Neuromuscular blockade for optimising surgical conditions during abdominal and gynaecological surgery: a systematic review

Background: The level of neuromuscular blockade (NMB) that provides optimal surgical conditions during abdominal surgery has not been well established. The aim of this systematic review was to evaluate current evidence on the use of neuromuscular blocking agents in order to optimise surgical conditions during laparoscopic procedures and open abdominal surgery.

Methods: A wide search was performed in PubMed, Cochrane library and Embase with systematic approach including PRISMA recommendations. Individual risk of bias was assessed and systematic data extraction were performed.

Results: Fifteen studies with data from 998 patients were included. There is good evidence that the use of deep NMB compared with moderate NMB is associated with optimised surgical conditions during laparoscopic cholecystectomy, hysterectomy and nephrectomy/prostatectomy. In laparoscopic cholecystectomy during low pressure pneumoperitoneum, deep NMB marginally improves the surgical conditions. However, to ensure acceptable surgical conditions, it may be necessary to increase the intra-abdominal pressure in up to half of the patients regardless of level of NMB. There is good evidence that moderate NMB improves surgical conditions in some cases during open radical retropubic prostatectomy. However, good and excellent surgical conditions may be achievable even without NMB. There is good evidence to recommend deep NMB in laparoscopic cholecystectomy, nephrectomy and prostatectomy to improve surgical conditions. There is insufficient evidence to recommend an ideal level of NMB creating optimal surgical condition during laparotomy.

Conclusion: Use of deep NMB in certain laparoscopic procedures may improve surgical conditions. In open abdominal surgery, use of NMB may optimise surgical conditions under certain circumstances.