, Golfier F, Raupp C, Raudrant D,
Boulétreau P. Gynecologic laparoscopy with or without curare.
Ann Fr Anesth Reanim 1996;15:1013–7
	10.	 Chen BZ, Tan L, Zhang L, Shang YC. Is muscle relaxant neces-
sary in patients undergoing laparoscopic gynecological surgery
with a ProSeal LMA™? J Clin Anesth 2013;25:32–5
	11.	Kurer FL, Welch DB. Gynaecological laparoscopy: clini-
cal experiences of two anaesthetic techniques. Br J Anaesth
1984;56:1207–12
	12.	Swann DG, Spens H, Edwards SA, Chestnut RJ. Anaesthesia
for gynaecological laparoscopy–a comparison between the
laryngeal mask airway and tracheal intubation. Anaesthesia
1993;48:431–4
	13.	 Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation
of surgical conditions during laparoscopic surgery in patients
with moderate vs deep neuromuscular block. Br J Anaesth
2014;112:498–505
	14.	 Williams MT, Rice I, Ewen SP, Elliott SM. A comparison of the
effect of two anaesthetic techniques on surgical conditions dur-
ing gynaecological laparoscopy. Anaesthesia 2003;58:574–8
	15.	 Staehr-Rye AK, Rasmussen LS, Rosenberg J, Juul P, Gätke MR.
Optimized surgical space during low-pressure laparoscopy
with deep neuromuscular blockade. Dan Med J 2013;60:A4579
	16.	Salonia A, Crescenti A, Suardi N, Memmo A, Naspro R,
Bocciardi AM, Colombo R, Da Pozzo LF, Rigatti P, Montorsi F.
General versus spinal anesthesia in patients undergoing radical
retropubic prostatectomy: results of a prospective, randomized
study. Urology 2004;64:95–100
	17.	King M, Sujirattanawimol N, Danielson DR, Hall BA,
Schroeder DR, Warner DO. Requirements for muscle relax-
ants during radical retropubic prostatectomy. Anesthesiology
2000;93:1392–7
	18.	Divine G, Norton HJ, Hunt R, Dienemann J. Statistical grand
rounds: a review of analysis and sample size calculation con-
siderations for Wilcoxon tests. Anesth Analg 2013;117:699–710
	19.	Dexter F. Wilcoxon-Mann-Whitney test used for data that are
not normally distributed. Anesth Analg 2013;117:537–8
	20.	 Barczyński M, Herman RM. A prospective randomized trial on
comparison of low-pressure (LP) and standard-pressure (SP)
pneumoperitoneum for laparoscopic cholecystectomy. Surg
Endosc 2003;17:533–8
	21.	 Joshipura VP, Haribhakti SP, Patel NR, Naik RP, Soni HN, Patel
B, Bhavsar MS, Narwaria MB, Thakker R. A prospective ran-
domized, controlled study comparing low pressure versus high
pressure pneumoperitoneum during laparoscopic cholecystec-
tomy. Surg Laparosc Endosc Percutan Tech 2009;19:234–40
	22.	Sarli L, Costi R, Sansebastiano G, Trivelli M, Roncoroni L.
Prospective randomized trial of low-pressure pneumoperito-
neum for reduction of shoulder-tip pain following laparoscopy.
Br J Surg 2000;87:1161–5
	23.	Perrakis E, Vezakis A, Velimezis G, Savanis G, Deverakis S,
Antoniades J, Sagkana E. Randomized comparison between
different insufflation pressures for laparoscopic cholecystec-
tomy. Surg Laparosc Endosc Percutan Tech 2003;13:245–9
	24.	 Kandil TS, El Hefnawy E. Shoulder pain following laparoscopic
cholecystectomy: factors affecting the incidence and severity.
J Laparoendosc Adv Surg Tech A 2010;20:677–82
	25.	 Yasir M, Mehta KS, Banday VH, Aiman A, Masood I, Iqbal B.
Evaluation of post operative shoulder tip pain in low pressure
versus standard pressure pneumoperitoneum during laparo-
scopic cholecystectomy. Surgeon 2012;10:71–4
	26.	 Meyhoff CS, Lund J, Jenstrup MT, Claudius C, Sørensen AM,
Viby-Mogensen J, Rasmussen LS. Should dosing of rocuronium
in obese patients be based on ideal or corrected body weight?
Anesth Analg 2009;109:787–92
	27.	 Tammisto T, Olkkola KT. Dependence of the adequacy of mus-
cle relaxation on the degree of neuromuscular block and depth
of enflurane anesthesia during abdominal surgery. Anesth
Analg 1995;80:543–7
	28.	Moerer O, Baller C, Hinz J, Buscher H, Crozier TA.
Neuromuscular effects of rapacuronium on the diaphragm
and skeletal muscles in anaesthetized patients using cervical
magnetic stimulation for stimulating the phrenic nerves. Eur J
Anaesthesiol 2002;19:883–7
	29.	Dhonneur G, Kirov K, Slavov V, Duvaldestin P. Effects of an
intubating dose of succinylcholine and rocuronium on the lar-
ynx and diaphragm: an electromyographic study in humans.
Anesthesiology 1999;90:951–5
1092   www.anesthesia-analgesia.org anesthesia  analgesia
Optimizing Surgical Space Conditions
	30.	 Donati F, Meistelman C, Plaud B. Vecuronium neuromuscular
blockade at the diaphragm, orbicularis oculi and adductor pol-
licis muscles. Can J Anaesth 1990;37:S13
	31.	 Pansard JL, Chauvin M, Lebrault C, Gauneau P, Duvaldestin P.
Effect of an intubating dose of succinylcholine and atracurium
on the diaphragm and the adductor pollicis muscle in humans.
Anesthesiology 1987;67:326–30
	32.	Ibrahim S, Hean TK, Ho LS, Ravintharan T, Chye TN, Chee
CH. Risk factors for conversion to open surgery in patients
undergoing laparoscopic cholecystectomy. World J Surg
2006;30:1698–704
	33.	Thesbjerg SE, Harboe KM, Bardram L, Rosenberg J. Sex dif-
ferences in laparoscopic cholecystectomy. Surg Endosc
2010;24:3068–72
Annotations
Surgical space conditions during low-pressure laparoscopic
cholecystectomy with deep versus moderate neuromuscular
blockade: A randomized clinical study
Staehr-Rye, Anne K.; Rasmussen, Lars S.; Rosenberg, Jacob; Juul, Poul; Lindekaer,
Astrid L.; Riber, Claus; Gätke, Mona R.
