Dissertation committee:
Λουτράδης Δημήτριος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Ροδολάκης Αλέξανδρος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Δρακάκης Πέτρος, Καθηγητής, Ιατρική Σχολή, ΚΠΑ
Πρωτοπαπάς Αθανάσιος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Καλλιανίδης Κωνσταντίνος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αθανασίου Σταύρος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Γρηγοριάδης Θεμιστοκλής, Επίκουρος Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Introduction
Laparoscopic technique constitutes one of the most important advances
regarding surgery the last three decades. Its historical benefits such as
shorter hospital stay, less postoperative pain and small scars have
contributed to the wide expansion of this operative technique and its
application for augmenting indications, not only in gynecology but also in
other surgical specialties as well. One of the most important prerequisites
for an effective laparoscopic operation is the need to constantly maintain
a good operative field throughout the whole length of the procedure.
Mechanical Bowel Preparation (MBP) is widely used preoperatively not
only to minimize the possibility of infection after inadvertent bowel
injury, but also to improve the operating field visualization. This practice
though may increase patient discomfort. Deep Neuromuscular Blockade
is also suggested, from an anesthetic point of view, as a possible factor
for a better surgical field quality.
Objective
To examine the importance of mechanical bowel preparation before
benign gynecologic laparoscopic procedures, evaluating the quality of
small and large bowel and surgical field overall. Moreover, we studied
the effect of deep neuromuscular blockade on surgical field and on
patients postoperative pain.
Materials and Methods
It is a single blind, randomized, controlled trial that was undertaken on a
tertiary University Hospital. 150 women with the indication of
gynecologic laparoscopic surgery for benign pathology were randomized
in three groups regarding bowel preparation method. Patients on the first
group received liquid diet the preoperative day, on the second group
mechanical bowel preparation with Polyethylene glucol solution (PEG)
and on the third minimal residual diet for three days. The patients then
were randomized in two groups, regarding the depth of neuromuscular
blockade during the operation. The primary outcomes were the quality of
the surgical field regarding preoperative practice for bowel preparation
and anesthesia method. Moreover, the intensity of postoperative pain
experienced from the patients according to the anesthesia method applied,
was one of the primary parameters we analyzed. Secondary outcome was
the patient discomfort provoked from the bowel preparation method used
which was evaluated with a questionnaire of pre and postoperative
symptoms. Postoperative and intraoperative complications were recorded
and analyzed as well.
Results
150 patients were finally randomized and 144 completed the study. Our
study revealed no benefit from the use of deep neuromuscular blockade
on the quality of small bowel (2.63 vs 2.79, p=0,17), the large bowel
(2.25 vs 2.51, p=0.054) and the surgical field overall (2.44 vs 2.68,
p=0.057). On the contrary patients that received deep neuromuscular
blockade experienced less postoperative pain (2.39 vs 0.79, p<0.001) and
received less strong analgesic therapy (4,1% vs 18.3%, p=0.007)
compared to patients on standard NMB. Moreover the patients on deep
blockade who underwent prolonged laparoscopic surgeries (>90min) had
less subcutaneous emphysema episodes intraoperatively.
Regarding bowel preparation, our study revealed that there is no benefit
from the use of mechanical bowel preparation before gynecologic
laparoscopic operations. The quality of small bowel was not better when
mechanical bowel preparation was applied compared to patients on liquid
diet or minimal residue diet (2.51 vs 2.82 vs 2.81, p=0.041) respectively,
and the same results were found for large bowel (2.26 vs 2.41 vs 2.48,
p=0.323) and surgical field overall (2.34 vs 2.67 vs 2.67, p=0.03).
Moreover, patients on MBP group experienced more significantly anal
irritation and fecal incontinence preoperatively, but the clinical
significance of this finding is not well established. Finally, patients
showed their discomfort on MBP as only 46.8% had a willing to receive
the same preparation on the future if needed, compared to 98% of the
patients on the liquid diet group and 83.3% on minimal residue diet
group.
Conclusions
Our study revealed that the application of deep neuromuscular blockade
failed to improve the quality of the surgical field in gynecologic
laparoscopic operations for benign pathology. It may reduce significantly
though, the patients postoperative pain and contribute to less analgesic
consumption. In laparoscopies with prolonged duration (>90min), deep
neuromuscular blockade is correlated with significant reduction of
episodes of intraoperative subcutaneous emphysema, an important
complication during this operative technique.
