Background: Although laparoscopic cholecystectomy (LC) results in less pain than open cholecystectomy, it is not a pain-free procedure. Many methods of analgesia for pain after laparoscopy have been evaluated. Methods: Forty-two randomized controlled trials assessing interventions to reduce pain after LC are reviewed, as are the mechanisms and nature of pain after this procedure. Results: Non-steroidal anti-inflammatory drugs, wound local anaesthetic, intraperitoneal local anaesthetic, intraperitoneal saline, a gas drain, heated gas, low-pressure gas and nitrous oxide pneumoperitoneum have been shown to reduce pain after LC. The clinical significance of this pain reduction is questionable. Conclusion: Pain after LC is multifactorial. Although many methods of analgesia produce short-term benefit, this does not equate with earlier discharge or improved postoperative function. However, single trials evaluating low-pressure insufflation, heated gas and multimodal analgesia suggest that clinically relevant benefits can be achieved.

Pain after laparoscopic cholecystectomy.

Background

Postoperative shoulder-tip pain occurs frequently following laparoscopic cholecystectomy. The aim of this randomized clinical trial was to evaluate the efficacy of a low-pressure carbon dioxide pneumoperitoneum during laparoscopic surgery in reducing the incidence of postoperative shoulder-tip pain.



Methods

Ninety consecutive patients undergoing laparoscopic cholecystectomy were randomized prospectively into low-pressure (group A) and normal-pressure (group B) laparoscopic cholecystectomy groups. Patients in group A (n = 46) underwent laparoscopic cholecystectomy with 9 mmHg carbon dioxide pneumoperitoneum during most of the operation, and those in group B (n = 44) had laparoscopic cholecystectomy with 13 mmHg pneumoperitoneum. Shoulder-tip pain was recorded on a visual analogue pain scale 1, 3, 6, 12, 24 and 48 h after operation.



Results

The low-pressure pneumoperitoneum did not increase the duration of surgery. There were no significant intraoperative or postoperative complications in either group. Fourteen patients (32 per cent) in group B and five (11 per cent) in group A complained of shoulder pain (P < 0·05). Mean shoulder-tip pain scores at 12 and 24 h and postoperative analgesia requirements were also significantly lower in the low-pressure laparoscopic cholecystectomy group (P < 0·001).



Conclusion

A carbon dioxide pneumoperitoneum pressure lower than that usually utilized to perform laparoscopic surgery reduces both the frequency and intensity of shoulder-tip pain following laparoscopic cholecystectomy. © 2000 British Journal of Surgery Society Ltd

Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy.

Objective To evaluate the effectiveness of the pulmonary recruitment maneuver (PRM) and intraperitoneal normal saline infusion (INSI) in removing postlaparoscopic carbon dioxide from the abdominal cavity to decrease laparoscopy-induced abdominal or shoulder pain after surgery. Design, Setting, and Patients A prospective, randomized, controlled trial was conducted at Taipei Veterans General Hospital, Taipei, Taiwan, from August 1, 2009, through June 30, 2010. One hundred fifty-eight women undergoing laparoscopic surgery for benign gynecologic lesions were randomly assigned to 3 groups: the PRM group (n = 53), the INSI group (n = 54), and the control group (n = 51). Interventions Postoperative maneuvers included PRM and INSI. Main Outcome Measures Evaluation of pain, including abdominal pain and shoulder pain, was performed at 12, 24, and 48 hours postoperatively. Results The frequency of postoperative shoulder pain at 24 and 48 hours was significantly decreased in the INSI group compared with that of either the PRM or control group (40.7% and 24.1% in the INSI group vs 66.0% and 50.9% in the PRM group [P = .009 and .004, respectively] or vs 72.5% and 54.9% in the control group [both P  Conclusions Both PRM and INSI could effectively reduce pain after laparoscopic surgery, but INSI might be better for both upper abdominal and shoulder pain. Trial Registration clinicaltrials.gov Identifier: NCT01135836

https://jamanetwork.com/journals/jamasurgery/articlepdf/1107256/soa110001_1360_1366.pdf

Maneuvers to decrease laparoscopy-induced shoulder and upper abdominal pain: A randomized controlled study

Background
Post-laparoscopic pain syndrome is well recognized and characterized by abdominal and particularly shoulder tip pain; it occurs frequently following laparoscopic cholecystectomy. The etiology of post-laparoscopic pain can be classified into three aspects: visceral, incision, and shoulder. The origin of shoulder pain is only partly understood, but it is commonly assumed that the cause is overstretching of the diaphragmatic muscle fibers owing to a high rate of insufflations. This study aimed to compare the frequency and intensity of shoulder tip pain between low-pressure (7 mmHg) and standard-pressure (14 mmHg) in a prospective randomized clinical trial.

Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial.

Background
Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholecystolithiasis. Despite the many advantages over open surgery, many patients complain about referred pain to the shoulder during the postoperative course. The purpose of this review was to evaluate different intraoperative surgical methods to minimize shoulder pain (SP).

Surgical techniques to minimize shoulder pain after laparoscopic cholecystectomy. A systematic review

Shoulder pain (SP) is frequently mentioned in recent literature following laparoscopic operations. In the literature, many causes have been declared to explain shoulder pain after CO2 insufflation, such as direct peritoneal irritation of the CO2 gas, excessive traction of the triangular ligament, and overstretching of the diaphragmatic muscle fibers due to the high rate of insufflation. This study was planned as multicentric, and 76 patients, aged between 35 to 45, were entered into the study. They were all selected by a randomized sampling method, with equal numbers of men and women, to achieve true evaluation. The low flow-rate (LFR) group was insufflated with 2.5 L/min and the high flow-rate (HFR) group with 7.5 L/min. All cases were evaluated by subjective pain classification on postoperative day 3. According to the subjective pain scale method, shoulder pain average was 23.9+/-3.1 in the LFR group and 55.4+/-6.5 in the HFR group. The difference between these groups was significant (p > 0.01). There is no significant difference for the operation time (LFR%: 64+/-15 minutes, HFR: 61+/-20 minutes, p > 0.05). Our results suggest that there is a significant statistical relation between the postoperative shoulder pain levels and increased insufflation rates. For this reason, low insufflation rate significantly reduces the shoulder pain but does not increase the operation time. Therefore, a low insufflation rate should be applied in all cases for patients' comfort and safety.

The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain.

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The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain.