Low Pressure Pneumoperitoneum and Deep Neuromuscular Blockade Versus Standard Laparoscopy During RARP to Improve the Quality of Recovery and Immune Homeostasis; Study Protocol for a Randomized Controlled Study
Phase: NA
Conditions: Quality of Life, Postoperative Complications, Acute Pain, Immune System Tolerance
Sponsor: Radboud University Medical Center

 
 
RECOVER - 2 
 
 
Low impact laparoscopy (low pressure pneumoperitoneum and deep 
neuromuscular blockade) versus standard laparoscopy during robot 
assisted radical prostatectomy to improve the quality of recovery and 
immune homeostasis; a randomized controlled study. 
 
 
 
 
 
 
 
 
 
 
 
 
NCT number: NCT04250883 
 
Versie 1.6, 14-05-2020 
Verrichter: Radboud umc 
Principal investigator: M. Warle 
Researcher PhD: G.T.J.A. Reijnders 
 

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Inhoud 
1 
INTRODUCTION AND RATIONALE .................................................................................................. 6 
2 
OBJECTIVES ................................................................................................................................... 10 
3 
STUDY DESIGN .............................................................................................................................. 10 
4 
STUDY POPULATION ..................................................................................................................... 11 
4.1 
Population ............................................................................................................................. 11 
4.2 
Inclusion criteria ................................................................................................................... 11 
4.3 
Exclusion criteria ................................................................................................................... 11 
4.4 
Sample size calculation ......................................................................................................... 12 
5 
TREATMENT OF SUBJECTS ............................................................................................................ 12 
5.1 
Investigational product/treatment ...................................................................................... 12 
5.2 
Use of co-intervention (if applicable) .................................................................................. 14 
5.3 
Escape medication (if applicable) ......................................................................................... 14 
6 
NON-INVESTIGATIONAL PRODUCT .............................................................................................. 15 
7 
INVESTIGATIONAL PRODUCT ....................................................................................................... 15 
7.1 
Name and description of non-investigational product(s) ................................................... 15 
7.2 
Summary of findings from non-clinical studies ................................................................... 15 
7.3 
Summary of findings from clinical studies ........................................................................... 15 
7.4 
Summary of known and potential risks and benefits.......................................................... 16 
7.5 
Description and justification of route of administration and dosage ................................. 17 
7.6 
Dosages, dosage modifications and method of administration ......................................... 17 
7.7 
Preparation and labelling of non-investigational medicinal product ................................. 18 
7.8 
Drug accountability ............................................................................................................... 18 
8 
METHODS ...................................................................................................................................... 19 
8.1 
Main study endpoints ........................................................................................................... 19 
8.2 
Other study parameters ....................................................................................................... 19 
8.3 
Study procedures .................................................................................................................. 20 
9 
SAFETY REPORTING ...................................................................................................................... 22 
9.1 
Temporary halt for reasons of subject safety ...................................................................... 22 
9.2 
AE’s, SAE’s and SUSAR’s ....................................................................................................... 22 
9.2.1 
Adverse events (AE’s) ................................................................................................... 22 
9.2.2 
Serious adverse events (SAE’s) ..................................................................................... 22 
9.2.3 
Suspected Unexpected serious adverse reactions (SUSAR’s) ..................................... 23 
9.3 
Annual safety report ............................................................................................................. 23 

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9.4 
Follow-up of adverse events ................................................................................................ 23 
9.5 
Data Safety Monitoring Board (DSMB) ................................................................................ 23 
10 
STATISTICAL ANALYSIS.............................................................................................................. 24 
10.1 
Primary study parameter(s) ................................................................................................. 24 
10.2 
Secondary study parameter(s) ............................................................................................. 24 
10.3 
Interim analyse ..................................................................................................................... 24 
11 
ETHICAL CONSIDERATIONS ....................................................................................................... 25 
11.1 
Regulation statement ........................................................................................................... 25 
11.2 
Recruitment and consent ..................................................................................................... 25 
11.3 
Benefits and risks assessment .............................................................................................. 25 
11.4 
Compensation for injury ....................................................................................................... 26 
12 
ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION .............................................. 27 
12.1 
Handling and storage of data and documents ..................................................................... 27 
12.2 
Monitoring and quality assurance ....................................................................................... 27 
12.3 
Amendments ......................................................................................................................... 27 
12.4 
Annual progress report ......................................................................................................... 27 
12.5 
Temporary halt and (prematurely) end of study report ..................................................... 27 
12.6 
Public disclosure and publication policy .............................................................................. 28 
13 
STRUCTURED RISK ANALYSIS .................................................................................................... 29 
13.1 
Potential issues of concern ................................................................................................... 29 
13.2 
Synthesis ............................................................................................................................... 29 
14 
REFERENCES .............................................................................................................................. 32 
 
 
 

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SUMMARY 
Rationale: Intra-abdominal pressure (IAP) needed to create sufficient workspace during 
laparoscopic surgery affects the surrounding organs with ischemia-reperfusion injury and a 
systemic immune response. This effect is related to postoperative recovery, pain scores, 
opioid consumption, bowel function recovery, morbidity and possibly mortality. In clinical 
practice standard pressures of 12-16mmHg are applied instead of the lowest possible IAP, but 
accumulating evidence shows lower pressure pneumoperitoneum (PNP) (6-8mmHg) to be 
non-compromising for sufficient workspace, when combined with deep neuromuscular 
blockade (NMB) in a vast majority of patients. Therefore, low impact laparoscopy, meaning 
low pressure PNP facilitated by deep NMB, could be a valuable addition to Enhanced Recovery 
After Surgery (ERAS) Protocols. 
Increased IAP can cause peritoneal mesothelial injury either directly or by compression of 
small vessels including capillaries, leading to a variable degree of ischemia reperfusion injury. 
The compromised perfusion of the parietal peritoneum can be visualized and quantified by a 
fluorescent marker such as Indocyanine green (ICG), as shown in a previous pilot study. 
Hypoxic injury of intra-abdominal organs and/or tissues may cause the release of Danger 
Associated Molecular Patterns (DAMPs). It is known that after trauma and sepsis, the release 
of DAMPs is associated with immunoparalysis and a higher susceptibility to infectious 
complications. The use of low pressure PNP may reduce hypoxic injury and the release of 
DAMPs and thereby contributing to a better preservation of innate immune function which 
may help to reduce the risk of infectious complications. 
 
Objective: 
Primary objectives: 
- 
To establish the relationship between the use of deep neuromuscular blockade (NMB) 
with low pressure pneumoperitoneum (PNP) and the quality of recovery after RARP. 
- 
To establish the relationship between the use of deep neuromuscular blockade (NMB) 
with low pressure pneumoperitoneum (PNP) and innate immune function after RARP. 
Secondary objectives:  
- 
To study whether low pressure PNP and/or deep NMB affects the perfusion of the 
parietal peritoneal layer during RARP. 
Study design: A mono-center, randomized controlled clinical trial. 
 
Study population:  Adult patients undergoing elective RARP without extended lymph node 
dissection. 
 