01 Mendeley User Page no. 1
6/4/2015 6:40
Le degré de relâchement musculaire en chirurgie coelioscopique de la vésicule biliaire fait partie du
quotidien des discussions entre anesthésistes et chirurgiens au bloc opératoire. Au fond tous sont
convaincus de l'efficacité du curare : le chirurgien qui le demande et l'anesthésiste qui pense lui à sa
décurarisation.Cette étude teste curarisation profonde versus curarisation de routine dans la chirurgie
coelioscopique de la vésicule biliaire. Avec comme première question est-ce qu'une curarisation
profonde permet de travaillert avec une pression abdominable moindre?, pression dont on sait qu'elle
est pourvoyeuse de douleur post-opératoire.La réponse est que le degré de curarisation participe de
façon marginale au confort du chirurgien... et ne permet pas plus fréquemment de travailler à pression
abdominale basse.

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Aa 2014 119-5

  • 1. 1084 www.anesthesia-analgesia.org November 2014 • Volume 119 • Number 5 Copyright © 2014 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000316 T he number of laparoscopic procedures is increasing with laparoscopic cholecystectomy being one of the most common procedures. Laparoscopic cholecystec- tomy is normally performed with an intraabdominal pres- sure of 12 to 15 mm Hg, but a pneumoperitoneum <12 to 15 mm Hg is associated with less postoperative pain1 and fewer adverse effects on pulmonary function2 and hemo- dynamics.3 However, the impact of decreasing the intraab- dominal pressure on surgical space conditions and safety has not been well established. Neuromuscular blocking drugs are used during laparo- scopic surgery to improve surgical exposure. The degree of neuromuscular blockade is measured at the adductor pol- licis muscle.4 However, this muscle may show no response to train-of-four (TOF) stimulation, while the diaphragm and muscles in the abdominal wall have partly recovered from the neuromuscular blockade,5–7 resulting in inadequate BACKGROUND: Laparoscopic cholecystectomy performed during low intraabdominal pressure (<12 mm Hg) is associated with significantly less postoperative pain than standard pressure (≥12 mm Hg). The impact on surgical space conditions and safety of operating at lower pres- sures has not been adequately described, but deep neuromuscular blockade may be beneficial. We investigated if deep muscle relaxation would be associated with a higher proportion of procedures with “optimal” surgical space conditions compared with moderate relaxation during low-pressure (8 mm Hg) laparoscopic cholecystectomy. METHODS: In this assessor-blinded study, 48 patients undergoing elective laparoscopic cho- lecystectomy were administered rocuronium for neuromuscular blockade and randomized to either deep neuromuscular blockade (rocuronium bolus plus infusion maintaining a posttetanic count 0–1) or moderate neuromuscular blockade (rocuronium repeat bolus only for inadequate surgical conditions with spontaneous recovery of neuromuscular function). Patients received anesthesia with propofol, remifentanil, and rocuronium. The primary outcome was the propor- tion of procedures with optimal surgical space conditions (assessed by the surgeon as 1 on a 4-point scale). Secondary outcomes included the proportion of procedures completed at pneu- moperitoneum 8 mm Hg and surgical space conditions on dissection of the gallbladder (numeric rating scale 0–100; 0 = optimal surgical space conditions; 100 = unacceptable surgical space conditions). RESULTS: Optimal surgical space conditions during the entire procedure were observed in 7 of 25 patients allocated to deep neuromuscular blockade and in 1 of 23 patients allocated to moderate blockade (P = 0.05) with an absolute difference of 24% between the groups (95% confidence interval, 4%–43%). Laparoscopic cholecystectomy was completed at pneumoperito- neum 8 mm Hg in 15 of 25 and 8 of 23 patients in the deep and moderate group, respectively (95% confidence interval, −2% to 53%; P = 0.08). Surgical space conditions during dissection of the gallbladder assessed by use of the numeric rating scale were 20 (10–50) (median [25%– 75% range]) in the deep neuromuscular blockade group and 30 (10–50) in the moderate group (P = 0.58; Wilcoxon-Mann-Whitney odds, 1.2; 95% confidence interval, 0.6–2.5). No operations were converted to laparotomy. CONCLUSIONS: Deep neuromuscular blockade was associated with surgical space conditions that were marginally better than with moderate muscle relaxation during low-pressure laparo- scopic cholecystectomy.  (Anesth Analg 2014;119:1084–92) Surgical Space Conditions During Low-Pressure Laparoscopic Cholecystectomy with Deep Versus Moderate Neuromuscular Blockade: A Randomized Clinical Study Anne K. Staehr-Rye, MD,* Lars S. Rasmussen, MD, PhD, DMSc,† Jacob Rosenberg, MD, DMSc,‡ Poul Juul, MD,§ Astrid L. Lindekaer, MD,|| Claus Riber, MD,§ and Mona R. Gätke, MD, PhD* From the *Department of Anesthesiology, University of Copenhagen, Herlev Hospital, Herlev; †Department of Anesthesia, Centre of Head and Orthopedics, University of Copenhagen, Rigshospitalet, Copenhagen; ‡Department of Surgery, University of Copenhagen, Herlev Hospital, Herlev; and Departments of §Surgery and ||Anesthesia, Aleris-Hamlet Hospital, Soeborg, Denmark. Accepted for publication April 21, 2014. Funding: Supported by the University of Copenhagen, Denmark (to ­AKS-R), The Sophus Johansens Foundation of 1981, Copenhagen, Denmark (to AKS-R), Tryg Foundation, Lyngby, Denmark (to LSR), and The Lippmann Foundation, Copenhagen, Denmark (to AKS-R). This work was also supported in part by a research grant from the Investigator Initiated Studies Program of Merck Sharp & Dohme Corp (to MRG). The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. Conflict of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Anne K. Staehr-Rye, MD, Department of Anes- thesiology, University of Copenhagen, Herlev Hospital, Herlev Ringvej 75, Herlev DK-2730, Denmark. Address e-mail to akstaehr1@hotmail.com. Section Editor: Peter S. A. Glass Society for Ambulatory Anesthesiology 01 06/04/2015 Mdl. User
