Interventions to reduce shoulder pain following gynaecological laparoscopic procedures

The abdominal compliance index and postoperative pain after laparoscopic gynecologic surgery: a preliminary observational cohort study

Background/aim

In gynecology, laparoscopic surgery has the advantages of reduced scarring, less postoperative pain, faster recovery, and lower risk of complications. Despite these advantages, shoulder pain still remains a major concern, affecting up to 90% of patients undergoing gynecologic laparoscopic surgery. Use of the abdominal compliance index (ACI) may offer the benefit of increased space for safer surgery and may prevent the drawback of high insufflation pressures. The aim of this study was to investigate the relationship between shoulder pain, abdominal pain, and analgesic use with the recently advised ACI, a surrogate index of abdominal expansion in patients undergoing gynecologic laparoscopic surgery.

Materials and methods

Thirty-one patients with American Society of Anesthesiologists scores of 1-3 who underwent elective gynecologic laparoscopic surgery were included. The insufflation pressure was set to 12 mmHg. ACI, defined as insufflated intraabdominal volume (L) per body surface area (m2), was used to estimate the relationship between abdominal compliance and postoperative pain.

Results

The 31 patients were separated into two groups based on median ACI level (range 1.37-2.73 L/m2), with those having values of 2.16 L/m2 or lower as group 1 and those with higher values as group 2. Abdominal visual analogue scale (VAS) scores at 30 min postoperative were significantly higher in group 2 than in group 1 (p < 0.001). Shoulder pain VAS scores at 24 h and 36 h postoperative were also significantly higher in group 2 than in group 1 (p = 0.021 and p = 0.002, respectively). The total amount of analgesic infusion and additional analgesic requirements were lower in group 1 than in group 2 (p = 0.049 and p = 0.001, respectively). ACI did not differ with patient demographic characteristics or history of abdominal/laparoscopic surgery, parity, abdominal drainage, and pneumoperitoneum time.

Conclusion

ACI, a surrogate index of abdominal expansion capacity, may be used to guide individualization of insufflation pressures by identifying female patients under risk of higher postoperative pain.

Association between postoperative shoulder pain and left-side laparoscopic urologic surgery: a single-center retrospective cohort study

PURPOSE

Postoperative shoulder pain is a common problem after laparoscopic surgery. This study aimed to investigate the association between operative side and postoperative shoulder pain following urologic laparoscopic surgery performed in the lateral recumbent position.

METHODS

This was a retrospective cohort study conducted at a single tertiary care center. A total of 506 patients who underwent urologic laparoscopic surgery (including adrenalectomy, radical nephrectomy, partial nephrectomy, and pyeloplasty) between January 2010 and December 2019 were included. Patients who underwent total nephroureterectomy or resection of other organs were excluded. The primary outcome was the incidence of postoperative shoulder pain. A multivariable logistic regression analysis investigated the association between the operative side and postoperative shoulder pain.

RESULTS

Among the 506 included patients, there were an equal number of surgeries on the left and right sides. Eighty-eight patients had postoperative shoulder pain. The incidence of postoperative shoulder pain in the left-side group was significantly higher than that in the right-side group (21.3% [54/253] versus 13.4% [34/253], crude odds ratio = 1.75, 95% confidence interval [CI] 1.07-2.89). After adjustment for potential confounders (age, sex, body mass index, operation duration, operative technique, epidural block, peripheral nerve block, American Society of Anesthesiologists physical status classification, and intraoperative rocuronium dose), the left operative side was found to be associated with postoperative shoulder pain (adjusted odds ratio = 1.89, 95% CI 1.15-3.09).

CONCLUSION

The left operative side is associated with an increased incidence of postoperative shoulder pain after urologic laparoscopic surgery performed in the lateral recumbent position.

Research hotspots and trends in postlaparoscopic shoulder pain from 2003 to 2023: A bibliometric analysis

The incidence of postlaparoscopic shoulder pain has recently increased and has attracted increasing attention from clinical workers, but no study has performed bibliometric and visual analysis of the relevant literature. This study used bibliometric and visual analysis to conduct a comprehensive and systematic evaluation of postlaparoscopic shoulder pain to help researchers understand the latest global trends and hotspots and provide a reference for caregivers to carry out PLSP care interventions and research. Related studies on postlaparoscopic shoulder pain from 2003 to 2023 were retrieved from the Web of Science Core Collection. We analysed current research trends and hotspots in this field using VOSviewer and CiteSpace. A total of 2451 authors from 352 institutions in 50 countries published 464 studies related to postlaparoscopic shoulder pain. The United States was the country with the most publications and worked closely with other countries. Donmez Turgut was the researcher with the most published articles, while Bisgaard T had the most citations per article. The Journal of Surgical Endoscopy was cited most frequently, totalling 356 times. Through keyword significance analysis, we found that relieving postlaparoscopic shoulder pain in patients through integrated care interventions was an emerging research hotspot. This bibliometric and visual analysis provides a comprehensive review of studies related to postlaparoscopic shoulder pain. The current global research trend and hotspot is to alleviate postlaparoscopic shoulder pain through integrated care interventions, but the advantages of this approach are not outstanding. However, further research and global collaboration are still needed. Our findings can help researchers understand the current status of postlaparoscopic shoulder pain research and identify new directions for future research.

Does transcutaneous electrical nerve stimulation reduce the laparoscopic related shoulder pain?

OBJECTIVE

Although laparoscopic surgery is a good substitute for laparotomy in reducing postsurgical pain, many patients complain of shoulder pain after laparoscopic surgery and require pain-relief. Post-operative pain management leads to increased patient satisfaction. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological, noninvasive modality that reduces pain by activating the descending inhibitory systems in the central nervous system. Given the importance of decreasing shoulder pain after gynecological laparoscopy, the current study aimed to investigate the management of shoulder pain in these patients using TENS.

