Deep Neuromuscular Blockade Leads to a Larger Intraabdominal Volume During Laparoscopy

This video demonstrates a myomectomy performed by a single port laparoscopy. In this procedure, relaxation of abdominal muscles is induced through deep neuromuscular blockade via rocuronium. This treatment allows the surgeon to work in a larger operating space, which is critical for a laparoscopic procedure being done via one small incision in the belly button.

Comparisons of measurements taken before and after induction of the blockade demonstrate how muscle relaxation allows the surgeon more space to work and better access to internal organs. The use of deep neuromuscular blockade to enlarge intraabdominal volume during surgery reduces the risk of postoperative complications often associated with laparoscopic procedures. Yeah, today we started with a case, a 30 5-year-old woman with two fibroids, one angulated fibroid, big large.

It was 450 grams and a smaller one on the anterior side of the uterus, and she wanted to get pregnant and she suffered from pain and bleeding from this fibroids and we performed laparoscopic myomectomy. It went nicely and we did it with the low pressure system and deep block. There is some indication in the literature that if you're working on lower pressure, the patient will have less pain afterwards.

Begin by anesthetizing the patient using standard Hospital procedures. The patient is administered propofol and Remi fentanyl until loss of consciousness occurs. Once the patient is fully unconscious, prep the abdominal Area for surgery begin by making a 1.5 centimeter incision in the umbilicus.

Once an incision has been made, use a trocar to maneuver a cannula bag through the hole and into the abdominal Cavity. Lower the inner ring of the cannula into the hole to secure the opening. Then Use scissors to cut away any extraneous cannula material so as to keep the hole clear.

During the procedure, Attach a laparoscopic single port onto the inner ring. Once the port is secure, attach valved air hoses for carbon dioxide insufflation. Some patients will require multiple ports due to the presence of adherences inside the patient.

Begin the insufflation at 12 millimeters of mercury and slowly insert the laparoscopic camera through the port and into the abdominal Cavity. Using The digital camera display, guide the laparoscopic camera towards the uterus to identify and locate the fibrosis. Once a fibrosis has been found, a grasper is extended into the port and in it reaches the promontory while maintaining finger position.

The grasper is then removed and placed on the surgical table by lining the index finger with the table's edge. The length of the grasper on the table is noted using a marker. This measurement represents the distance between the promontory and the surface of the skin at the umbilicus.

Then adjust the insulation pressure to eight millimeters of mercury and repeat this measurement. Next, administer 0.6 milligrams per kilogram of rocuronium to the patient through intravenous injection to induce neuromuscular blockade. An injection of vasopressin is also given directly to the fibrosis in order to prevent bleeding upon removal.

Monitor the level of block with a nerve stimulator to monitor deep blockade. The PTC or post satanic count mode must be used. A PTC of less than two indicates deep blockade has been achieved, which is essential for this procedure.

Following the successful induction of deep neuromuscular blockade, remeasure the distance between the promontory and the surface of the skin at the umbilicus at 12 millimeters of mercury. Use a ruler To measure these distances in centimeters and compare between the two measurements. These measurements represent the distances from the surface of the skin to the promontory with and without deep neuromuscular block at a given pressure.

Repeat this second measurement at eight Millimeters of mercury, maintain a pressure of eight millimeters of mercury for the duration of this procedure. Individual fibrosis are then carefully cauterized and finally removed through the port system in small pieces. Next, turn off the carbon dioxide pressure And carefully remove the port anesthesiologists.

Monitor the train of four or TOF ratio to determine when deep blockade has worn off. When the TOF reaches greater than 90%the patient is ready to be brought out of anesthesia and woken up. Once the patient has regained consciousness, They can be extubated and moved to recovery.

The Outcome For the patient would be very important because less pain, faster return home, faster recovery and less pain. And, but we need to have the same space in the operating field. And we had them made a small study here, which really showed that we had the same space we measured from the crematorium to the umbilicus.

And we did that during block and without block at eight millimeters and at 12 millimeters. And it, the results was that we had the same without block on 12 as width, block on eight, the same distance, the same working space. And that's important for us.

There has been indication in the literature that you're also reducing addition additions during surgery if you have lower pressure, and especially when we do this single port surgery in with only one hole in the belly button, then we need good working space because it's more complicated procedures. So that's also important.