Moderate vs Deep Neuromuscular Block in Lower Pressure Pneumoperitoneum
Condition: Gynecologic Disease; Neuromuscular Blockade
MeSH terms: Pneumoperitoneum; Genital Diseases, Female
Study type: Interventional

Summary: 
      The investigators hypothesized that deep neuromuscular block compare to moderate
      neuromuscular block would reduce the rate of increasing intraabdominal pressure and operation
      can be completely done in lower pressure pneumoperitoneum and would improve laparoscopic
      space by measuring distance from the sacral promontory to the inserted trocar in patients
      undergoing laparoscopic gynaecological surgery.
    

Detailed description: 
      Laparoscopic surgery has increasing popularity and slowly replacing conventional open surgery
      as it offers more benefit to patient and health care practitioner. The overall risk of
      complications during laparoscopic surgery is recognized to be lower than during laparotomy.
      Laparoscopic hysterectomy compare to open vaginal hysterectomy reduces postoperative pain,
      reduce post op analgesics requirement and shorter duration of hospital admission.1 However,
      the increase intra-abdominal pressure created during laparoscopic surgery can affect
      cardiovascular, pulmonary and renal physiology. Besides the risk of post-operative nausea and
      vomiting, it is also stated that the pneumoperitoneum created during laparoscopic surgery is
      an important factor in the cause of postoperative shoulder pain.2 Traditionally
      pneumoperitoneum created at 15mmHg3. Insufflation of intraabdominal carbon dioxide may cause
      post-operative shoulder pain up to 70% in some study in gynaecologic laparoscopic surgery. 4
      Use a lower pressure pneumoperitoneum might decrease postoperative pain, decrease
      post-operative shoulder tip pain5 and reduce the risk of laparoscopic related complication6.
      Many studies used lower insufflation of intraabdominal pressure as an intraoperative
      intervention to reduce the complication7,8. However, a lower intraabdominal pressure may
      worsen surgical space and increase the risk of conversion to open surgery.

      Though many factors contribute to the quality of surgical space include non-modifiable such
      as obesity, previous abdominal surgery and modifiable factors such as anaesthesia related
      factor, patient position and intraabdominal pressure. Numerous studies also have been carried
      out showing that deep neuromuscular block improves surgical condition in different type of
      laparoscopic surgery includes robotic assisted laparoscopic surgery.9,10,11 Currently with
      the advancement of technology where neuromuscular monitoring is widely available and the
      selective reversal binding agent suggamadex where post-operative complication of inadequate
      reversal can be markedly reduced, several studies have been done to observe the benefit of
      low intraabdominal pressure with deep neuromuscular block to surgical space quality and
      intraoperative complication related to high pressure intraabdominal complication compare to
      usual moderate block.9,10,12 However there is still few study objectively measure the
      possible effect of deep neuromuscular blocker on the surgical space and the ability of
      surgery to be completely done in low pressure pneumoperitoneum in laparoscopic gynaecological
      surgery.

      This study will compare the rate of increasing intraabdominal pressure, skin to sacral
      promontary distance, and post operative pain between deep neuromuscular block and moderate
      neuromuscular block.
    

Intervention name(s): Deep neuromuscular block using intravenous rocuronium induction at 1.2mg/kg and maintainance of 8-12mcg/kg/min for deep neuromuscular block
Intervention type(s): Drug
Intervention description(s): both arm are using low pressure pneumoperitoneum in laparoscopic surgery, moderate and deep neuromuscular block are monitor with neuromuscular monitoring. if surgical condition is inadequate, surgeon are allowed to increase intraabdominal pressure as per standard care
Intervention MeSH terms: Rocuronium
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Other
Keywords: deep neuromuscular block; low pressure pneumoperitoneum; laparoscopic gynaecological surgery