  • 2.   November 2014 • Volume 119 • Number 5 www.anesthesia-analgesia.org 1085 abdominal muscle relaxation during abdominal surgery. With the establishment of deep, continuous neuromuscular block- ade, defined as a posttetanic count (PTC) of 0 to 1, all muscles will be paralyzed.8 This may optimize surgical space condi- tions during low-pressure laparoscopic cholecystectomy. To the authors’ knowledge, no published studies have investigated the impact of muscle relaxation on surgical con- ditions during low-pressure laparoscopic surgery, and only few have investigated this aspect during standard-pressure laparoscopic surgery.9–14 One study reported a difference in the proportion of adequate pneumoperitoneum between muscle relaxation (100%) and no muscle relaxation (72%) in 40 patients undergoing gynecological laparoscopic surgery, but the degree of neuromuscular blockade was not described.14 We designed this study to assess the effect of deep, con- tinuous neuromuscular blockade on surgical space condi- tions during low-pressure laparoscopic cholecystectomy. We hypothesized that deep, continuous neuromuscular blockade compared to moderate blockade was associated with a higher proportion of procedures with “optimal” ­surgical space conditions as assessed by the surgeon. METHODS This investigator-initiated, randomized, assessor-blinded study was approved by the Danish Medicines Agency and the Regional Ethics Committee. The study (NCT01523886) was registered at ClinicalTrials.gov (January 19, 2013) before enrollment of the first patient. Written informed consent was obtained from all patients. Eligible patients were ≥18 years of age and scheduled for elective laparoscopic cholecystec- tomy. Women had to be postmenopausal, surgically steril- ized, or use reliable birth control. Exclusion criteria were allergy to rocuronium or sugammadex, indication for rapid sequence induction, pregnancy or breastfeeding, known neuromuscular disorders that might impair neuromuscular blockade, and significant liver or renal dysfunction. Female patients, who were not postmenopausal or surgically steril- ized, had to provide a negative urine pregnancy test within 24 hours before surgery. Included patients were randomized immediately before arrival in the operating room by a computer randomiza- tion system to ensure adequate allocation concealment. The computer-generated randomization sequence allocated patients to either deep, continuous neuromuscular blockade or moderate neuromuscular blockade with stratification for body mass index (<30 vs ≥30 kg/m2 ). A standardized protocol emphasized optimal periop- erative care15 including ventilatory strategy, fluid ther- apy, antibiotics, adequate temperature control as well as administration of analgesics and antiemetics. Anesthesia was induced with propofol 2 mg/kg and remifentanil 0.5 μg/kg/min IV. Anesthesia was maintained with IV infu- sion of propofol and remifentanil and adjusted under guid- ance of entropy (Entropy Sensor, GE Healthcare, Hillerød, Denmark) and arterial blood pressure. Neuromuscular monitoring was performed with accel- eromyography (TOF-Watch SX® , MSD, Ballerup, Denmark) connected to a computer using the software TOF-Watch SX (version 2.5 INT 2007, Organon, Oss, The Netherlands) in accordance with “Good Clinical Research Practice in Pharmacodynamic Studies of Neuromuscular Blocking Agents II.”4 The study arm was immobilized and a preload was placed on the thumb for monitoring acceleration (Hand Adapter® , MSD). After calibration and stabilization of the TOF-Watch, tracheal intubation was facilitated with rocuronium 0.3 mg/kg IV in both groups, which is the standard practice at the institution. Moreover, in patients allocated to deep muscle relaxation, an IV bolus of rocuronium (0.7 mg/kg) was given 2 minutes after the first dose, which was imme- diately before tracheal intubation. An IV infusion with rocuronium (3–4 mg/kg/h) was started when the PTC was >0, with titration toward PTC 0 to 1. PTC was measured every 3 to 4 minutes. In patients allocated to the moderate blockade group, no additional rocuronium was given imme- diately before intubation, but a similar volume of saline was given, and an infusion of saline 0.9% (0.3 mL/kg/h) was started approximately 20 to 30 minutes later. PTC was measured every 3 to 4 minutes, and TOF measurement was made every 15 seconds. In the moderate blockade group, no further rocuronium was administered unless as per pro- tocol (see below) surgical space conditions were assessed as inadequate at 12 mm Hg. Neuromuscular function was therefore allowed to recover spontaneously. Pneumoperitoneum was obtained with insufflation of CO2 through a Veress needle to 12 mm Hg, but reduced to 8 mm Hg after the introduction of the 4 trocars. After insuffla- tion, patients were positioned in 20° reverse Trendelenburg verified by angle measurement. All laparoscopies were performed by 1 of 2 experienced surgeons, and they were asked to evaluate surgical space conditions with modification of a 4-point scale previously used by others9,14,16,17 : grade 1 (optimal) = optimal surgical space conditions; grade 2 (good) = nonoptimal conditions, but an intervention was not considered; grade 3 (accept- able) = an intervention was considered to improve surgical space; grade 4 (poor) = inadequate conditions and an inter- vention was necessary to ensure acceptable surgical space. They also rated surgical space conditions on a numeric rating scale (NRS), where NRS 0 indicated optimal surgi- cal space conditions and NRS 100 indicated unacceptable surgical space conditions and an intervention was needed to secure acceptable surgical space. The assessments were made during dissection of the gallbladder and at the end of the surgery, based on overall space conditions as well as the time during surgery, when surgical space conditions were determined as worst. In case of inadequate surgical space conditions, the fol- lowing 3-step intervention procedure was used in both groups: 1.  Increase of preset intraabdominal pressure to 12 mm Hg. 2.  If still inadequate, patients allocated to moderate muscle relaxation were given a bolus of rocuronium (0.6 mg/kg) IV. Patients allocated to deep muscle relax- ation were given an equivalent volume of 0.9% NaCl. 3.  If still not adequate, the surgeon would decide accord- ing to usual clinical practice. If any of the above-mentioned interventions were required, surgical space conditions were automatically
  • 3. 1086   www.anesthesia-analgesia.org anesthesia analgesia Optimizing Surgical Space Conditions rated as 4 (4-point scale) and 100 (NRS) in the assessment, based on the time of surgery when surgical space conditions were determined as worst. Sugammadex 2 to 8 mg/kg IV was given at the end of surgery, if the TOF ratio was 0.90.15 Endotracheal extubation was only performed when the patients were fully awake and had a stable T1 response between 80% and 120%, a TOF ratio ≥0.90 and a variation of the T1 response ≤5% for 2 minutes. At the end of the surgery, the surgeon was asked if any sur- gical difficulties had occurred. Moreover, the patients’ charts were reviewed to assess whether macroscopic cholecystitis, adhesions, or any other surgical difficulties had been described. The primary outcome was the proportion of procedures with optimal surgical space conditions during the entire pro- cedure (assessed as 1 on the 4-point scale based on the time of surgery, when surgical space conditions were determined as worst). The secondary outcomes were surgical space con- ditions based on the time of surgery, when surgical space conditions were determined as worst (NRS), on dissection of the gallbladder (4-point scale and NRS) and overall sur- gical space conditions as an average of the entire procedure (4-point scale and NRS), proportion of laparoscopies per- formed with an intraabdominal pressure of 8 mm Hg, and duration of surgery and anesthesia. Other outcomes were pain expressed as the area under the curve from the first postoperative assessment to 1 week after surgery, pain at arrival in the postoperative care unit, 2 hours after surgery and 1 day after surgery, postoperative consumption of anal- gesics, antiemetics, and incidence of