Intervention: The participants will be randomly assigned in a 1:1 fashion to: 
A. Experimental group: low impact laparoscopy (low pressure (8 mmHg) and deep NMB 
(PTC 1-2)) 

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B. Control group: standard laparoscopy (standard pressure (14 mmHg) and moderate 
NMB (TOF 1-2)) 
At the start of surgery, after intra-abdominal insufflation, ICG injection will take place to 
quantify parietal peritoneum perfusion, and a parietal peritoneal biopsy will be taken. At the 
end of surgery, a second parietal peritoneum biopsy will be taken.  
 
Main study parameters/endpoints: 
Primary endpoints 
- 
Quality of recovery score (QoR-40) at postoperative day 1. 
- 
IL-6 and IL-10 response upon whole blood LPS stimulation at postoperative day 7. 
- 
Perfusion index of the parietal peritoneum as calculated from the slope of ICG 
fluorescence intensity, and time to maximal intensity in seconds. (extracted from video 
registration).  
Secondary endpoints 
- 
QoR-40 score (day 1 and day 10-12), SF-36 score (1 day before, 10-12 days and 3 
months after surgery), McGill pain questionnaire (3 months after surgery). 
- 
Pain scores, analgesia use, PONV, time to reach discharge criteria, length of hospital 
stay, surgical conditions and postoperative complications  scored by Clavien Dindo 
classification (table 2 (1)). 
 
Nature and extent of the burden and risks associated with participation: 
The use of a deep NMB enables the safe use of low-pressure PNP. If despite a deep NMB 
visibility is compromised, pressure will be increased to minimize surgery related risks. A deep 
NMB is achieved by higher doses of rocuronium which are within normal therapeutic range 
used in clinical practice, and is safe to use. Depth of NMB will be monitored throughout the 
whole surgery. At the end of surgery, the effects of rocuronium will be antagonized by 
sugammadex to avoid residual paralysis. Indocyanine green is a registered product routinely 
used to quantify tissue perfusion during this surgery. The total dose during surgery is below 
the advised maximum dose of 5 mg/kg. Any possible risk factors or interactions as mentioned 
in the Summary of Product Characteristics are covered by exclusion criteria in order to fully 
eliminate risk of participation. Regarding the peritoneal biopsies; peritoneal tissue is directly 
visible and easily accessible during laparoscopic surgery and biopsies are obtained in a 
standardized manner with hemostasis when needed under direct vision. Therefore, no 
additional complications are expected. Blood samples will be combined with routine 
laboratory assessment where possible. Previous studies have shown low-pressure PNP is 
associated with reduced postoperative pain scores, reduced opioid consumption and 
improved bowel function. This may lead to enhanced recovery. The burden for participants is 
mainly related to the evaluation of the endpoints during the early postoperative phase. 
Assessment of pain scores, nausea, complications and discharge criteria are part of the normal 
treatment. Questionnaires will take approximately 10-15 minutes per time-point. 
 

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1 INTRODUCTION AND RATIONALE  
 
Release of DAMPs in surgical patients 
By induction of a pneumoperitoneum with carbon dioxide (CO2) a surgical field is created for 
laparoscopic surgery. A sufficient surgical field is important because of the intra-operative 
complications related to a limited workspace, although the side-effects of an increased IAP 
are just as important, but not directly present. The pressure to maintain a sufficient workspace 
affects the surrounding organs and vasculature. Standard PNP (usually 12-14 mmHg) causes a 
temporarily decreased perfusion leading to ischemia-reperfusion injury with oxidative stress 
and release of Danger Associated Molecular Patterns (DAMPs) (2–7). DAMPs elicit  an immune 
response of innate immune cells, which results in a systemic inflammatory response syndrome 
(SIRS) followed by a compensatory anti-inflammatory reaction (8). This response causes 
sensitization of nociceptors enhancing postoperative pain, the anti-inflammatory reaction is 
related to fatigue and leaves more susceptibility for infections (9–11). Maca et al. shows the 
relation between DAMPs and the degree of surgical trauma, and predicted morbidity and 
mortality after elective major abdominal 
surgery (12). Fragidiakis et al described a 
strong correlation between immune status 
and 
recovery 
from 
surgery. 
Signaling 
responses downstream in monocytes were 
particularly strong correlates of recovery 
outcomes including pain and fatigue (13).  
Upon (surgical) trauma DAMPS e.g. nuclear 
DNA, Heat Shock Protein-70, mitochondrial 
DNA, are released and bind to receptors on 
immune cells such as macrophages, which 
induces 
an 
anti-inflammatory 
response 
predominantly characterized by IL-10 release. 
In turn this leads to immune suppression, 
reflected by decreased monocytic HLA-DR 
expression as well as reduces production of 
TNF-alpha and IL-6 and increased production 
of IL-10 upon ex vivo stimulation with LPS 
(figure 1 (14)).  
 
Alternatively,  DAMPs can exert direct 
immunosuppressive effects, such as HSP10-
induced LPS-tolerance in monocytes. All these 
events take place in a very early phase after 
surgery. 
Figure 1. Adapted from Timmermans et al. (14) 

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Low pressure PNP and immune homeostasis after surgery 
Accumulating evidence shows the safety and advantages of low-pressure PNP (6-8mmHg); 
clinically relevant reduction in postoperative pain (15,16), reduced cumulative opioid 
consumption (17) and improved bowel function (16,18). Furthermore, it preserves innate 
immune homeostasis, reflected by reduced increase in pro-inflammatory mediators IL-6, IL-
10 and TNF-alfa (19–22). And a reduced decrease in monocytic HLA-DR expression (19). 
Therefore, it is of clinical importance to elucidate the relation between the degree of PNP with 
its peritoneal and organ perfusion and preservation of innate immune function, to enhance 
postoperative recovery. 
A limited number of studies investigated the immune response after low pressure 
laparoscopy. It was found that low pressure pneumoperitoneum was associated with a 
reduced increase in serum levels of pro-inflammatory cytokines like IL-6 and TNF-alpha (19–
21) and also with lower levels of anti-
inflammatory 
IL-10 
(22). 
Moreover, 
Schietroma et al. also described a better 
preservation of monocyte function as 
reflected by higher levels of HLA-DR 
expression on monocytes (19). Altogether 
this provides indirect evidence that lower 
intra-abdominal pressures may contribute 
to recovery by a reduced stress response 
and subsequently a better preservation of 
innate immune function as compared to 
laparoscopy with higher intra-abdominal 
pressures. The interim-analysis of the 
RECOVER 
PLUS 
study 
showed 
that 
patients 
undergoing 
laparoscopic 
colorectal surgery showed a reduced ex 
vivo TNF- and IL-6 response upon whole 
blood stimulation at postoperative day 1 
which reflects immune suppression due to 
surgical trauma (Figure 2) (23). 
Patients allocated to low pressure PNP 
with deep NMB the TNF- response was 
almost 
restored 
to 
baseline 
at 
postoperative day 3, whereas patients 
allocated to standard pressure with 
moderate NMB showed ongoing immune 
suppression.  
Figure 2. Preliminary/interim results from the RECOVER PLUS study. 
After ex vivo stimulation of whole blood, the release of TNF-α and IL-6 
is significantly reduced at POD 1. In patients allocated to low pressure 
PNP with deep NMB, TNF-α release is almost restored as compared to 
baseline. This indicates that low pressure with deep NMB is associated 
with better preservation of immune function after laparoscopic 
colorectal surgery. (23) 

