Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block

Br J Anaesth. 2014 Mar;112(3):498-505. doi: 10.1093/bja/aet377. Epub 2013 Nov 15.


Background: The routine use of neuromuscular blocking agents reduces the occurrence of unacceptable surgical conditions. In some surgeries, such as retroperitoneal laparoscopies, deep neuromuscular block (NMB) may further improve surgical conditions compared with moderate NMB. In this study, the effect of deep NMB on surgical conditions was assessed.

Methods: Twenty-four patients undergoing elective laparoscopic surgery for prostatectomy or nephrectomy were randomized to receive moderate NMB (train-of-four 1-2) using the combination of atracurium/mivacurium, or deep NMB (post-tetanic count 1-2) using high-dose rocuronium. After surgery, NMB was antagonized with neostigmine (moderate NMB), or sugammadex (deep NMB). During all surgeries, one surgeon scored the quality of surgical conditions using a five-point surgical rating scale (SRS) ranging from 1 (extremely poor conditions) to 5 (optimal conditions). Video images were obtained and 12 anaesthetists rated a random selection of images.

Results: Mean (standard deviation) SRS was 4.0 (0.4) during moderate and 4.7 (0.4) during deep NMB (P<0.001). Moderate block resulted in 18% of scores at the low end of the scale (Scores 1-3); deep block resulted in 99% of scores at the high end of the scale (Scores 4 and 5). Cardiorespiratory conditions were similar during and after surgery in both groups. Between anaesthetists and surgeon, there was poor agreement between scores of individual images (average κ statistic 0.05).

Conclusions: Application of the five-point SRS showed that deep NMB results in an improved quality of surgical conditions compared with moderate block in retroperitoneal laparoscopies, without compromise to the patients' peri- and postoperative cardiorespiratory conditions. Trial registration The study was registered at clinicaltrials.gov under number NCT01361149.

Keywords: laparoscopy; nephrectomy; neuromuscular block; prostatectomy; rocuronium; sugammadex; urological surgical procedures.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Androstanols / administration & dosage
  • Androstanols / antagonists & inhibitors
  • Anesthesia, Intravenous
  • Anesthetics, Intravenous
  • Consciousness Monitors
  • Data Interpretation, Statistical
  • Electric Stimulation
  • Electromyography
  • Endpoint Determination
  • Hemodynamics
  • Humans
  • Isoquinolines / administration & dosage
  • Isoquinolines / antagonists & inhibitors
  • Laparoscopy*
  • Middle Aged
  • Mivacurium
  • Monitoring, Intraoperative
  • Muscle Contraction / physiology
  • Neuromuscular Blockade*
  • Neuromuscular Blocking Agents* / antagonists & inhibitors
  • Neuromuscular Nondepolarizing Agents / administration & dosage
  • Neuromuscular Nondepolarizing Agents / antagonists & inhibitors
  • Propofol
  • Rocuronium
  • Sample Size
  • Sufentanil
  • Sugammadex
  • Video Recording
  • gamma-Cyclodextrins


  • Androstanols
  • Anesthetics, Intravenous
  • Isoquinolines
  • Neuromuscular Blocking Agents
  • Neuromuscular Nondepolarizing Agents
  • gamma-Cyclodextrins
  • Sugammadex
  • Mivacurium
  • Sufentanil
  • Rocuronium
  • Propofol

Associated data

  • ClinicalTrials.gov/NCT01361149