postoperative nausea and/or vomiting up to 24 hours after surgery, and number of days after surgery before resumption of normal activity. Before surgery, all included patients were carefully instructed by the same investigator in use of a visual analog scale (VAS). Pain was evaluated as abdominal pain, incisional pain, shoulder pain, and overall pain using VAS (VAS 0 = no pain, 100 = worst possible pain). Each assessment was done at rest and during mobilization. Patients were discharged on the day of surgery. A questionnaire was given to the patients to be completed every morning after discharge from hospital and until they experienced no pain. The same investigator contacted the patient on the first postoperative day and again 1 week after surgery to ensure that postoperative pain assess- ment was made and to assess any discomfort. Any adverse event or reaction developed within the first 21 postoperative days was recorded. An adverse event or reaction was consid- ered serious if it was fatal, life threatening, caused permanent disability, or required prolonged hospitalization. The surgeons, surgical staff, patients, personnel in the postoperative care unit as well as the investigator collecting postoperative data were blinded to group allocation. In a sep- arate room, syringes containing rocuronium, sugammadex, and NaCl were prepared. The patient’s hand with the neu- romuscular monitoring equipment and the connecting neu- romuscular monitor were covered to keep the surgical team blinded to group allocation. However, the investigator who gave rocuronium was able to follow the level of neuromus- cular blockade via a connected computer using the software TOF-Watch SX (version 2.5 INT 2007, Organon). Information about group allocation, administered doses of rocuronium and sugammadex, and neuromuscular data were recorded on a separate form and placed in a sealed opaque envelope when the patient left the operating room. After the end of surgery, the surgeon was asked which group he/she believed the patient was allocated to and to indicate why. The patient was asked the same questions on postoperative day 7. Thestudywasmonitoredbyanindependentinspectorfrom the department of Good Clinical Practice, Bispebjerg, Denmark and conducted according to the International Conference on Harmonization/Good Clinical Practice guidelines. Statistical Analysis All outcomes were reported with median (interquar- tile range) or number (%) and compared with the Mann- Whitney U test, the χ2 test, or the Fisher exact test. The Wilcoxon-Mann-Whitney odds and 95% confidence inter- vals were calculated for the continuous outcomes.18,19 A P value of 0.05 was considered statistically significant. Analyses were performed using SAS statistical software version 9.2 (SAS Institute Inc., Cary, NC). A difference in the proportion of adequate pneumo- peritoneum of 28% was previously found between no muscle relaxation (72%) and muscle relaxation (100%) in laparoscopic surgery.14 We calculated that a sample size of 48 patients would allow us to detect a clinically relevant dif- ference of 28% in the proportion of optimal surgical space conditions during the entire procedure with a power of 80% and a type 1 error risk of 5%. RESULTS Forty-eight patients were included and received the inter- vention (Fig. 1). Demographic and perioperative character- istics were similar in the 2 groups (Table 1, Fig. 2). The intended depth of neuromuscular blockade was achieved during 91% (median; range, 70%–100%) of the proce- dure from surgical incision to administration of sugammadex in the deep group (PTC, 0–1). In the moderate group, a TOF count ≥2 was present during 87% (median; range, 67%–100%) of the procedure. Neuromuscular data are shown in Table 2. Optimal surgical space conditions during the entire pro- cedure were found in 7 of 25 (28%) patients allocated to deep blockade and in 1 of 23 (4%) patients allocated to moderate blockade (P = 0.05) with an absolute difference of 24% between the groups (95% confidence interval, 0.04–0.43; Table 3). Laparoscopic cholecystectomy was completed at pneu- moperitoneum 8 mm Hg in 15 (60%) patients in the deep group compared with 8 (35%) patients in the moderate group, respectively (95% confidence interval, −0.02 to 0.53; P = 0.08). Twenty-five patients had pneumoperitoneum increased to 12 mm Hg due to inadequate surgical space conditions. PTC was 0 to 1 in 7 of 8 (88%) of the patients in the deep group when the pneumoperitoneum was increased and TOF count was ≥2 in 12 of 13 (92%) of the patients in the moderate group when the pressure was increased. Data were missing in 4 patients. In the moderate group, 3 patients coughed during the recruitment maneuvers at the end of surgery, but no other signs of poor relaxation were seen. The median duration of anesthesia and postoperative hospitalization was 60 and 230 minutes in patients in the deep group and 58 and 236 minutes in the moderate group (P = 0.77 and P = 0.60). We conducted correlation analyses to assess concur- rent validity of the 4-point scale and the NRS (Table 4). A
  • 4.   November 2014 • Volume 119 • Number 5 www.anesthesia-analgesia.org 1087 logistic regression analysis showed that none of the fol- lowing factors was predictive of inferior surgical space conditions based on the time during surgery, when surgi- cal space conditions were determined as worst: male, age 60 years, previous intraabdominal surgery and cholecys- titis (Table 5). Forty-three of 48 patients had returned the question- naire by postoperative day 21. There were no significant differences in postoperative pain between the 2 groups. The median consumption of oxycodone within 24 hours postop- eratively was 20 mg in both groups. The median number of days after surgery before resumption of normal activity was 6 and 5 days in the deep and moderate group, respectively (P  =  0.29). There were no significant differences in post- operative nausea, vomiting, or administered ondansetron within 24 hours postoperatively. There were no major anesthetic or surgical intraopera- tive complications, and no procedure was converted to open surgery. Overall, 48% of the patients experienced an adverse event in the follow-up period. Serious adverse events were seen in 4 patients: prolonged hospitalization due to postop- erative observation (2 patients) and readmission to hospital because of pain from undiagnosed gallstones in the com- mon bile duct (2 patients). There were no reported adverse reactions or serious adverse reactions considered related to rocuronium or sugammadex by the investigators. The surgeons correctly identified 20 of 48 patients’ alloca- tion and 12 of the 48 patients correctly identified their alloca- tion. There were no indications of unblinding in their answers. DISCUSSION Deep, continuous neuromuscular blockade was associated with surgical space conditions that were marginally better than with moderate muscle relaxation during low-pressure laparoscopic cholecystectomy. There tended to be more pro- cedures completed at 8 mm Hg in the deep muscle relax- ation group than in the moderate group. Forty-eight percent of laparoscopies were successfully completed at 8 mm