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To ensure the safety of  low-pressure PNP, deep NMB facilitates a sufficient surgical field. 
Several studies show a significant reduction in IAP with deep NMB compared to moderate 
NMB, without compromising surgical conditions in patients undergoing laparoscopic surgery 
(18,24). Current evidence indicates a reduction of 3-4mmHg of IAP when deep NMB is used, 
with a sufficient and safe surgical field measured and quantified by Leiden-surgical-rating-
scale (L-SRS) (25).  
Low pressure PNP improves intra-abdominal perfusion 
Our group performed the PERFUSION study in which patients undergoing robot assisted 
laparoscopic colorectal surgery were allocated to an intra-abdominal pressure of 8, 12, or 16 
mmHg. Subsequently fluorescence of the parietal peritoneum was recorded after injection of 
a standardized dose of indocyanine green (26). The time to maximum fluorescent intensity 
was significantly lower in patients allocated to 8 mmHg. Also, the maximal fluorescent 
intensity was significantly lower at 8 mmHg as compared to 12 and 16 mmHg (Figure 3). These 
data indicate that perfusion of intra-abdominal organs and/or tissues is better below 12 
mmHg.  
 
Figure 3. Recordings of 
the parietal peritoneum 
after injection of a bolus 
of indocyanine green. 
The images are typical 
examples 
of 
three 
patients 
representing 
the 
mean 
time 
to 
maximum 
fluorescent 
intensity at 8, 12 and 16 
mmHg. (26) 
 
 
Figure 4. Preliminary/interim results from the RECOVER PLUS 
study. The increase in expression of HIF-1ain peritoneal biopsy 
after laparoscopic colorectal surgery compared to the intra-
abdominal pressure used. Values are presented as means with 
standard error of the mean. 8 mmHg (n=4), 10 mmHg (n=3), 12 
mmHg (n=12). (26) 
 
 
 

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Biopsies of the parietal peritoneum were taken after trocar introduction and at the end of 
surgery. Patients who underwent surgery with a pneumoperitoneum pressure of 8 or 10 
mmHg showed lower expression of Hypoxia Induced Factor-1a as compared to those with an 
intra-abdominal pressure of 12 mmHg. These data support the hypothesis that the use of 
intra-abdominal pressures below 12 mmHg leads to an improved perfusion of intra-abdominal 
organs and tissues and thereby reducing hypoxia and ischemic injury. 
The aim of this study is to assess the mechanisms and impact of low pressure on: 
- 
perfusion of the parietal peritoneum, 
- 
tissue markers of ischemia and inflammation in the parietal peritoneum, 
- 
serum cytokines and DAMP´s, 
- 
ex vivo innate immune function, 
- 
clinical outcomes i.e. pain scores, quality of recovery and (infectious) complications. 
The study is designed to reveal the precise mechanism underlying the clinical benefits of the 
use of low-pressure PNP facilitated by deep NMB. 
 

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2 OBJECTIVES    
Primary objectives: 
- 
To establish the relationship between the use of deep neuromuscular blockade (NMB) 
with low pressure pneumoperitoneum (PNP) and the quality of recovery after RARP. 
- 
To establish the relationship between the use of deep neuromuscular blockade (NMB) 
with low pressure pneumoperitoneum (PNP) and immune function after RARP. 
 
Secondary objectives:  
- 
To study whether low pressure PNP and/or deep NMB affects the perfusion of the 
parietal peritoneal layer during RARP. 
3 STUDY DESIGN   
A mono-center blinded randomized controlled clinical trial at the Canisius Wilhelmina Hospital 
in Nijmegen, where approximately 300 robot assisted radical prostatectomy (RARP) 
procedures are performed annually. We expect that the screening and inclusion period 
(recruitment period) will be 15 months.  
Treatments to be compared 
• Experimental group: Low impact laparoscopy; low pressure PNP (8 mmHg) and deep 
NMB 
and 
reversal 
of 
NMB 
with 
sugammadex 
4mg/kg. 
 
RARP
n=96
Moderate: Tof 1-3
Deep: PTC 1-2
RECOVER-2 STUDY
Prostate dissection
14 mmHg
(insufficient conditions:
14>16>18>20 mmHg)
Prostate dissection
8 mmHg
(insufficient conditions: 
8>10>12>14 mmHg)
Dorsal venous plexus transection
14 mmHg
Dorsal venous plexus transection
20 mmHg
Low Impact Laparoscopy
Standard Laparoscopy
Urethral reconstruction
8 mmHg
Urethral reconstruction
14 mmHg

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• Control group: Standard laparoscopy; standard pressure PNP (14 mmHg) and 
moderate NMB and spontaneous recovery of neuromuscular function (only if one or 
more additional boluses of rocuronium are required, it is allowed to reverse with 
sugammadex 2mg/kg) 
All study endpoints will be arbitrated by a blinded researcher. Also the perfusion index is 
extracted from video registration with MATLAB (R2017a version 9.2.0) by a researcher blinded 
to the level of pressure and NMB depth.  
4 STUDY POPULATION   
4.1 
Population  
Adult patient undergoing elective robot assisted radical prostatectomy  
 
4.2 
Inclusion criteria   
To participate in this trial, a subject must meet all of the following criteria: 
- 
Age ≥ 18 years 
- 
Undergoing elective robot assisted radical prostatectomy (RARP) 
- 
Obtained informed consent 
 
4.3 
Exclusion criteria   
A potential subject will be excluded from participation when meeting any of the 
following criteria: 
- 
Laparoscopic radical prostatectomy without robot assistance 
- 
Insufficient control of the Dutch language to read the patient information and to fill 
out de questionnaires 
- 
(Chronic) use of immunosuppressive medication 
- 
Chronic use of NSAID’s and/or opiods or psychotropic drugs 
- 
Use of NSAID’s shorter than 5 days before surgery 
- 
Severe liverdisease (Child-Pugh B and C) or chronic kidney disease (stage 4 and 5) 
- 
Neuromuscular disease 
- 
Hyperthyroidism or thyroid adenomas 
- 
Deficiency of vitamin K dependent clotting factors or coagulopathy 
- 
Planned diagnostics or treatment with radioactive iodine < 1 week after surgery 
- 
Indication for rapid sequence induction 
- 
BMI >35kg/m2  
- 
Known of suspected hypersensitivity to ICG, sodium iodide, iodine, rocuronium or 
sugammadex 
- 
Use of medication interfering with ICG absorption as listed in the summary of 
product characteristics (SPC); anticonvulsants, bisulphite compounds, haloperidol, 
heroin, meperidine, metamizol, methadone, morphium, nitrofurantoin, opium 
alkaloids, phenobarbital, phenylbutazone, cyclopropane, probencid.  
 

