Name: deep neuromuscular blockade leads to a larger intraabdominal volume during laparoscopy
Uploaded: 2013-06-25T12:00:00
Description: Watch this Scientific Journal Video about Deep Neuromuscular Blockade Leads to a Larger Intraabdominal Volume During Laparoscopy at JoVE.com

1. Case Presentation
<ol>
	<li>The patient is set up for a visit at the gynecological clinic, often due to the occurrence of bleeding disorders. A physical examination is performed.
	<ol>
		<li>If deemed appropriate, the patient is scheduled for a hysterectomy. The paperwork is prepared, and the patient is given the premedication for the day of surgery.</li>
		<li>Patients 60 years and older must first submit blood samples and monitored by electrocardiography (or ECG) prior to the procedure.</li>
	</ol>
	</li>
...

<ol>
	<li>Jones, R. K., Caldwell, J. E., Sorin, C. B., Brull, J., Soto, R. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reversal+of+Profound+Rocuronium-induced+Blockade+with+Sugammadex.">Reversal of Profound Rocuronium-induced Blockade with Sugammadex.</a> Anesthesiology. 109, 816-824 (2008).</li><li>Berg, H., Roed, J., Viby-Mogensen, J., Mortensen, C. R., Enfbaek, J., Skovgaard, L. T., Krintel, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Residual+neuromuscular+block+is+a+risk+factor+for+post-operative+pulmonary+complications:+A+prospective,+randomized,+and+blinded+study+of+postoperative+pulmonary+complications+after+atracurium,+vecuronium+and+pancuronium.">Residual neuromuscular block is a risk factor for post-operative pulmonary complications: A prospective, randomized, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium.</a> Acta Anaesthesiol. Scand. 41, 1095-1103 (1997).</li><li>Abrishami, A., Ho, J., Wong, J., Yin, L., Chung, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sugammadex,+a+selective+reversal+medication+for+preventing+postoperative+residual+neuromuscular+blockade.">Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade.</a> The Cochrane Collaborations. , (2009).</li><li>Plaud, B., Debaene, B., Donati, F., Marty, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Residual+Paralysis+after+Emergence+from+Anesthesia.">Residual Paralysis after Emergence from Anesthesia.</a> Anesthesiology. 112, 1013-1022 (2010).</li><li>Lee, D. W., Kim, M. J., Lee, Y. K., Lee, H. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+Intraabdominal+Pressure+Affect+Development+of+Subcutaneous+Emphysema+at+Gynecologic+Laparoscopy?.">Does Intraabdominal Pressure Affect Development of Subcutaneous Emphysema at Gynecologic Laparoscopy?.</a> Minimally Invasive Gynecology. , 761-765 (2011).</li><li>Sandhu, T., Yamada, S., Ariyakachon, V., Chakrabandhu, T., Chongruksut, W., Ko-iam, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low-pressure+pneumoperitoneum+versus+standard+pneumoperitoneum+in+laparoscopic+cholecystectomy,+a+prospective+randomized+clinical+trial.">Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial.</a> Surg. Endosc. 23, 1044-1047 (2009).</li><li>Sarli, L., Coisti, R., Sansebastiano, G., Trivelli, M., Roncoroni, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+randomized+trial+of+low-pressure+pneumoperitoneum+for+reduction+of+shoulder-tip+pain+following+laparoscopy.">Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy.</a> British Journal of Surgery. 87, 1161-1165 (2000).</li><li>Kandil, T. S., El Hefnawy, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Shoulder+pain+following+laparoscopic+cholecystectomy:+factors+affecting+the+incidence+and+severity.">Shoulder pain following laparoscopic cholecystectomy: factors affecting the incidence and severity.</a> J. Laparoendosc. Adv. Surg. Tech. A. 8, 677-682 (2010).</li><li>Mulier, J. P., Dillemans, B. R. S., Crombach, M., Missant, C., Sels, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=On+the+abdominal+pressure+volume+relationship.">On the abdominal pressure volume relationship.</a> The internet Journal of Anesthesiology. 21, (2009).</li><li>Srvastava, A., Niranjan, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Secrets+of+safe+laparoscopic+surgery:+Anaesthetic+and+surgical+considerations.">Secrets of safe laparoscopic surgery: Anaesthetic and surgical considerations.</a> J. Minim. Access. Surg. 6, 91-94 (2010).</li><li>Grosse-Sundrup, M., Henneman, J. P., Sandberg, W. S., Bateman, B. T., Uribe, J. V., Nguyen, N. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intermediate+acting+non-depolarizing+neuromuscular+blocking+agents+and+risk+of+postoperative+respiratory+complications:+prospective+propensity+score+matched+cohort+study.">Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study.</a> BMJ. 345, e6329 (2012).</li><li>Kaneko, G., Miyajima, A., Yazawa, S., Yuge, K., Kikuchi, E., Asanuma, H., Nakagawa, K., Oya, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=What+is+the+predictor+of+prolonged+operative+time+during+laparoscopic+radical+prostatectomy?.">What is the predictor of prolonged operative time during laparoscopic radical prostatectomy?.</a> Int. J. Urol. 20 (3), 330-336 (2012).</li><li>Drahonovsky, J., Haakova, L., Otcenasek, M., Krofta, L., Kucera, E., Feyereisl, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+randomized+comparison+of+vaginal+hysterectomy,+laparoscopically+assisted+vaginal+hysterectomy,+and+total+laparoscopic+hysterectomy+in+women+with+benign+uterine+disease.">A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease.</a> Eur. J. Obstet. Gynecol. Reprod. Biol. 148 (2), 172-176 (2010).</li></ol>

