SUGAMMADEX VERSUS NEOSTIGMINE IN PATIENTS RECEIVING INTRAOPERATIVE DEEP NEUROMUSCULAR BLOCK FOR MINIMALLY INVASIVE SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

Background: Deep neuromuscular blockade (NMB), defined by post-tetanic count (PTC) of 1–2 with no train-of-four (TOF) response, is used in minimally invasi surgery (MIS) to optimise surgical workspace and reduce insufflation pressures. The availability of sugammadex, which reliably reverses deep NMB, has enabled its routine clinical use. Whether this strategy meaningfully improves patient outcomes compared with moderate or shallow NMB reversed with neostigmine remains contested. Objectives: To systematically identify, appraise, and synthesise evidence from randomised controlled trials (RCTs) comparing deep NMB reversed with sugammadex versus moderate or shallow NMB reversed with neostigmine in adult patients undergoing minimally invasive surgery, across all clinically relevant perioperative outcomes. Search Methods: A web-based search of PubMed-indexed records, PubMed Central, ScienceDirect, Springer Nature, Frontiers in Medicine, and ClinicalTrials.gov was conducted in June 2026. Full multi-database search (Embase, CENTRAL, Scopus) was not completed in this draft. Eligibility Criteria: RCTs; adult patients; laparoscopic, robotic, or video-assisted thoracoscopic (VATS) minimally invasive surgery; intervention = deep NMB (PTC 1–2) reversed with sugammadex; comparator = moderate or shallow NMB reversed with neostigmine; any perioperative outcome. Results: Five eligible RCTs were identified (n = 840 participants analysed): Geldner et al. 2012 (laparoscopic surgery, n = 131); Putz et al. 2016 (laparoscopic hysterectomy, n = 100); Boggett et al. 2020 (laparoscopic surgery, n = 284); Williams et al. 2020 (robotic prostatectomy, n = 100); and Terranova et al. 2025 (laparoscopic hysterectomy, n = 220). A correction to an earlier draft of this review is noted here: neuromuscular reversal time (time to TOF ratio ≥0.9) could not be pooled across studies. Only one eligible study (Terranova et al. 2025, n = 220) reported this outcome in a directly usable mean ± SD format; Putz et al. 2016 reports a different outcome (time from end of surgery to operating room discharge, a downstream composite measure), which is not statistically interchangeable with time-to-TOF≥0.9 and has been analysed separately. In Terranova et al. 2025 alone, mean reversal time was 2.46 ± 1.37 minutes with sugammadex versus 8.13 ± 3.72 minutes with neostigmine, mean difference −5.67 minutes (95% CI −6.42 to −4.93). For operating room discharge time, Putz et al. 2016 reported 9.15 ± 4.28 minutes (sugammadex) versus 13.87 ± 11.43 minutes (neostigmine), p = 0.005, as a single, non-poolable study. Across all five studies, a consistent direction of faster neuromuscular recovery with sugammadex was observed, though the evidence base for a pooled point estimate is now smaller than previously reported. No eligible study demonstrated a significant difference in postoperative quality of recovery, shoulder pain, intra-abdominal insufflation pressure, or surgical rating scale scores. Three studies reported no benefit of deep NMB on surgical conditions. Following a completed RoB 2 assessment (below), GRADE certainty for the reversal-time estimate is Low, downgraded for indirectness (single study, single surgical context) and imprecision. Conclusions: Deep NMB with sugammadex reversal consistently accelerates objective neuromuscular recovery compared with neostigmine reversal of moderate/shallow NMB, but does not demonstrably improve clinically meaningful outcomes including quality of recovery, pain, or surgical conditions in existing evidence. Formal multi-database systematic review with complete risk-of-bias assessment is required before definitive recommendations.