Laparoscopic Herniotomy Clinical Trial
Official title:
Optimizing Surgical Conditions During Laparoscopic Umbilical, Incisional -and Linea Alba Herniotomy With Deep Neuromuscular Blockade
The purpose of this study is to investigate surgical work space and surgical conditions in patients scheduled for laparoscopic umbilical, -linea alba and incisional herniotomy. The patients will act as their own control with evaluation of surgical work space and surgical conditions during both deep NMB and no NMB.
Umbilical herniotomy is a frequent surgical procedure worldwide, and the larger hernia
defects are preferably operated by laparoscopic technique. The advantages of the laparoscopic
approach are shorter convalescence with earlier mobilization, and less wound complications
[1]. A preferred approach is currently to close the defect by laparoscopic suturing in order
to reduce the formation of seroma in the hernia sac [2] , and then apply a mesh by
intraperitoneal onlay technique (IPOM technique). However, it may be difficult to suture the
defect if there is tension in the abdominal wall muscles together with the applied
pneumoperitoneum.
There is evidence that muscle relaxation improves conditions for endotracheal intubation[3]
and reduces laryngeal morbidity but only a few studies investigate the necessity of
relaxation during laparoscopic surgery [4].
During laparoscopic surgery muscle relaxation is used with great variability. Sometimes the
procedure is performed without muscle relaxation and sometimes with a so-called surgical
neuromuscular blockade, which with objective neuromuscular monitoring means that
train-of-four (TOF) is kept at 3-4 responses to nerve stimulation of the ulnar nerve. In this
way there is a great variability in the neuromuscular blockade and rarely the patients are
receiving deep neuromuscular blockade.
Traditionally, neuromuscular monitoring is done by measuring the muscle strength of the
adductor pollicis muscle on the thumb. The response to TOF nerve stimulation may be zero,
while muscle relaxation of more resistant muscles such as the abdominal muscles and the
diaphragm [5;6] are not complete which means that the patients may cough and their abdominal
wall may feel "tight" during surgery, even though no response at the thumb is recorded. It is
possible to quantify a deep neuromuscular block by the use of post-tetanic-count (PTC). With
establishment of deep, continuous neuromuscular blockade with PTC value 0-1 all muscles
including abdominal muscles and diaphragm are paralyzed [7]. It is therefore possible, that a
deep neuromuscular blockade (NMB) where the diaphragm and the abdominal wall muscles are more
paralyzed will optimize the surgical work space, ease the surgical procedure, reduce
operative time for the suturing part of the procedure as well as the total procedure time,
and reduce the number of recurrences by long term follow-up.
The purpose of this study is to investigate surgical work space and surgical conditions in
patients scheduled for laparoscopic umbilical, -linea alba and incisional herniotomy. The
patients will act as their own control with evaluation of surgical work space and surgical
conditions during both deep NMB and no NMB.
Hypothesis:
Deep NMB defined as TOF=0 and post-tetanic count PTC ≥1, will give better surgical workspace,
better surgical conditions, as well as shorter duration of surgery and reduced number of
recurrences of hernias compared with no NMB.
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