The main objective of the study is to compare the frequency of intraoperative spontaneous diaphragmatic movements and breath-initiation efforts in participants undergoing robotic and/or thoracic surgery under deep neuromuscular blockade (NMB), using either the TetraGraph or TwitchView applied to the dominant hand. These events will serve as objective indicators to evaluate each device's ability to monitor and maintain adequate deep NMB.

This study is a prospective intraoperative device comparison trial evaluating neuromuscular blockade monitoring using two quantitative EMG-based devices, the TetraGraph (Senzime) and TwitchView (Blink), during elective laparoscopic, robotic, or video-assisted thoracoscopic (VATS) abdominal surgeries requiring neuromuscular blockade. Participants will be assigned to receive both monitoring devices simultaneously, placed on opposite upper extremities, allowing each subject to serve as their own control. Standard anesthesia care will be maintained throughout the procedure, including volatile anesthetic titration, opioid administration as needed, mechanical ventilation targeting normocapnia, temperature regulation, and routine neuromuscular blockade management with rocuronium and reversal with sugammadex per institutional practice. Neuromuscular function will be continuously assessed using train-of-four (TOF), train-of-four ratio, and post-tetanic count (PTC) measurements, with data recorded at predefined intraoperative time points including baseline, post-paralytic administration, maintenance, reversal, and prior to extubation. Additional data will include dosing of neuromuscular blocking agents, physiologic parameters, and intraoperative clinical observations relevant to depth of blockade and recovery. Provider usability and workflow integration will be evaluated postoperatively through brief standardized surveys assessing device usability, signal quality, and overall satisfaction. All collected data will be derived from device outputs and routine perioperative clinical documentation without altering standard patient care.

Inclusion Criteria:

• Adult male or female patients aged ≥ 18 years old.
• Patients undergo elective abdominal laparoscopic/robotic or thoracic video-assisted (VAT) surgeries requiring general anesthesia for greater than 3 hours at The Ohio State University Wexner Medical Center.
• Able to provide a signed, written informed consent.
• Able to speak, read, and write in English.
• ASA physical status I-III.

Exclusion Criteria:

• Patients who require emergency surgery or an emergent intervention.
• Any documented cognitive or psychological disorders that, in the investigator's opinion, can interfere with the patient's pain perception.
• Vulnerable populations: pregnant females, prisoners, breastfeeding.
• Presence of any medical condition that, in the opinion of the principal investigator, should exclude the patient from the study (patients with pre-existing neuromuscular diseases.
• Allergy or contraindications to any of the anesthetics, NMB agents, or sugammadex.
• Patients with anatomical abnormalities of the hands or arms that prevent proper placement of the sensors for nerve stimulation.
• Limited access to the monitoring area due to surgical positioning.
• Patients with peripheral vascular disease, since it may affect measurement accuracy.

Only the designated primary (dominant) monitoring device will be visible to clinicians and used for clinical decision-making regarding neuromuscular blockade management. The secondary device will remain blinded to the clinical team, and its measurements will not be available for guiding NMB management.