The depth of neuromuscular block does reduce the values of pneumoperitoneum and its consequences.
There is no relationship directly between dept of block and values of pneumoperitoneum. But, patient's diaphragmatic effort associated with insufficient block may increase gas leakage from laparoscopic holes. Moreover at our hospital, surgeons says that ''hey what's going on man? the patient is performing belly dance:)) ''
Some recent works show the contrary: see the article by John Vlot of surgical endoscopy may 2013, Martini BJA (3) 2014; I have seen that increasing the neuromuscular blockade is possible to reduce the values of the pneumoperitoneum.
I guess that what Dr. Consani means is that a deeper block would allow for a better pneumoperitoneum (or at least one of an equal quality) but with lower intraabdominal pressure values. I have observed this behavior frequently during surgery. Even the surgeons notice it, some of them start complaining about muscular blockade the minute they see the intraabdominal pressure starts to climb.
Yes, increasing the neuromuscular block is possible to reduce the pneumoperitoneum and reach values as in robotic surgery 8mmhg.
Do you use neromuscular monitorization routinly? What is the end point for depth?
yes, I routinely use neuromuscular monitoring and the end point for depth is Post tetanic count ( PTC) < a 5 always PTC 1-2.
In my practice, I see a lot of laparoscopic Nissen fundoplication surgery I find a very deep block is required to prevent diaphragmatic movement. By this I mean a PTC of at least about 5. Hence i don't find this that helpful- the surgeon usually can detect the recovery of the diaphragm before my monitors (Because the surgeon is operating on the diaphragm, and it is the most resistant muscle to neuromuscular blockade,)
Of course the surgery finishes very quickly and it is difficult to fully reverse the patient quickly or is very expensive as a large dose of sugammadex is required.
I find that using a remifentanil infusion suppresses the diaphragmatic movements and allows the surgery to proceed even when the neuromuscular block has worn off. In some patients, a small top up of roc is required, but frequently not. Reversal is then not a problem, and the remi wears off quickly.
Adequate anaesthesia ( Entropy 40 to 50) , adequate analgesia (Remifental 4- 6ng/mls Effect site concentration) with deep blockade (PTC 1 -3) may be required in some individuals to optimise surgical field vision and provide optimal surgical conditions. One bariatric surgeon I work with regularly will generally note decreased surgical field vision just before TOF count of one appears using electromyography at the abductor digiti minimi.
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