Abstract
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 ...
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. Results150 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 intra operatively. 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 analirritation 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 dietgroup. 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. Preoperative mechanical bowel preparation has no benefit for patients undergoing gynecologic laparoscopy. This practice failed to improve the quality of small, large bowel and surgical field overall and on the contrary it may increase patient discomfort. Therefore, it is time to abandon MBP from the daily clinical practice before gynecologic laparoscopy.
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