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4.4 
Sample size calculation 
The main study includes 48 patients per study arm (low impact and standard laparoscopy). 
With this number of patients we will have sufficient power for the primary and secondary 
analyses: 
1) Quality of recovery at POD 1 as reflected by the QoR-40 questionnaire. Although Myles et 
al. reported a minimal clinically relevant difference (MCID) of 6.3 for the QoR-40 
questionnaire, consensus about the MCID is lacking. As 6.3 is a relatively small difference 
on a scale ranging from 40-200, we feel that a MCID of 10 points is more appropriate. A 
sample size of 48 patients per group is needed to provide 90% power to detect a 10 point 
difference in the QoR-40 at POD 1 (alpha 5%) with an estimated standard deviation of 15. 
2) Innate immune function as reflected by the ex vivo release of IL-6 and IL-10 upon LPS 
stimulated leukocytes at POD 7. A sample size of 45 patients per group is needed to 
provide 90% power to detect a 3.000 pg/mL difference in IL-6 release (alpha 2.5%) with an 
estimated standard deviation of 4.000 pg/mL at POD 7. A sample size of 42 patients per 
group is needed to provide 90% power to detect a 50 pg/mL difference in IL-10 release 
(alpha 2.5%) with an estimated standard deviation of 65 pg/mL. As two cytokines are 
measured, a Bonferroni correction was used (alpha 2.5%). 
 
5 TREATMENT OF SUBJECTS 
5.1 
Investigational product/treatment 
The head practitioner will ask the patient for permission to let the researcher contact 
and inform him. After informed consent is given the participants will be randomly 
assigned in a 1:1 fashion to: 
- 
Experimental group: low impact laparoscopy (low pressure (8 mmHg) and deep NMB 
(PTC 1-2)) 
- 
Control group: standard laparoscopy (standard pressure (14 mmHg) and moderate 
NMB (TOF 1-2)) 
At the start of surgery, after intra-abdominal insufflation, ICG injection will take place with  
peritoneal perfusion, and a parietal peritoneal biopsy will be taken. At the end of surgery 
a second parietal peritoneum biopsy will be taken.  
 Perioperative ERAS protocol 
A standardized perioperative ERAS protocol is used for this study. Adherence of ERAS key 
elements (27) as presented by the ERAS society will be scored. 
Anesthesia protocol and titration of intra-abdominal pressure  
Standardized anesthesia protocol: 

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- 
Premedication according to local protocol 
- 
No epidural anesthesia: if conversion to open surgery is necessary, epidural anesthesia can 
be given postoperatively according to the preference of the attending anesthesiologist.  
- 
General anesthesia will be achieved with Total Intravenous Anesthesia (TIVA), 
consisting of propofol bolus 1-3 mg/kg and maintenance aimed at a bispectral index 
score between 45 and 55, remifentanil 0,25-2mcg/kg/min, lidocaine 1% 1-1,5mg/kg 
bolus followed by 0,5-3mg/kg/h and esketamine bolus 0,25-1mg/kg. 
- 
Dexamethason is avoided to prevent influencing the immune response 
- 
Neuromuscular monitoring is initiated, after the set-up and calibration procedures, 
with rocuronium (intubation dose 0,6mg/kg). Tracheal intubation is performed 2 
minutes after administration in all groups.  
- 
Postoperative pain management will be paracetamol and oxycodone or patient 
controlled analgesia (PCA) with morphine.  
- 
After introduction of the camera trocar, insufflation of carbon dioxide is titrated to an IAP 
of 8mmHg in the experimental group, and 14 mmHg in the control group. After placement  
of the last trocar the injection of ICG and video registration of peritoneum will take place, 
and a peritoneal biopsy will be taken. There after surgery will take place, for dissection of 
the venous plexus, IAP is titrated to 14 mmHg in the experimental group and 20mmHg in 
the controle group. A second parietal peritoneum biopsy will be taken at the end of 
surgery. If surgical conditions remain compromised despite adequate pressure and 
neuromuscular block, the surgeon can decide to convert to an open- or hand-assisted 
procedure.  
- 
Neuromuscular monitoring is initiated after set-up and calibration procedures.  
- 
The control group with standard laparoscopy will be monitored with TOF count 
every 5 minutes in standardized fashion. After intubation, a bolus or continuous 
infusion of rocuronium is administered as normally done in clinical practice, 
titrating towards TOF count 1-2. When TOF count is 0, infusion of rocuronium will 
be stopped until neuromuscular function is recovered to maximal TOF 2.  
- 
The experimental group with low impact laparoscopy will be monitored with PTC 
every 5 minutes. After intubation, continuous infusion of rocuronium (0,3-
0,4mg/kg) is started and titrated towards PTC 1-2. When PTC is 0, continuous 
infusion of rocuronium will be decreased, not stopped, until a PTC of 1-2 is reached.  
- 
During surgery patients are ventilated by pressure-regulated volume-controlled 
ventilation through an endotracheal tube with a mixture of oxygen in air, PEEP of 5cmH2O 
and tidal volumes between 6-8ml/kg. Minute ventilation is adjusted to main end-tidal 
carbon dioxide between 31-43mmHg by changing respiratory rate. Oxygenation is 
adjusted to main saturation between 97-100% by changing the mixture of oxygen in air. 
- 
According to local protocol a nasogastric tube will be placed for gastric decompression.  
- 
Minimal infusion of fluids and losses will be replaced. 
- 
Core temperature is measured continuously, aiming at 36-37 C. 
- 
The use of drains is avoided 

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- 
After skin closure, the NMB is reversed using sugammadex 4mg/kg in the experimental 
group, and 2mg/kg in the control group unless the TOF ratio is >0,9. If neuromuscular 
function has recovered spontaneously in the control group, no sugammadex will be 
administered.  
- 
Extubation will be performed when TOF ratio is stable at >0,9 for more than 2 minutes and 
the patient is fully awake.  
5.2 
Use of co-intervention (if applicable) 
Not applicable 
5.3 
Escape medication (if applicable) 
Not applicable 

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6 NON-INVESTIGATIONAL PRODUCT 
Not applicable 
7 INVESTIGATIONAL PRODUCT 
7.1 
Name and description of non-investigational product(s) 
 
a. Rocuronium 10 mg/ml solution for infusion. Rocuronium bromide is indicated as an 
adjunct to general anaesthesia to facilitate tracheal intubation during routine 
sequence induction and to provide skeletal muscle relaxation during surgery.  
b. Sugammadex (Bridion®) 100 mg/mL solution for injection. Bridion reverses 
neuromuscular blockade induced by rocuronium or vecuronium in adults, by selective 
binding with the relaxant agent.  
 
7.2 
Summary of findings from non-clinical studies 
 
a. Rocuronium: preclinical data reveal no special hazard for humans based on 
conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, 
toxicity to reproduction and development. Carcinogenicity studies have not been 
performed with rocuronium bromide (28).  
b. Sugammadex: preclinical data reveal no special hazard for humans based on 
conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity 
potential, and toxicity to reproduction, local tolerance or compatibility with blood.  
Sugammadex is rapidly cleared in preclinical species, although residual sugammadex 
was observed in bone and teeth of juvenile rats. Preclinical studies in young adult and 
mature rats demonstrate that sugammadex does not adversely affect tooth colour or 
bone quality, bone structure, or bone metabolism. Sugammadex has no effects on 
fracture repair and remodelling of bone (29). 
 
