ABSTRACT
BACKGROUND: Evidence indicates that low-pressure pneumoperitoneum (PNP) reduces postoperative pain and analgesic consumption. A lower insufflation pressure may hamper visibility and working space. The aim of the study is to investigate whether deep neuromuscular blockade (NMB) improves surgical conditions during low-pressure PNP. METHODS: This study was a blinded randomized controlled multicenter trial. 34 kidney donors scheduled for laparoscopic donor nephrectomy randomly received low-pressure PNP (6 mmHg) with either deep (PTC 1-5) or moderate NMB (TOF 0-1). In case of insufficient surgical conditions, the insufflation pressure was increased stepwise. Surgical conditions were rated by the Leiden-Surgical Rating Scale (L-SRS) ranging from 1 (extremely poor) to 5 (optimal). RESULTS: Mean surgical conditions were significantly better for patients allocated to a deep NMB (SRS 4.5 versus 4.0; p < 0.01). The final insufflation pressure was 7.7 mmHg in patients with deep NMB as compared to 9.1 mmHg with moderate NMB (p = 0.19). The cumulative opiate consumption during the first 48 h was significantly lower in patients receiving deep NMB, while postoperative pain scores were similar. In four patients allocated to a moderate NMB, a significant intraoperative complication occurred, and in two of these patients a conversion to an open procedure was required. CONCLUSIONS: Our data show that deep NMB facilitates the use of low-pressure PNP during laparoscopic donor nephrectomy by improving the quality of the surgical field. The relatively high incidence of intraoperative complications indicates that the use of low pressure with moderate NMB may compromise safety during LDN. Clinicaltrials.gov identifier: NCT 02602964.
Subject(s)
Laparoscopy , Nephrectomy/methods , Neuromuscular Blockade/methods , Pneumoperitoneum, Artificial/methods , Tissue and Organ Harvesting/methods , Adult , Double-Blind Method , Female , Humans , Insufflation/adverse effects , Insufflation/methods , Intraoperative Complications/epidemiology , Intraoperative Complications/etiology , Kidney Transplantation , Male , Neuromuscular Blockade/adverse effects , Pain, Postoperative/epidemiology , Pain, Postoperative/prevention & control , Pneumoperitoneum, Artificial/adverse effects , Pressure , Treatment OutcomeABSTRACT
BACKGROUND: Pain after laparoscopic surgery can be divided into three components: incisional or superficial wound pain, deep intra-abdominal pain and referred shoulder pain. Better understanding and adequate assessment of post-operative pain may be an important clue to the optimisation of recovery after laparoscopic surgery. Therefore, we performed a components of pain assessment after laparoscopic donor nephrectomy. METHODS: Twenty patients who underwent a laparoscopic donor nephrectomy were included in this prospective study. Pain was subdivided into three components: superficial wound pain, deep intra-abdominal pain and referred shoulder pain, and for each component a numeric rating scale (from 0 to 10) was obtained at 1, 24 and 48 h after surgery. RESULTS: Repeated measurements analysis of variance showed that during the first 48 h after surgery, the superficial wound and deep intra-abdominal pain components were significantly higher as compared with the referred shoulder pain component. Although the deep intra-abdominal pain component was slightly higher as compared with superficial wound pain, this difference was not significant (P = 0.097). Further assessment of superficial wound pain showed that the Pfannenstiel incision was the most significant determinant of this component of pain (P = 0.004), whereas deep intra-abdominal pain was significantly higher at the ipsilateral side of the abdomen (P = 0.015). DISCUSSION: The components of pain assessment revealed that pain related to the Pfannenstiel incision and the deep intra-abdominal pain component are the most important determinants of pain after laparoscopic donor nephrectomy. Further improvement of the management of post-operative pain should focus on these components of pain.
Subject(s)
Laparoscopy/adverse effects , Living Donors , Nephrectomy/adverse effects , Pain Measurement/methods , Pain, Postoperative/diagnosis , Abdominal Pain/diagnosis , Abdominal Pain/etiology , Adult , Analysis of Variance , Female , Humans , Male , Middle Aged , Pain, Postoperative/drug therapy , Postoperative Nausea and Vomiting/diagnosis , Postoperative Nausea and Vomiting/therapy , Prospective Studies , Shoulder Pain/diagnosis , Shoulder Pain/etiologyABSTRACT
Nowadays, laparoscopic donor nephrectomy (LDN) has become the gold standard to procure live donor kidneys. As the relationship between donor and recipient loosens, it becomes of even greater importance to optimize safety and comfort of the surgical procedure. Low-pressure pneumoperitoneum has been shown to reduce pain scores after laparoscopic cholecystectomy. Live kidney donors may also benefit from the use of low pressure during LDN. To evaluate feasibility and efficacy to reduce post-operative pain, we performed a randomized blinded study. Twenty donors were randomly assigned to standard (14 mmHg) or low (7 mmHg) pressure during LDN. One conversion from low to standard pressure was indicated by protocol due to lack of progression. Intention-to-treat analysis showed that low pressure resulted in a significantly longer skin-to-skin time (149 ± 86 vs. 111 ± 19 min), higher urine output during pneumoperitoneum (23 ± 35 vs. 11 ± 20 mL/h), lower cumulative overall pain score after 72 h (9.4 ± 3.2 vs. 13.5 ± 4.5), lower deep intra-abdominal pain score (11 ± 3.3 vs. 7.5 ± 3.1), and a lower cumulative overall referred pain score (1.8 ± 1.9 vs. 4.2 ± 3). Donor serum creatinine levels, complications, and quality of life dimensions were not significantly different. Our data show that low-pressure pneumoperitoneum during LDN is feasible and may contribute to increase live donors' comfort during the early post-operative phase.