Hg, which is less than the success rates of approximately 70% to 100% previously reported in stud- ies comparing pain after low- and standard-pressure laparo- scopic cholecystectomy.20–23 However, in the present study, the proportion of patients having acute or chronic inflam- mation of the gallbladder was relatively high (50%) com- pared with previous studies (18%),20 which may explain the need for better exposure. The lower completion rate at 8 mm Hg in our study may also have been caused by a less restric- tive inclusion of patients. Some of the previous studies only included patients with uncomplicated symptomatic gall- stones and excluded patients with previous upper abdomi- nal surgery.20,21 Also, the level of neuromuscular blockade was not described uniformly in the previous studies. Other Patients planned for elective laparoscopic cholecystectomy and assessed for eligibility (n=87) Not enrolled (n=38) Refusal (n=15) Unable to informed consent (n=1) Indication for rapid sequence induction (n=9) No available investigators (n=13) Other reasons (n=0) Randomized (n=49) BMI 30 kg/m2 (n=13) Allocated to moderate neuromuscular blockade (n=24) Received intervention (n=23) Did not receive intervention (n=1) Reason - Surgery cancelled Allocated to deep neuromuscular blockade (n=25) Received intervention (n=25) Included in the intention-to-treat analysis (n=23) of - surgical space conditions when they were worst - overall surgical space conditions - surgical space conditions during dissection - proportion of procedures performed at PnP 8 mmHg Procedures completed at PnP 8 mmHg (n=8) PnP increased to 12 mmHg (n=15) Before dissection of GB (n=7) After dissection of GB (n=7) Missing data (n=1) Required deep NMB (n=3) PnP increased to 12 mmHg (n=1) Procedures completed at PnP 8 mmHg (n=15) PnP increased to 12 mmHg (n=10) Before dissection of GB (n=7) During dissection of GB (n=1) After dissection of GB (n=2) Required deep NMB (n=2) PnP increased to 12 mmHg (n=2) Included in the intention-to-treat analysis (n=25) of - surgical space conditions when they were worst - overall surgical space conditions - surgical space conditions during dissection - proportion of procedures performed at PnP 8 mmHg Figure 1. Trial profile. BMI = body mass index; PnP = pneumoperitoneum; GB = gallbladder.
  • 5. 1088   www.anesthesia-analgesia.org anesthesia analgesia Optimizing Surgical Space Conditions influential factors could have been administration of total IV anesthesia instead of inhaled anesthesia, blinding of the surgeons, and other surgical difficulties experienced intra- operatively including adhesions and increased amount of intraabdominal fat. Moreover, the surgeons in our study were not familiar with low-pressure laparoscopic surgery before beginning the study. However, we found no signifi- cant difference between the first 24 and the last 24 proce- dures or between the 2 surgeons with respect to successfully completed procedures at low-pressure pneumoperitoneum. Many factors contribute to pain after laparoscopic cho- lecystectomy with pain coming from the incision sites, the dissected viscera, and from the pneumoperitoneum. The exact mechanism of pain related to pneumoperitoneum has not been clarified. Low-pressure pneumoperitoneum has been associated with significantly less postoperative pain,1,20,21,24 including shoulder tip pain.20,22,24,25 We found no difference in postoperative pain characteristics or incidence of postoperative nausea or vomiting between patients, who had received a deep or a moderate neuromuscular blockade during laparoscopic cholecystectomy, but the results may have been impacted by the need to increase the intraab- dominal pressure when exposure was inadequate. Neuromuscular blockade is often used during lapa- roscopic surgery to improve surgical space conditions, but only few studies have focused on defining optimal or necessary muscle relaxation in the context of abdominal surgical space conditions. To our knowledge, only 7 stud- ies have described the association between neuromuscu- lar blockade and surgical conditions during laparoscopic surgery,9–14,26 and only 3 reported the actual degree of mus- cle relaxation.9,13,26 Traditionally, a TOF count of the adduc- tor pollicis muscle between 1 and 2 has been associated with adequate surgical relaxation.27 However, the clinical situa- tion in which abdominal muscle and diaphragmatic relax- ation seems inadequate despite minimal response of the adductor pollicis to ulnar nerve stimulation is frequently encountered. This may primarily be explained by the effects of neuromuscular blocking drugs being muscle dependent6 ; the diaphragm shows a lower peak effect5,7,28 and a more rapid recovery5,7,28–31 of a given dose of a neuromuscular blocking drug than the adductor pollicis muscle. The lateral abdominal muscles have a time course somewhere between the diaphragm and the adductor pollicis regarding sen- sitivity and time to recovery.7 Therefore, there may be no response of the adductor pollicis muscle to TOF stimulation, while the diaphragm and the muscles in the abdominal wall have recovered partly from the neuromuscular blockade. To ensure total paralysis of the diaphragm, the neuromuscular blockade measured at the adductor pollicis muscle should be intense, that is, PTC = 0. The results of our study indi- cate that deep, continuous muscle relaxation optimizes the surgical space conditions compared with moderate muscle relaxation during low-pressure laparoscopic cholecystec- tomy, although it is not effective in all patients. Thus, 60% of patients in the deep group had optimal to acceptable condi- tions compared with 35% in the moderate group. To evaluate surgical space conditions, we used the 4-point scale as well as a NRS. It is, however, a limitation that these scales have not been validated for assessment Table 1.  Characteristics of 48 Patients Who Underwent Laparoscopic Cholecystectomy Deep NMB (n = 25) Moderate NMB neuromuscular block group (n = 23) Age (y) 45 (42–49) 48 (35–59) Gender (male:female) 10:15 6:17 BMI (kg/m2 ) 27 (24–29) 26 (22–31) BMI ≥30.0 kg/m2 6 (24%) 7 (30%) ASA physical status category (I:II:III) 22:3:0 20:3:0 Coexisting disease 5 (20%) 8 (35%) Previous intraabdominal surgery 10 (40%) 9 (39%) Previous upper abdominal surgery 0 1 (4%) Crystalloid infused (mL) 500 (350–690) 500 (350–700) Estimated blood loss (mL) 10 (5–18) 10 (5–20) Acute cholecystitis 5 (20%) 2 (9%) Chronic cholecystitis 12 (48%) 10 (43%) Surgical difficulties due to  Adhesions 3 (12%) 5 (22%)  Intraabdominal obesity 4 (16%) 2 (9%)  Other reasons 5 (20%)a 9 (43%)   Anatomic abnormalities 2 3   Poor placement of the trocars 1 2   Serosa lesion 0 1   Bleeding from liver bed 0 2   Diffuse bleeding 1 0   Big/multiple gall stones 2 1 Bile leak into the peritoneal cavity 5 (20%) 5 (22%) Rocuronium dose (mg) 80 (71–91) 21 (18–23) Sugammadex dose (mg) 380 (330–440) 120 (0–170) Propofol dose (mg) 474 (446–566) 430 (410–570) Remifentanil dose (μg) 3390 (2736–4290) 2940 (2544–4200) Data are median (interquartile range) or number of patients (%). NMB = neuromuscular blockade; BMI = body mass index. a Two types of surgical difficulties in 1 subject.