7.3 
Summary of findings from clinical studies 
 
a. Rocuronium: the standard intubation dose for geriatric patients and patients with 
hepatic and/or biliary tract disease and/or renal failure during routine anaesthesia is 
0.6mg/kg rocuronium bromide. Regardless of the anaesthetic technique used, the 
recommended infusion rate is 0.3-0.4 mg/kg/h. For children and adolescents the 
recommended intubation dose during routine anaesthesia and maintenance dose are 
similar to those in adults. When used in overweight or obese patients (defined as 
patients with a body weight of 30% or more above ideal body weight) doses should be 
reduced taking into account ideal body weight. The following conditions may influence 
the pharmacokinetics and/or pharmacodynamics of Rocuronium: hepatic and/or 
biliary tract disease and renal failure, prolonged circulation time, neuromuscular 

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disease, 
hypothermia, 
obesity, 
burns, 
hypokalaemia, 
hypermagnesaemia, 
hypocalcaemia, hypoproteinaemia, dehydration, acidosis, hypercapnia and cachexia 
(28). 
b. Sugammadex: the use of sugammadex in patients with severe renal impairment 
(including patients requiring dialysis (CrC1 < 30 mL/min)) is not recommended. Studies 
in patients with severe renal impairment do not provide sufficient safety information 
to support the use of sugammadex in these patients. For mild and moderate renal 
impairment (creatinine clearance ≥ 30 and < 80 mL/min): the dose recommendations 
are equal to adults without renal impairment. In obese patients, the dose of 
sugammadex should be based on actual body weight. For mild to moderate hepatic 
impairment no dose adjustments is required, as sugammadex is mainly excreted 
renally (29).  
 
7.4 
Summary of known and potential risks and benefits 
 
a. Rocuronium: the most commonly occurring adverse drug reactions include injection 
site pain/reaction, changes in vital signs and prolonged neuromuscular block. The most 
frequently reported serious adverse drug reactions during post-marketing surveillance 
is 'anaphylactic and anaphylactoid reactions' and associated symptoms (28). 
b. Sugammadex: sugammadex is administered concomitantly with neuromuscular 
blocking agents and anaesthetics in surgical patients. The causality of adverse events 
is therefore difficult to assess. The most commonly reported adverse reactions in 
surgical patients were cough, airway complication of anesthesia, anaesthetic 
complications, procedural hypotension and procedural complication (common ((≥ 
1/100 to < 1/10).  
 
System organ class 
Frequencies 
Adverse reactions (preferred terms) 
Immune 
system 
disorders 
Uncommon  
Drug hypersensitivity reactions 
Respiratory, thoracic 
and 
mediastinal 
disorders 
Common  
Cough  
Injury, poisoning and 
procedural 
complications 
Common  
Airway complication of anaesthesia 
Anaesthetic complication 
Procedural hypotension 
Procedural complication 
The following adverse reactions were reported in placebo controlled trials where 
subjects received anaesthesia and/or neuromuscular blocking agents (1,078 subject 
exposures to sugammadex versus 544 to placebo) (29):  

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[Very common (≥ 1/10), common (≥ 1/100 to <1/10), uncommon (≥ 1/1.000 to < 
1/100), rare (≥ 1/10.000 to <1/1.000), very rare (<1/10.000)]  
 
Fusidic acid and flucloxacillin can cause displacement of sugammadex and should not be 
administered 6 hours after administration of sugammadex. Sugammadex can also encapsulate 
hormonal contraceptives, which may leave them less effective (30). Therefore, sugammadex 
use should be considered as one missed dose of hormonal contraceptive (but this issue is not 
applicable in this study) 
7.5 
Description and justification of route of administration and dosage 
 
a. Rocuronium: rocuronium bromide is administered intravenously (i.v.) either as a bolus 
injection or as a continuous infusion. The standard intubating dose during routine 
anaesthesia is 0.6 mg rocuronium bromide per kg body weight, which results in 
adequate intubation conditions within 60 seconds in nearly all patients. If rocuronium 
bromide is administered by continuous infusion, it is recommended to give a loading 
dose of 0.6 mg rocuronium bromide per kg body weight and, when the neuromuscular 
block starts to recover, to start administration by infusion. In adults under intravenous 
anaesthesia, the infusion rate required to maintain the neuromuscular block ranges 
from 0.3 - 0.6 mg/kg/h. Under inhalational anaesthesia the infusion rate ranges from 
0.3 - 0.4 mg/kg/h (28).  
b. Sugammadex: sugammadex should be administered intravenously as a single bolus 
injection. A dose of 4 mg/kg sugammadex is recommended if recovery has reached at 
least 1-2 post-tetanic counts (PTC) following rocuronium or vecuronium induced 
blockade. A dose of 2 mg/kg sugammadex is recommended, if spontaneous recovery 
has occurred up to at least the reappearance of T2 following rocuronium or 
vecuronium induced blockade (29). 
 
7.6 
Dosages, dosage modifications and method of administration 
 
a. Rocuronium: in both groups, a bolus of 0.6 mg/kg rocuronium is administered 
intravenously before tracheal intubation. After tracheal intubation, in group A (low 
pressure with deep NMB), a bolus of 0.6 mg/kg rocuronium is administered and 
continuous infusion of rocuronium (0.4 mg/kg) is started and titrated towards PTC 1-
2. In group B (normal pressure with moderate NMB), a bolus or continuous infusion of 
rocuronium is administered, titrating towards a TOF count of 1-2. Dosage in both 
groups is within normal therapeutical range used in clinical practice (28).  
b. Sugammadex: if TOF-ratio is <0.9 the NMB is reversed with an intravenous bolus 
injection of 2 (moderate NMB) or 4 (deep NMB) mg/kg. If TOF-ratio > 0.9 the patient 
can be extubated safely (29). 
 

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7.7 
Preparation and labelling of non-investigational medicinal product 
Sugammadex will be provided by MSD. Both Rocuronium and Sugammadex will be prepared 
and labelled at the Radboudumc pharmacy. The clinical trials unit of the Radboudumc 
pharmacy will distribute batches of Rocuronium and Sugammadex to the pharmacy of the 
Canisius Wilhelmina hospital by courier. 
7.8 
Drug accountability 
Administration of stock, preparation and labelling, distribution of batches and returns will be 
coordinated and logged by the clinical trials unit of the Radboudumc pharmacy. Locally, in the 
Canisius Wilhelmina hospital, drug registration will be logged on patient level (e.g. batch and 
ampoule number for each patient). 
 

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8 METHODS  
8.1 
Main study endpoints   
- 
Quality of recovery score (QoR-40) at postoperative day 1. 
- 
IL-6 response upon whole blood LPS stimulation at postoperative day 10-12 
- 
Perfusion index of the parietal peritoneum as calculated from the slope of ICG 
fluorescence intensity, and time to maximal intensity in seconds. (extracted from video 
registration).  
 