Directly calculating the working volume available for laproscopic surgery is difficult, but the relationship between insufflating CO2 pressure and abdominal volume is easier to measure9. Here, we present a method to use the surgical grasper to estimate the space within the abdomen during insufflation, as an alternative to the method of recording the volume of insufflated CO2. These measurements have demonstrated that it is possible to maintain a steady volume when loweri...

Neuromuscular blocking agents are commonly used to facilitate tracheal intubation, and, during anesthesia, to facilitate surgery. The use of pharmacological agents to achieve deep relaxation throughout the laparoscopic procedure allows the surgeons either to proceed at the same level of CO2 insufflation while benefitting from better surgical conditions, or lowering the insufflating pressure to lower the risk of surgical complications. Several studies have shown the positive effect of lowering the working pressure 5,6,7. One symptom that is often seen after laparoscopic hysterectomies is shoulder pain, which is often stated as a major problem and the most important issue when speaking to the patient at follow up.8
Laproscopic myomectomy or hysterectomy is usually recommended when more conservative methods fail to control the symptoms caused by uterine fibroids. At our institution, these procedures are performed at an insufflating CO2 pressure of 12 mm Hg. There are two highly experienced gynecologists performing all the gynecologic cases. All our cases are anaesthetized with propofol and remifentanil, and intubation is often facilitated with a low dose of rocuronium (15 mg).
From our daily clinical work we have identified shoulder pain as one of the most disturbing side effects after laparoscopic hysterectomies, which is supported by the literature 8. Studies have shown that reducing the intraabdominal pressure can also reduce shoulder pain. In an effort to reduce the CO2 insufflation pressure, one of our prior concerns was if the surgical field and visibility during the procedure would be compromised. Trying to determine the overview during the procedure, we set up a method to compare the intraabdominal working space. However, it can be very difficult to monitor the exact intra-abdominal volume within a patient during surgery. In a Belgian study, the volume-pressure relationship has been described, but the study authors concluded that there are major inter individual variations 9. In order to get a more reliable statement of the intraabdominal space, we use the distance from the promontory to the skin as the metric.

deep neuromuscular blockade leads to a larger intraabdominal volume during laparoscopy