  • 6.   November 2014 • Volume 119 • Number 5 www.anesthesia-analgesia.org 1089 of surgical space conditions. The correlation analyses indicated concurrent validity of the 4-point scale and the NRS, even though the evaluation of surgical space conditions could be influenced by other factors. There were more patients with cholecystitis and of male gen- der in the deep relaxation group, which together with previous upper abdominal surgery, advanced age (60 years), and higher body weight (65 kg) has been asso- ciated with increased risk of converting laparoscopic cholecystectomy to open surgery.32,33 However, a logis- tic regression analysis showed no significant impact of sex, cholecystitis, previous abdominal surgery, or age on the primary outcome. All patients received a small dose of rocuronium (0.3 mg/kg) to facilitate tracheal intubation. This was the only dose given to the moder- ate group, because it is the standard regime for lapa- roscopic cholecystectomy at the institution. Completely omitting giving rocuronium to patients in the control group could have allowed a better separation regarding surgical space conditions but could also have impaired tracheal intubation conditions. Most importantly, there was a clear separation in the degree of neuromuscular blockade between the 2 groups during dissection of the gallbladder as well as in the situations where the pneu- moperitoneum was increased. We assessed the effect of deep, continuous muscle relaxation compared with moderate neuromuscular blockade on abdominal surgical space conditions during low-pressure laparoscopic cholecystectomy, for which surgical conditions and safety have not been adequately described. All laparoscopies were performed by only 2 surgeons, each with 10 years of surgical experience and 1000 performed laparoscopic cholecystectomies, which reduces the variability in assessment of surgical space conditions. Two experts conducted neuromuscular monitoring in accordance with “Good Clinical Research Practice in Pharmacodynamic Studies of Neuromuscular Blocking Agents II.”4 All patients scheduled for laparo- scopic cholecystectomy during the study period were consecutively evaluated for fulfillment of inclusion and exclusion criteria regardless of age, gender, or body mass index. All randomized, evaluable patients had a thorough follow-up with assessment of adverse intra- and post- operative events. We therefore believe that the results of this study are applicable to a general surgical population undergoing low-pressure laparoscopic cholecystectomy performed by experienced surgeons; however, the results may not be generalizable to standard-pressure laparo- scopic cholecystectomy, other laparoscopic procedures, or other types of anesthesia. In conclusion, we found that the proportion of opti- mal surgical space conditions with deep neuromuscular blockade was marginally greater than with moderate muscle relaxation during low-pressure laparoscopic cho- lecystectomy. However, intraabdominal pressure was increased from 8 to 12 mm Hg in approximately half of the procedures to secure acceptable surgical space condi- tions. E Blood pressure 0 20 40 60 80 100 120 140 160 mmHg Heart rate 0 10 20 30 40 50 60 70 80 90 beatsprmin Deep neuromuscular blockade Systolic pressure Diastolic pressure Heart rate Moderate neuromuscular blockade Systolic pressure Diastolic pressure Heart rate Tpre Tinc T25% T50% T75% Tend Tpre Tinc T25% T50% T75% Tend Figure 2. Hemodynamic changes in patients undergoing low-pressure laparoscopic cholecys- tectomy with deep or moderate neuromuscular blockade. Values are medians and interquar- tile range (error bars). Time measurements: Tpre = preoperatively; Tinc = at surgical incision; T25% = at 25% of surgical duration; T50% = at 50% of surgical duration; T75% = at 75% of surgi- cal duration; Tend = at end of surgery. Table 2.  Neuromuscular Data for 45 Patients Who Underwent Laparoscopic Cholecystectomy Time point Deep NMB (n = 25) Moderate NMB (n = 20) At surgical incision PTC0 (PTC0–TOF4) T1 0 (0–8) At 25% of duration of surgery PTC0 (PTC0–PTC1) T1 10 (0–76) At 50% of duration of surgery PTC0 (PTC0–PTC4) T1 47 (17–103) At 75% of duration of surgery PTC1 (PTC0–PTC10) T1 89 (61–108) At end of surgery T1 93 (0–103) T1 99 (96–103) Data are median (range). Three patients are missing in the moderate group because they received a deep neuromuscular blockade due to unacceptable surgical space conditions at pneumoperitoneum 12 mm Hg. NMB = neuromuscular blockade; PTC = posttetanic count; T1 = normalized T1 response in %.