8.2 
Other study parameters   
General 
- 
Baseline parameters as age, gender, length, weight, body mass index, comorbidity, 
indication for and type of surgery. 
- 
Intraoperative parameters routinely measured (at administration of ICG): blood 
pressure, temperature and level of NMB (train of four response). 
Questionnaires 
- 
Quality of recovery score (QoR-40) at 1 day before surgery and day 10-12 after surgery. 
- 
SF-36 general health questionnaire (Dutch version) 1 day before surgery, day 10-12 
and 3 months after surgery. 
- 
McGill pain Questionnair 3 months after surgery 
Pain scores 
- 
Pain at rest and movement (NRS 0-10) at 1, 8, 24, 72 hours after surgery 
- 
Is pain acceptable (yes/no) at 1, 8, 24, 72 hours after surgery 
- 
Referred shoulder pain (yes/no) at 1, 8, 24, 72 hours after surgery 
PONV 
- 
PONV (yes/no) at 1, 8, 24 and 72 hours after surgery  
Medication use 
- 
Cumulative opiate use 
- 
Cumulative use of other analgesics and anti-emetics 
Clinical parameters 
- 
Time to reach discharge criteria* 
- 
Length of hospital stay 
- 
Surgical conditions: Leiden Surgical Rating Scale to quantify the quality of the surgical 
field during the pneumoperitoneum phase (after introduction of the Hasson trocar, 
after introduction of the third trocar and then every 15 minutes) 
- 
Postoperative complications scored by Clavien Dindo classification (table 2 (1)) 
Immune function 
- 
Peritoneal mesothelial hypoxia as reflected by peritoneal HIF1-alfa mRNA expression 
- 
Histological peritoneal mesothelial cell injury.  
- 
Plasma levels of DAMPs, cytokines and ex vivo immune function at baseline, 24 hours 
after surgery and 10-12 days after surgery. 

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*discharge criteria are: adequate pain control with oral medication, passage of flatus or 
defecation, intake of solid food tolerated, patient is mobilized and independent and patient 
accepts discharge. Discharge criteria will be evaluated daily. If the donor for social reasons 
wants to stay longer (e.g. long distance from partner of child who are still hospitalized) the 
‘virtual’ discharge date is listed. A physician who is independent and blinded (ward physician) 
is responsible for the actual discharge date.   
8.3 
Study procedures   
Randomization:  
Computer-generated randomization (supported by our statistician) will be used with 
stratification for center. To ensure a balanced distribution, we will use block randomization.  
 
Blinding and treatment allocation:  
Blinding of the surgeons to the level of pressure and NMB is ensured by facing monitoring 
equipment away or covering these under sterile drapes. The level IAP will be set and adjusted 
by the anesthesiologist who is not blinded to the allocation of treatment. Surgical conditions 
will be assessed after introduction of the trocars, every 15 minutes or when the surgeon 
indicates inadequate surgical conditions. When SRS is ≤3 (table 1), pressure is increased with 
2mmHg to max 14mmHg in group A and B or 16mmHg in group C and D. The anesthesiologist 
(not blinded) or his/her assistant titrates the dose of rocuronium to the desired level of NMB. 
The nerve stimulator and computer are placed behind the sterile drapes away from the 
surgeons. The research physician alongside the anesthetic staff will not be blinded in order to 
ensure depth of the NMB is continuously adequately monitored. To minimize the risk of 
observer bias and/or unblinding of the entire team, the following measures will be taken: 
Surgical adverse events will be registered directly after surgery by the blinded, primary 
surgeon. Surgeons, scrub nurses, postoperative care nurses, and ward physicians are blinded. 
Postoperative clinical outcomes (e.g. QoR-40 questionnaires) are collected by a blinded 
researcher. 
 
Perioperative procedures: 
The peri-operative flowchart is shown in figure 6.  
During insufflations of the abdomen, the insufflator will be set at an intra-abdominal pressure 
of 8 or 14 mmHg. The usual dose of indocyanine green (0.2mg/kg) as regularly used will be 
injected intravenously. The camera trocar is aimed at the lateral abdominal wall and video is 
recorded for 3 minutes.  
An overview of measurements and questionnaires for the primary and secondary endpoints, 
are given in table 3. Assessment of pain, PONV, discharge criteria and postoperative 
complications are part of normal medical treatment. Extra for this study, patients are asked 
to complete the QoR-40, SF-36 and McGill questionnaire. For the secondary endpoints on 
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Paxgene RNA tube) will be combined with routine laboratory assessment as much as possible. 
Otherwise, blood will be drawn by vena puncture. Peritoneal biopsy will be performed during 
laparoscopy when the patient is under anesthesia and peritoneal tissue is directly visible and 
easily accessible. A biopsy will be taken as previously described and performed by Schaefer et 
al. (31) and Williams et al. (32) at the start and end of surgery. Briefly, a small part of the 
parietal peritoneum (0.5-1 x 0.5-1 cm, 2-4mm deep) tissue sample is excised. Half of the 
sample is fixed and used for histology the other half is used to determine HIF1α mRNA 
expression. 
Withdrawal of individual subjects 
Subjects can leave the study at any time for any reason if they wish to do so without any 
consequences. The investigator can decide to withdraw a subject from the study for urgent 
medical reasons or with one of the following criteria:  
- 
Before operation (for example postponement or adjustment of operation) 
- 
During surgery (for example conversion to open procedure) 
- 
After surgery ( for example non response to questionnaire) 
In case of withdrawal the patient will not be followed. Patients withdrawing will be replaced, 
with a maximum of 10 patients.  
Premature termination of the study 
Not applicable 
 
 
 
 

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9 SAFETY REPORTING 
9.1 
Temporary halt for reasons of subject safety 
In accordance to section 10, subsection 4, of the WMO, the sponsor will suspend the study if 
there is sufficient ground that continuation of the study will jeopardize subject health or 
safety. The sponsor will notify the accredited METC without undue delay of a temporary halt 
including the reason for such an action. The study will be suspended pending a further positive 
decision by the accredited METC. The investigator will take care that all subjects are kept 
informed. 
9.2 
AE’s, SAE’s and SUSAR’s 
9.2.1 Adverse events (AE’s) 
Adverse events are defined as any undesirable experience occurring to a subject during 
the study, whether or not considered related to the investigational product, trial 
procedure and/or the experimental intervention. All adverse events reported 
spontaneously by the subject or observed by the investigator or his staff will be 
recorded. 
9.2.2 Serious adverse events (SAE’s) 
A serious adverse event is any untoward medical occurrence or effect that  
- 
results in death;  
- 
is life threatening (at the time of the event);  
- 
requires hospitalisation or prolongation of existing inpatients’ hospitalisation;  
- 
results in persistent or significant disability or incapacity;  
- 
is a congenital anomaly or birth defect;  
- 
or any other important medical event that did not result in any of the outcomes 
listed above due to medical or surgical intervention but could have been based 
upon appropriate judgement by the investigator.  
 
An elective hospital admission will not be considered as a serious adverse event.  
The sponsor will report the SAEs through the web portal ToetsingOnline to the 
accredited METC that approved the protocol, within 7 days of first knowledge for SAEs 
that result in death or are life threatening followed by a period of maximum of 8 days 
to complete the initial preliminary report. All other SAEs will be reported within a period 
of maximum 15 days after the sponsor has first knowledge of the serious adverse events.  
The product summaries for rocuronium and sugammadex will be used to evaluate 
whether the adverse event or reaction is expected or unexpected. The following adverse 
events are considered to be inevitable in surgery and will not be recorded: blood loss 
<500 ml, surgical site infection and wound dehiscence. However, if any of these 
complications is considered an serious adverse event, they will be recorded. 

