There is increasing evidence for the use of lower insufflation pressures during laparoscopic surgery [
1‐
5]. Consensus guidelines recommend using the lowest intra-abdominal pressure with an adequate view of the surgical field [
6,
7]. This level varies between patients based on many factors that influence compliance of the abdominal wall. Deep neuromuscular blockade (NMB) allows for a safe reduction in intra-abdominal pressure without compromising the quality of the surgical field. Our research group has performed multiple studies investigating surgical conditions in living kidney donors. In a randomized controlled trial in laparoscopic donor nephrectomy patients, we show that compared to moderate NMB, deep NMB allows for lower mean insufflation pressures while maintaining significantly better surgical conditions on the Leiden-Surgical Rating Scale (L-SRS, displayed in Table
1) [
9]. Similar results have been reported for surgical conditions during other abdominal laparoscopic procedures. Meta-analysis shows that compared to moderate NMB, deep NMB improves laparoscopic surgical space conditions with a mean difference of 0.65 (95% CI 0.47–0.83) on the L-SRS scale [
10]. While there is considerable evidence to support superior surgical conditions during deep NMB, only a limited amount of studies investigate patient outcomes. Moreover, results are not always consistent between studies. Understandably, results can vary between different types of laparoscopic surgery. As carefully outlined by Fuchs-Buder and colleagues in their review, the location of the surgical field (e.g., is the space confined, encompassed by muscular tissue or close to the diaphragm) will have a great influence on the effect of lower pneumoperitoneum pressures or deep neuromuscular block on surgical conditions [
11]. A systematic review by Madsen et al. provides evidence for the use of deep NMB during laparoscopic cholecystectomy, prostatectomy, and nephrectomy [
12]. Results of Torensma et al. support deep NMB during laparoscopic bariatric surgery [
13]. Only a few studies have investigated the influence of lower intra-abdominal pressure or deep NMB on surgical conditions and patient outcomes for colorectal laparoscopic surgery. Koo et al. found less abrupt increases in intra-abdominal pressure with deep NMB as compared to moderate NMB [
14]. Cho and colleagues found decreasing intra-abdominal pressure during laparoscopic colorectal surgery provides no cardiopulmonary benefits, regardless of the level of NMB [
15]. Diaz-Cambronero et al. used an individualized strategy to titrate intra-abdominal pressure and found 78% of colorectal surgeries could be completed at low pressure (8 mmhg) [
16]. Kim et al. found that compared to moderate NMB, deep NMB allows titration to lower insufflation pressures (9.3 mmHg versus 12 mmHg) while maintaining the surgical field. Additionally, they report lower postoperative pain scores, a lower incidence of postoperative shoulder tip pain and faster recovery of bowel function in the deep NMB group [
17]. Whether low pressure pneumoperitoneum and deep NMB improve early quality of recovery after laparoscopic colorectal surgery is still unknown. We hypothesize low pressure pneumoperitoneum facilitated by deep NMB will enhance postoperative quality of recovery.
Table 1Leiden-Surgical Rating Scale [
8]
1 | Extremely poor conditions | The surgeon is unable to work due to coughing or due to the inability to obtain a visible laparoscopic field because of inadequate muscle relaxation. Additional muscle relaxants must be given. |
2 | Poor conditions | There is a visible laparoscopic field but the surgeon is severely hampered by inadequate muscle relaxation with continuous muscle contractions and/or movements with the hazard of tissue damage. Additional muscle relaxants must be given. |
3 | Acceptable conditions | There is a wide visible laparoscopic field but muscle contractions and/or movements occur regularly causing some interference with the surgeon’s work. There is the need for additional muscle relaxants to prevent deterioration. |
4 | Good conditions | There is a wide laparoscopic working field with sporadic muscle contractions and/or movements. There is no immediate need for additional muscle relaxants unless there is the fear for deterioration. |
5 | Optimal conditions | There is a wide visible laparoscopic working field without any movement or contractions. There is no need for additional muscle relaxants. |