Shoulder pain is a commonly reported symptom following laparoscopic procedures such as myomectomy or hysterectomy, and recent studies have shown that lowering the insufflation pressure during surgery may reduce the risk of post-operative pain. In this pilot study, a method is presented for measuring the intra-abdominal space available to the surgeon during laproscopy, in order to examine whether the relaxation produced by deep neuromuscular blockade can increase the working surgical space sufficiently to permit a reduction in the CO2 insufflation pressure. Using the laproscopic grasper, the distance from the promontory to the skin is measured at two different insufflation pressures: 8 mm Hg and 12 mm Hg. After the initial measurements, a neuromuscular blocking agent (rocuronium) is administered to the patient and the intra-abdominal volume is measured again. Pilot data collected from 15 patients shows that the intra-abdominal space at 8 mm Hg with blockade is comparable to the intra-abdominal space measured at 12 mm Hg without blockade. The impact of neuromuscular blockade was not correlated with patient height, weight, BMI, and age. Thus, using neuromuscular blockade to maintain a steady volume while reducing insufflation pressure may produce improved patient outcomes.

This pilot study of 15 patients was performed to assess the impact of deep neuromuscular blockade during laparoscopic surgery.
The method illustrated here was used to obtain measurements of intra-abdominal space in patients undergoing laparoscopic hysterectomy (Figure 1). In each patient, measurements of intra-abdominal space were taken under the following conditions: 12 mm Hg pressure without deep neuromuscular blockade, 12 mm Hg with blockade, 8 mm Hg without blockade, and ...

Watch this Scientific Journal Video about Deep Neuromuscular Blockade Leads to a Larger Intraabdominal Volume During Laparoscopy at JoVE.com

Deep Neuromuscular Blockade Leads to a Larger Intraabdominal Volume During Laparoscopy

This article presents a method for measuring the working abdominal volume during laproscopic myomectomy using the surgical grasper, and applies this technique to obtain pilot data on whether deep neuromuscular blockade (NMB) can enable the use of lower insufflation pressure. Reduced insufflation pressure during laproscopic surgery has been shown to reduce post-operative pain, and thus the use of NMB during surgery may enable improved patient outcomes.

Shoulder pain is a commonly reported symptom following laparoscopic procedures such as myomectomy or hysterectomy, and recent studies have shown that ...

Research

JoVE Journal

Medicine

Intra-Operative Behavioral Tasks in Awake Humans Undergoing Deep Brain Stimulation Surgery

Deep brain stimulation (DBS) is a surgical procedure that directs chronic, high frequency electrical stimulation to specific targets in the brain through ...

Dorsal Column Steerability with Dual Parallel Leads using Dedicated Power Sources:  A Computational Model

In spinal cord stimulation (SCS), concordance of stimulation-induced paresthesia over painful body regions is a necessary condition for therapeutic ...

Utilizing Transcranial Magnetic Stimulation to Study the Human Neuromuscular System

Transcranial magnetic stimulation (TMS) has been in use for more than 20 years 1, and has grown exponentially in popularity over the past decade.  While ...

A Murine Model of Muscle Training by Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is a common clinical modality that is widely used to restore1, maintain2 or enhance3-5 muscle functional ...

Construction of Vapor Chambers Used to Expose Mice to Alcohol During the Equivalent of all Three Trimesters of Human Development

Exposure to alcohol during development can result in a constellation of morphological and behavioral abnormalities that are collectively known as Fetal ...

Clinical Assessment of Spatiotemporal Gait Parameters in Patients and Older Adults

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and ...

Using Saccadometry with Deep Brain Stimulation to Study Normal and Pathological Brain Function

The oculomotor system involves a large number of brain areas including parts of the basal ganglia, and various neurodegenerative diseases including ...

Assessment of Pulmonary Capillary Blood Volume, Membrane Diffusing Capacity, and Intrapulmonary Arteriovenous Anastomoses During Exercise

Exercise is a stress to the pulmonary vasculature. With incremental exercise, the pulmonary diffusing capacity (DLCO) must increase to meet the increased ...

A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...