Optimising abdominal space with deep neuromuscular blockade in gynaecologic laparoscopy--a randomised, blinded crossover study.

BACKGROUND: Insufflation of the abdomen during laparoscopy improves surgical space, but may cause post-operative shoulder pain. The incidence of shoulder pain is reduced using a lower insufflation pressure, but this may, however, compromise the surgical space. We aimed at investigating whether deep neuromuscular blockade (NMB) would enlarge surgical space, measured as the distance from the sacral promontory to the trocar in patients undergoing gynaecologic laparoscopy. METHODS: Fourteen patients were randomised in an assessor-blinded crossover design. The distance from the sacral promontory to the trocar was measured during deep NMB and without NMB at pneumoperitoneum 8 and 12 mmHg both. Additionally, we assessed surgical conditions while suturing the abdominal fascia using a 4-point subjective rating scale. Deep NMB was established with rocuronium and reversed with sugammadex. RESULTS: At 12 mmHg pneumoperitoneum, deep NMB improved surgical space with a mean of 0.33 cm (95% confidence interval 0.07-0.59) (P=0.01, paired t-test) compared with no NMB. At 8 mmHg pneumoperitoneum deep NMB improved surgical space with a mean of 0.3 cm (95% confidence interval, 0.06-0.54) (P=0.005) compared with no NMB. Deep NMB resulted in significantly better ratings of surgical conditions during suturing of the fascia (P=0.03, Mann-Whitney U-test). CONCLUSION: Deep NMB enlarged surgical space measured as the distance from the sacral promontory to the trocar. The enlargement, however, was minor and the clinical significance is unknown. Moreover, deep NMB improved surgical conditions when suturing the abdominal fascia.

Substitute decision-making and personal control: implications for self-determination.

Levels of personal control exercised by 76 adults with mental retardation were contrasted by substitute decision-making status. Individuals with no guardian or conservator exercised more personal control than did those with a conservator, who exerted more personal control than did participants with a guardian. Similar group differences in self-determination competencies were also observed. When self-determination competencies were controlled statistically, significant group differences in exercise of personal control remained. Restrictive substitute decision-making status, inappropriate to current competencies, may have constrained individuals' levels of personal control. Reviewing substitute decision-making status on a regular basis and limiting or removing guardianship/conservatorship when it is not appropriate, may enhance personal control.