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9.2.3 Suspected Unexpected serious adverse reactions (SUSAR’s) 
Not applicable 
9.3 
Annual safety report 
Not applicable 
9.4 
Follow-up of adverse events 
All AEs will be followed until they have abated, or until a stable situation has been reached. 
Depending on the event, follow up may require additional tests or medical procedures as 
indicated, and/or referral to the general physician or a medical specialist.  
SAEs need to be reported till end of study within the Netherlands, as defined in the protocol. 
9.5 
Data Safety Monitoring Board (DSMB) 
The need for a DSMB is assessed taking the EMEA guidelines on data monitoring committees 
into consideration. We believe that an interim evaluation does not increase patient safety, 
because safety of the procedure has already been proven. Study conduct and progress will be 
monitored according a monitor plan. Thus, a DSMB is not beneficial considering the proposed 
study design and will therefore not be established. 

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10 STATISTICAL ANALYSIS  
The principal investigator (PI) has final responsibility regarding the data; a web-based 
encrypted data management system will be used to minimize errors, to ensure traceability 
and privacy of the subjects. An independent statistician will provide assistance for data-
analysis. The data will be unblended after completion of the follow-up period and 
identification of protocol violations. 
10.1 Primary study parameter(s)  
- 
Quality of recovery score (QoR-40) at postoperative day 1. 
- 
For QOR-40 score, factorial ANCOVA will be used to compare groups and to adjust for 
co-variates i.e. age and gender. P-values <0.05 will be considered statistically 
significant. 
- 
IL-6 response upon whole blood LPS stimulation at postoperative day 7. 
- 
For mononuclear cell responsiveness, ANCOVA will be used to compare groups and to 
adjust for co-variates i.e. age and gender. As the primary endpoint includes changes in 
both IL-6 and IL-10 release, Bonferroni correction for multiple comparisons will be 
used. P-values < 0.025 will be considered statistically significant. 
- 
Perfusion index in sigmoid as calculated from the slope of ICG fluorescence intensity, 
and time to maximal intensity in seconds. (extracted from video registration).  
- 
Factorial ANCOVA will be used to compare groups and adjust for covariates i.e. age 
and gender. P-values <0.05 will be considered statistically significant. 
10.2 Secondary study parameter(s) 
Study parameters/endpoints 
Presentation of data 
QOR-40 (primary endpoint), SF-36, McGill pain questionnaire 
Quantative 
Pain scores 
Quantative 
PONV 
Quantative 
Medication use 
Quantative 
Length of hospital stay (days) 
Quantative 
Time to reach discharge criteria 
Quantative 
Surgical conditions 
Quantative 
Mesothelial hypoxia (HIF1-alfa mRNA expression) 
Quantative 
Histological peritoneal mesothelial cell injury and plasma levels 
of DAMPs and cytokines 
Quantative 
Ex vivo immune function (primary endpoint 2) 
Quantative 
 
10.3 Interim analyse  
Not applicable 

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11 ETHICAL CONSIDERATIONS  
11.1 Regulation statement   
This study will be conducted according to the principles of the Declaration of Helsinki (59th 
version, Seoul, October 2008) and other Dutch guidelines, regulations and Acts. Subjects will 
be coded by a numeric code (a unique study number will be assigned) in order to create an 
anonymous dataset. Investigators have access to this code and will store the subject 
identification code list at a separate location from the dataset. Data will be securely stored in 
the database of the department of surgery of the Radboud university medical center 
accessible to the investigators, in accordance with the Dutch Personal Data Protection Act. 
Videos are recorded in the operating room on CD-ROM, video files are imported from the disc 
into the database of the department of surgery of the Radboudumc by the researcher and 
saved anonymously under the study number. Only the investigators have access to the subject 
identification code list saved separately from the data. 
11.2 Recruitment and consent  
At Canisius Wilhelmina Hospital, 350 Robot-assisted radical prostatectomy procedures are 
performed annually. All eligible patients will be screened. With an inclusion rate of 
approximately 2 patients per week, we expect that the screening (and inclusion period) will 
be 12-15 months. We intend to include 96 patients at the Canisius Wilhelmina Hospital. 
Informed consent is obtained at least one week after providing written information about the 
study. During this 7-day interval, an independent physician can be consulted for questions. 
Informed consent will be obtained before or on the day of hospital admission. Then, a unique 
study number will be assigned. 
11.3 Benefits and risks assessment   
As explained in the rationale, the use of deep NMB enables safe use of low-pressure PNP. If 
visibility is compromised at low pressure, pressure will be increased to ensure no additional 
risks related to the surgery. A deep NMB is achieved by higher doses of rocuronium that are 
within normal therapeutical range used in clinical practice, and can safely be used. Depth of 
NMB will be monitored throughout the whole surgery. At the end of surgery, the effects of 
rocuronium are antagonized by sugammadex to ensure no extended effects. Randomized 
controlled trails have shown sugammadex can be safely administered. Regarding the biopsies, 
peritoneal tissue is directly visible and easily accessible during laparoscopic colorectal surgery. 
Biopsies are obtained in a standardized manner previously used in other studies (33,34) who 
report no complications. After biopsy, hemostasis will be established under direct vision and 
therefore no additional complications are to be expected. Blood samples will be combined 
with routine laboratory assessment as much as possible. Previous studies have shown low-
pressure PNP is associated with reduced postoperative pain scores, reduced opioid 
consumption and improved bowel function. This may lead to enhanced recovery. The burden 
for participants is mainly related to the evaluation of the endpoints during the early 
postoperative phase. Assessment of pain scores, nausea, complications and discharge criteria 
are part of the normal treatment. Questionnaires will take approximately 10-15 minutes per 

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time-point. Regarding the use of indocyanine green, the risks are negligible, as addressed 
above. 
11.4 Compensation for injury  
The Radboudumc has an insurance in accordance with the legal requirements in the 
Netherlands (Article 7 of the WMO and the Measure regarding Compulsory Insurance for 
Clinical Research in Humans of 23th June 2003). This insurance provides cover for damage to 
research subjects though injury or death caused by the study.  
1. € 650.000,-- (i.e. sixhundred and fifty thousand Euro) for death or injury for each 
subject who participates in the Research  
2. € 5.000.000,-- (i.e. fivemillion Euro) for death or injury for all subjects who participate 
in the Research  
3. € 7.500.000,-- (i.e. sevenmillion fivehundredthousand Euro) for the total damage 
incurred by the organisation for all damage disclosed by scientific research for the 
Sponsor as ‘verrichter’ in the meaning of said Act in each year of insurance coverage  
 
The insurance applies to the damage that becomes apparent during the study or within 4 years 
after the end of the study. 

