Neuromuscular Block Level for Laparoscopic Sigmoid Resection for Colon Cancer

Evidence for Deep vs. Moderate Neuromuscular Blockade

Deep neuromuscular blockade allows for significantly lower intra-abdominal pressures (9 mmHg) compared to moderate blockade (12 mmHg) while maintaining satisfactory surgical conditions during colorectal surgery 1, 2
In laparoscopic cholecystectomy, insufflation pressure needed to be increased from 8 mmHg to 12 mmHg in 34% of cases with moderate blockade versus only 12% with deep blockade 1
Deep blockade provides a 25% absolute difference in obtaining good or excellent operating conditions compared to moderate blockade 1

Enhanced recovery after surgery is a priority in colorectal cancer management, and deep neuromuscular blockade may contribute to this goal 3

Intraoperative monitoring of neuromuscular blockade is strongly recommended (GRADE 1+) 4
Quantitative adductor pollicis monitoring is recommended for accurate assessment of blockade depth and recovery 5, 6
For moderate blockade: maintain 1-2 TOF responses at the adductor pollicis 1
For deep blockade: maintain 1-2 post-tetanic count (PTC) responses at the adductor pollicis 1

After using deep blockade, appropriate reversal is critical to prevent residual neuromuscular blockade 5
For neostigmine reversal, await spontaneous recovery to four muscle responses at the adductor pollicis following TOF stimulation before administration 7
Sugammadex may be preferred for reversal of deep blockade as it allows for more rapid and complete reversal 5

Most studies have small sample sizes (n = 24 to 102) 1
No trials have shown significant differences between deep and moderate blockade in terms of intraoperative adverse surgical events or specific morbidity 1
The 2020 guidelines state it is "impossible to make a recommendation on the depth of neuromuscular blockade required to achieve a reduction in intraoperative and postoperative surgical morbidity" 1, 8

Optimal surgical field visualization is critical, and deep neuromuscular blockade may be beneficial in this context 1
Enhanced recovery is a priority, and deep neuromuscular blockade may contribute to this goal 3

Failing to monitor neuromuscular blockade quantitatively can lead to residual blockade 5
Residual neuromuscular blockade is associated with higher morbidity and mortality, critical respiratory events, postoperative pneumonia, and delayed discharge 5
Inadequate reversal of deep blockade may lead to prolonged recovery and respiratory complications 7