  • 7. 1090   www.anesthesia-analgesia.org anesthesia analgesia Optimizing Surgical Space Conditions DISCLOSURES Name: Anne K. Staehr-Rye, MD. Contribution: This author helped in study design, patient recruitment, data collection, data analysis, and writing of the first draft of the manuscript. Attestation: Anne K. Staehr-Rye approved the final manuscript and is the archival author. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Lars S. Rasmussen, MD, PhD, DMSc. Contribution: This author helped in study design, data analy- sis, and critical revision. Attestation: Lars S. Rasmussen approved the final manuscript. Conflicts of Interest: Spouse has received payments and travel funding for lectures from MSD. Total funding was approxi- mately €8700. Spouse has received investigator-initiated research funding of €93,800 from MSD. Table 4.  Rank Correlation of Surgical Space Conditions in Patients Who Underwent Laparoscopic Cholecystectomy Surgical space conditions when they were worst on 4-point scale in all patients (n = 48) Surgical space conditions when they were worst on 4-point scale in patients, who had their whole procedure undertaken at 8 mm Hg (n = 23) Surgical space conditions when less view on NRS r = 0.985 (P 0.0001) r = 0.878 (P 0.0001) Pneumoperitoneum completed at 8 mm Hg r = 0.914 (P 0.0001) Overall surgical space conditions on 4-point scale r = 0.561 (P 0.0001) r = 0.890 (P 0.0001) Overall surgical space conditions on NRS r = 0.613 (P 0.0001) r = 0.813 (P 0.0001) Surgical space conditions during dissection of the GB on 4-point scale r = 0.527 (P 0.0001) r = 0.771 (P 0.001) Surgical space conditions during dissection of the GB on NRS r = 0.457 (P = 0.0011) r = 0.688 (P = 0.0003) Duration of surgery r = 0.383 (P = 0.0073) r = 0.507 (P = 0.0097) Data are Spearman correlation. First column includes all patients. Second column includes only patients, who had their whole procedure performed at 8 mm Hg. Four-point scale: 0 = “optimal” surgical space conditions; 4 = poor surgical space conditions. NRS = numeric rating scale (0 = “optimal” surgical space conditions; 100 = unacceptable surgical space conditions); GB = gallbladder. Table 5.  A Logistic Regression Analysis of Inferior Surgical Space Conditions, Assessed at the Time During Surgery When They Were Worst as the Dependent Variable in Patients Who Underwent Laparoscopic Cholecystectomy Variable Regression coefficient SE Wald χ2 P value Odds ratio (95% CI) Sex (male) 0.091 0.50 0.032 0.86 1.20 (0.17–8.57) Age (60 y) 0.191 0.59 0.104 0.74 1.47 (0.14–15.05) Previous intraabdominal surgery 0.230 0.44 0.277 0.60 1.58 (0.29–8.79) Cholecystitis 0.650 0.47 1.883 0.17 3.67 (0.57–23.46) The table shows a logistic regression analysis of inferior surgical space conditions assessed at the time during surgery when they were worst (1 on the 4-point scale) as the dependent value and sex (male), age (60 y), previous intraabdominal surgery (yes) and cholecystitis, acute or chronic (yes) as the independent values. CI = confidence interval. Table 3.  Surgical Space Conditions in 48 Patients Who Underwent Laparoscopic Cholecystectomy Deep NMB (n = 25) Moderate NMB (n = 23) P value WMWodds “Optimal” surgical space conditions during the entire procedure 7 (28%) 1 (4%) 0.05   Surgical space conditions when they were worst on 4-point scale 3 (1–4) 4 (2–4) 0.07 1.9 [1.0–3.8] The distribution of surgical space conditions when they were worst on 4-point scale (1/2/3/4) 7/3/5/10 1/5/2/15     Surgical space conditions when they were worst on NRS 60 (10–100) 100 (40–100) 0.06 1.8 [1.0–3.8] Procedure completed at 8 mm Hg 15 (60%) 8 (35%) 0.08   Overall surgical space conditions on 4-point scale 2 (1–3) 2 (2–3) 0.97 1.0 [0.5–1.9] The distribution of overall surgical space conditions on 4-point scale (1/2/3/4) 8/7/10/0 4/13/6/0     Overall surgical space conditions on NRS 40 (10–50) 30 (20–50) 0.7 1.1 [0.6–2.3] Surgical space conditions during dissection of the GB on 4-point scale 2 (1–3) 2 (1–3) 0.91 1.0 [0.5–2.0] The distribution of surgical space conditions during dissection of the GB on 4-point scale (1/2/3/4) 9/7/8/1 6/11/4/2 Surgical space conditions during dissection of the GB on NRS 20 (10–50) 30 (10–50) 0.58 1.2 [0.6–2.5] Duration of surgery (min) 40 (29–47) 36 (31–54) 0.93 Data are number of patients (%), median (interquartile range) or median [95% confidence interval]. Four-point scale: 0 = “optimal” surgical space conditions; 4 = poor surgical space conditions. NMB = neuromuscular blockade; WMWodds = Wilcoxon-Mann-Whitney odds; NRS = numeric rating scale (0 = “optimal” surgical space conditions; 100 = unacceptable surgical space conditions); GB = gallbladder.
  • 8.   November 2014 • Volume 119 • Number 5 www.anesthesia-analgesia.org 1091 Name: Jacob Rosenberg, MD, DMSc. Contribution: This author helped in study design, data analy- sis, and critical revision. Attestation: Jacob Rosenberg approved the final manuscript. Conflicts of Interest: Jacob Rosenberg has been a member of the advisory board in MSD. Name: Poul Juul, MD. Contribution: This author helped in study design, patient recruitment, data collection, and critical revision. Attestation: Poul Juul approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Astrid L. Lindekaer, MD. Contribution: This author helped in study design, data collec- tion, and critical revision. Attestation: Astrid L. Lindekaer approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Claus Riber, MD. Contribution: This author helped in patient recruitment, data collection, and critical revision. Attestation: Claus Riber approved the final manuscript. Conflicts of Interest: The author has no conflicts of interest to declare. Name: Mona R. Gätke, MD, PhD. Contribution: This author helped in study design, data collec- tion, data analysis, and critical revision. Attestation: Mona R. Gätke approved the final manuscript. Conflicts of Interest: Mona R. Gätke has received payments and travel funding for lectures from MSD. Total funding was approximately €8700. Mona R. Gätke has received investiga- tor-initiated research funding of €93,800 from MSD. This manuscript was handled by: Peter S. A. Glass, MB, ChB. REFERENCES 1. Gurusamy KS, Samraj K, Davidson BR. Low pressure versus standard pressure pneumoperitoneum in laparoscopic chole- cystectomy. Cochrane Database Syst Rev 2009;2:CD006930 2. Strang CM, Freden F, Maripuu E, Ebmeyer U, Hachenberg T, Hedenstierna G. Improved ventilation-perfusion matching with increasing abdominal pressure during CO(2) -pneumo- peritoneum in pigs. Acta Anaesthesiol Scand 2011;55:887–96 3. Dexter SP, Vucevic M, Gibson J, McMahon MJ. Hemodynamic consequences of high- and low-pressure capnoperitoneum dur- ing laparoscopic cholecystectomy. Surg Endosc 1999;13:376–81 4. Fuchs-BuderT,ClaudiusC,SkovgaardLT,ErikssonLI,Mirakhur RK, Viby-Mogensen J; 8th International Neuromuscular Meeting. Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand 2007;51:789–808 5. Cantineau JP, Porte F, d’Honneur G, Duvaldestin P. Neuromuscular effects of rocuronium on the diaphragm and adductor pollicis muscles in anesthetized patients. Anesthesiology 1994;81:585–90 6. Hemmerling TM, Donati F. Neuromuscular blockade at the larynx, the diaphragm and the corrugator supercilii muscle: a review. Can J Anaesth 2003;50:779–94 7. Kirov K, Motamed C, Dhonneur G. Differential sensitivity of abdominal muscles and the diaphragm to mivacurium: an elec- tromyographic study. Anesthesiology 2001;95:1323–8 8. Dhonneur G, Kirov K, Motamed C, Amathieu R, Kamoun W, Slavov V, Ndoko SK. Post-tetanic count at adductor pol- licis is a better indicator of early diaphragmatic recovery than train-of-four count at corrugator supercilii. Br J Anaesth 2007;99:376–9 9. Chassard D, Bryssine B, Golfier F, Raupp C, Raudrant D, Boulétreau P. Gynecologic laparoscopy with or without curare. Ann Fr Anesth Reanim 1996;15:1013–7 10. Chen BZ, Tan L, Zhang L, Shang YC. Is muscle relaxant neces- sary in patients undergoing laparoscopic gynecological surgery with a ProSeal LMA™? J Clin Anesth 2013;25:32–5 11. Kurer FL, Welch DB. Gynaecological laparoscopy: clini- cal experiences of two anaesthetic techniques. Br J Anaesth 1984;56:1207–12 12. Swann DG, Spens H, Edwards SA, Chestnut RJ. Anaesthesia for gynaecological laparoscopy–a comparison between the laryngeal mask airway and tracheal intubation. Anaesthesia 1993;48:431–4 13. Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth 2014;112:498–505 14. Williams MT, Rice I, Ewen SP, Elliott SM. A comparison of the effect of two anaesthetic techniques on surgical conditions dur- ing gynaecological laparoscopy. Anaesthesia 2003;58:574–8 15. Staehr-Rye AK, Rasmussen LS, Rosenberg J, Juul P, Gätke MR. Optimized surgical space during low-pressure laparoscopy with deep neuromuscular blockade. Dan Med J 2013;60:A4579 16. Salonia A, Crescenti A, Suardi N, Memmo A, Naspro R, Bocciardi AM, Colombo R, Da Pozzo LF, Rigatti P, Montorsi F. General versus spinal anesthesia in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study. Urology 2004;64:95–100 17. King M, Sujirattanawimol N, Danielson DR, Hall BA, Schroeder DR, Warner DO. Requirements for muscle relax- ants during radical retropubic prostatectomy. Anesthesiology 2000;93:1392–7 18. Divine G, Norton HJ, Hunt R, Dienemann J. Statistical grand rounds: a review of analysis and sample size calculation con- siderations for Wilcoxon tests. Anesth Analg 2013;117:699–710 19. Dexter F. Wilcoxon-Mann-Whitney test used for data that are not normally distributed. Anesth Analg 2013;117:537–8 20. Barczyński M, Herman RM. A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy. Surg Endosc 2003;17:533–8 21. Joshipura VP, Haribhakti SP, Patel NR, Naik RP, Soni HN, Patel B, Bhavsar MS, Narwaria MB, Thakker R. A prospective ran- domized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystec- tomy. Surg Laparosc Endosc Percutan Tech 2009;19:234–40 22. Sarli L, Costi R, Sansebastiano G, Trivelli M, Roncoroni L. Prospective randomized trial of low-pressure pneumoperito- neum for reduction of shoulder-tip pain following laparoscopy. Br J Surg 2000;87:1161–5 23. Perrakis E, Vezakis A, Velimezis G, Savanis G, Deverakis S, Antoniades J, Sagkana E. Randomized comparison between different insufflation pressures for laparoscopic cholecystec- tomy. Surg Laparosc Endosc Percutan Tech 2003;13:245–9 24. Kandil TS, El Hefnawy E. Shoulder pain following laparoscopic cholecystectomy: factors affecting the incidence and severity. J Laparoendosc Adv Surg Tech A 2010;20:677–82 25. Yasir M, Mehta KS, Banday VH, Aiman A, Masood I, Iqbal B. Evaluation of post operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparo- scopic cholecystectomy. Surgeon 2012;10:71–4 26. Meyhoff CS, Lund J, Jenstrup MT, Claudius C, Sørensen AM, Viby-Mogensen J, Rasmussen LS. Should dosing of rocuronium in obese patients be based on ideal or corrected body weight? Anesth Analg 2009;109:787–92 27. Tammisto T, Olkkola KT. Dependence of the adequacy of mus- cle relaxation on the degree of neuromuscular block and depth of enflurane anesthesia during abdominal surgery. Anesth Analg 1995;80:543–7 28. Moerer O, Baller C, Hinz J, Buscher H, Crozier TA. Neuromuscular effects of rapacuronium on the diaphragm and skeletal muscles in anaesthetized patients using cervical magnetic stimulation for stimulating the phrenic nerves. Eur J Anaesthesiol 2002;19:883–7 29. Dhonneur G, Kirov K, Slavov V, Duvaldestin P. Effects of an intubating dose of succinylcholine and rocuronium on the lar- ynx and diaphragm: an electromyographic study in humans. Anesthesiology 1999;90:951–5
  • 9. 1092   www.anesthesia-analgesia.org anesthesia analgesia Optimizing Surgical Space Conditions 30. Donati F, Meistelman C, Plaud B. Vecuronium neuromuscular blockade at the diaphragm, orbicularis oculi and adductor pol- licis muscles. Can J Anaesth 1990;37:S13 31. Pansard JL, Chauvin M, Lebrault C, Gauneau P, Duvaldestin P. Effect of an intubating dose of succinylcholine and atracurium on the diaphragm and the adductor pollicis muscle in humans. Anesthesiology 1987;67:326–30 32. Ibrahim S, Hean TK, Ho LS, Ravintharan T, Chye TN, Chee CH. Risk factors for conversion to open surgery in patients undergoing laparoscopic cholecystectomy. World J Surg 2006;30:1698–704 33. Thesbjerg SE, Harboe KM, Bardram L, Rosenberg J. Sex dif- ferences in laparoscopic cholecystectomy. Surg Endosc 2010;24:3068–72
  • 10. Annotations Surgical space conditions during low-pressure laparoscopic cholecystectomy with deep versus moderate neuromuscular blockade: A randomized clinical study Staehr-Rye, Anne K.; Rasmussen, Lars S.; Rosenberg, Jacob; Juul, Poul; Lindekaer, Astrid L.; Riber, Claus; Gätke, Mona R. 01 Mendeley User Page no. 1 6/4/2015 6:40 Le degré de relâchement musculaire en chirurgie coelioscopique de la vésicule biliaire fait partie du quotidien des discussions entre anesthésistes et chirurgiens au bloc opératoire. Au fond tous sont convaincus de l'efficacité du curare : le chirurgien qui le demande et l'anesthésiste qui pense lui à sa décurarisation.Cette étude teste curarisation profonde versus curarisation de routine dans la chirurgie coelioscopique de la vésicule biliaire. Avec comme première question est-ce qu'une curarisation profonde permet de travaillert avec une pression abdominable moindre?, pression dont on sait qu'elle est pourvoyeuse de douleur post-opératoire.La réponse est que le degré de curarisation participe de façon marginale au confort du chirurgien... et ne permet pas plus fréquemment de travailler à pression abdominale basse.