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12 ADMINISTRATIVE ASPECTS, MONITORING AND 
PUBLICATION 
12.1 Handling and storage of data and documents 
Subjects will be coded by a numeric code in order to create and anonymous dataset. A Castor 
database will be developed and used for data management. Investigators have access to this 
code and will store the subject identification code list at a separate location from the dataset.  
Data will be securely stored in the database of the department of surgery of the Radboud 
university medical center accessible to the investigators, in accordance with the Dutch 
Personal Data Protection Act. 
12.2 Monitoring and quality assurance 
In our opinion, this study adds a low chance of mild damage and consequently adds a 
negligible risk according to the risk classification of the “Nederlandse Federatie van 
Universitair Medische Centra” (NFU). Monitoring will be conducted in accordance with 
negligible risk monitoring guidelines of the NFU, which will be reported in a monitorplan. 
 
Mild damage 
Intermediate 
damage 
Sever damage 
Low chance 
Negligible risk 
Negligible risk 
Intermediate risk 
Intermediate chance Negligible risk 
Intermediate risk 
High risk 
High chance 
Intermediate risk 
High risk 
High risk 
Risk classification in relation to the chance and severity of damage (34) 
12.3 Amendments 
Amendments are changes made to the research after a favourable opinion by the accredited 
METC has been given. All amendments will be notified to the METC that gave a favourable 
opinion. Non-substantial amendments will not be notified to the accredited METC and the 
competent authority, but will be recorded and filed by the sponsor. 
12.4 Annual progress report 
The sponsor/investigator will submit a summary of the progress of the trial to the accredited 
METC once a year. Information will be provided on the date of inclusion of the first subject, 
numbers of subjects included and numbers of subjects that have completed the trial, serious 
adverse events/ serious adverse reactions, other problems, and amendments. 
12.5 Temporary halt and (prematurely) end of study report 
The investigator/sponsor will notify the accredited METC of the end of the study within a 
period of 8 weeks. The end of the study is defined as the last patient’s last visit.  
The sponsor will notify the METC immediately of a temporary halt of the study, including the 
reason of such an action. 
In case the study is ended prematurely, the sponsor will notify the accredited METC within 15 
days, including the reasons for the premature termination. Within one year after the end of 

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the study, the investigator/sponsor will submit a final study report with the results of the 
study, including any publications/abstracts of the study, to the accredited METC. 
12.6 Public disclosure and publication policy 
The study will be registered at ClinicalTrials.gov. Results will be published in a peer reviewed 
international journal. 

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13 STRUCTURED RISK ANALYSIS  
13.1 Potential issues of concern 
Not applicable 
13.2 Synthesis 
As explained in the rationale, the use of deep NMB enables safe use of low-pressure PNP. If 
visibility is compromised at low pressure, pressure will be increased to ensure no additional 
risks related to the surgery. A deep NMB is achieved by higher doses of rocuronium that are 
within normal therapeutical range used in clinical practice, and can safely be used. Depth of 
NMB will be monitored throughout the whole surgery. At the end of surgery, the effects of 
rocuronium are antagonized by sugammadex to ensure no extended effects. Randomized 
controlled trials have shown sugammadex can be safely administered. Regarding the biopsies, 
peritoneal tissue is directly visible and easily accessible during laparoscopic surgery in the 
pelvis. After biopsy, hemostasis will be established under direct vision and therefore no 
additional complications are to be expected. Previous studies have shown low-pressure PNP 
is associated with reduced postoperative pain scores, reduced opioid consumption and 
improved bowel function. The burden for participants is mainly related to the evaluation of 
the endpoints during the early postoperative phase. Assessment of the pain scores and the 
QOR-40 questionnaire will take approximately 10-15 minutes per time-point. Blood samples 
will be combined with routine laboratory assessment as much as possible, this is standard 
before- and 24 hours after surgery. Blood samples taken during surgery (while under 
anesthesia) and 10-12 days after surgery will be drawn by venapuncture if necessary. 

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Figure 6: Perioperative flowchart 
 
Table 1: Leiden Surgical-Rating-Scale (L-SRS) (25) 
Scale  
Description  
1  
Extremely 
poor 
conditions  
The surgeon is unable to work because of coughing or the inability to obtain 
a visible laparoscopic field because of inadequate muscle relaxation.  
2  
Poor conditions  
There is a visible laparoscopic field, but the surgeon is severely hampered by 
inadequate muscle relaxation with continuous muscle contractions, 
movements or both with the hazard of tissue damage.  
3  
Acceptable 
conditions  
There is a wide visible laparoscopic field but muscle contractions, 
movements or both occur regularly causing some interference with the 
surgeon’s work.  
4  
Good conditions  
There is a wide laparoscopic field with sporadic muscle contractions, 
movements or both.  
5  
Optimal conditions  
There is a wide visible laparoscopic working field without any movement or 
contractions.  
 

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Table 2: Clavien Dindo classification(1) 
 
Definitions 
Modes of therapy 
I 
Any deviation from the 
normal 
postoperative 
course 
No pharmacological of surgical treatment, endoscopic of radiological 
interventions were required. Acceptable therapeutic regimens are drugs 
such as anti-emetics, antipyretics, analgesics, diuretics and electrolytes and 
physiotherapy. Wound infections of small abscess requiring incision at 
bedside is within this category. 
II 
Normal course altered 
Pharmacological management other than in grad 1. Blood transfusions and 
total parenteral nutrition are also included. 
III 
Complications 
that 
require intervention of 
various degrees 
Sub-classified into: 
- 
Grade IIIa – Complications that require an intervention performed 
under local anesthesia 
- 
Grade IIIb – Interventions that require general or epidural 
anesthesia 
IV 
Complications 
threatening 
life 
of 
patients 
(incl. 
CNS 
complication), 
requiring ICU support 
Sub-classified into: 
- 
Grade IVa -  Single organ dysfunction (incl. dialysis) 
- 
Grade IVb – Multi-organ dysfunction 
V 
Death of a patient 
 
 
Table 3: Overview of study endpoints 
 
QOR-40 
(primary 
endpoint 
in 
main 
study) 
Anti-
coagulated 
blood 
(ex 
vivo 
leukocyte 
responses, 
DAMP 
and 
cytokines) 
Indocyanin
e 
green 
fluorescen
ce 
of 
parietal 
peritoneu
m 
Peritoneal 
tissue 
biopsy 
(histology 
and 
HIF1alpha 
mRNA) 
Pain 
scores, 
PONV, 
Analgesia 
use 
Complicatio
ns, 
Discharge 
criteria, 
Length 
of 
hospital days 
SF-36 
QoL 
McGill 
Pain 
Questi
onnair 
-1 day 
X 
X 
 
 
 
 
X 
 
After trocar 
introduction 
 
 
X 
X 
 
 
 
 
At end of IAP 
 
 
 
X 
 
 
 
 
1hr  
 
 
 
 
X 
 
 
 
8 hr  
 
 
 
 
X 
 
 
 
24 hr  
X 
X 
 
 
X 
X 
 
 
48 hr  
 
 
 
 
X 
X 
 
 
10-12 days  
X 
X 
 
 
 
 
X 
 
3 months 
 
 
 
 
 
X 
X 
X 
 
 

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14 REFERENCES 
1.  
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