METHODS

This was a retrospective case-control study. A total of 112 women aged 18-45 years who experienced shoulder pain due to gynecologic laparoscopic surgery were included in the study. Patients were divided into TENS and control groups. In the TENS group, TENS was used twice for 20 minutes each, but in the control group, the patients received regular treatment. Patients were evaluated at intervals of 2, 4, 8, 24, 48, and 72 hours after laparoscopy for shoulder pain score.

RESULTS

The results showed a significant decrease in visual analog scale scores at 2, 4, and 8-hour in the TENS group compared with the control group. At 24 hours evaluation, although the pain was reduced, the difference was not significant. At 48- and 72-hour assessment, all patients in each group reported zero score for severity of pain.

CONCLUSION

The findings suggest that TENS significantly reduces postoperative shoulder pain.

The influence of the pulmonary recruitment maneuver on post-laparoscopic shoulder pain in patients having a laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Post-laparoscopic shoulder pain is very common after laparoscopy. One method to reduce postoperative shoulder pain is the pulmonary recruitment maneuver. It is used to reduce post-laparoscopic shoulder pain. This study utilizes a truly experimental, double-blinded, prospective randomized design to assess the effect of pulmonary recruitment maneuvers on post-laparoscopic shoulder pain after laparoscopic cholecystectomy.

METHODS

Sixty patients were allocated randomly into two groups. The intervention group received five manual pulmonary inflations for 5 s at a maximum pressure of 25 cm H2O. The control group included patients whose residual CO2 gas was evacuated from the abdominal cavity using passive exsufflation as the routine method at the end of surgery by abdominal massage. Gentle abdominal pressure was applied to facilitate CO2 gas removal.

RESULTS

When Ramsay's Sedation Score's results were compared between the two groups after the operation, there was no statistically significant difference between the two groups during the first and (p value = 0.20) second (p value = 0.61) hours. A repeated measures ANOVA revealed that the pulmonary recruitment maneuver is significant (p-value 0.001) and had a high effect size (0.527) in reducing shoulder pain among laparoscopic cholecystectomy patients after controlling the effect of other covariate patient characteristics.

CONCLUSION

Utilizing a pulmonary recruitment maneuver at the end of laparoscopic surgery reduces shoulder pain.

Pulmonary recruitment maneuver reduces the intensity of post-laparoscopic shoulder pain: a systematic review and meta-analysis

BACKGROUND

Post-laparoscopic shoulder pain (PLSP) is a common complication following laparoscopic surgeries. This meta-analysis aimed to investigate whether pulmonary recruitment maneuver (PRM) was beneficial to alleviated shoulder pain after laparoscopic procedures.

METHODS

We reviewed existing literature in the electronic database from the date of inception to January 31, 2022. The relevant RCTs were independently selected by two authors, after which data extraction, assessment of the risk of bias, and comparison of results.

RESULTS

This meta-analysis included 14 studies involving 1504 patients, among which 607 patients were offered pulmonary recruitment maneuver (PRM) alone or in combination with intraperitoneal saline instillation (IPSI), while 573 patients were treated with passive abdominal compression. The administration of PRM significantly decreased the post-laparoscopic shoulder pain score at 12 h (MD (95%CI) - 1.12(-1.57, - 0.66), n = 801, P < 0.001, I² = 88%); 24 h (MD (95%CI) - 1.45(-1.74, - 1.16), n = 1180, P < 0.001, I² = 78%) and at 48 h (MD (95%CI) - 0.97(-1.57, - 0.36), n = 780, P < 0.001, I² = 85%). We observed high heterogeneity in the study and analyzed the sensitivity but failed to identify the cause of the heterogeneity, which may have resulted from the different methodologies and clinical factors in the included studies.

CONCLUSION

This systematic review and meta-analysis indicate that PRM can reduce the intensity of PLSP. More studies may be needed to explore the usefulness of PRM in more laparoscopic operations besides gynecological surgeries and determine the optimal pressure of PRM or its appropriate combination with other measures. The results of this meta-analysis should be interpreted with caution owing to the high heterogeneity between the analyzed studies.

[The effect of intraperitoneal administration of dexamethasone on postoperative analgesia after laparoscopic cholecystectomy: a prospective randomized controlled double-blind study]

Introduction

the effect of intravenous corticosteroids on postoperative pain has been well demonstrated; however, few studies have focused on the efficacy of intraperitoneal corticosteroid use after laparoscopic surgery. The purpose of this study was to evaluate the effect of intraperitoneal administration of dexamethasone on postoperative analgesia after laparoscopic cholecystectomy.

Methods

we conducted a prospective, randomised, double-blind, controlled study, including patients scheduled for laparoscopic cholecystectomy and randomised into two groups: the group D (receiving 16 ml: 12 ml saline and 4 ml solution containing 16mg dexamethasone) and the group T (receiving 16 ml saline). The primary endpoint was: Visual Analogue Scale (VAS) for abdominal pain during the first 24 hours after surgery. The secondary endpoints were the incidence of shoulder pain, time to first request for analgesia, the consumption of morphine in the post-intervention surveillance room (PACU), the consumption of non-opioid analgesics and the incidence of nausea and vomiting during the first 24 hours after surgery as well as the presence of complications.

Results

sixty patients were included in the study and divided into two groups of 30. Demographic parameters, duration of surgical and anesthesia procedures, as well as intraoperative fentanyl consumption were comparable between the two groups. Abdominal pain VAS values (p≤0.001), the incidence of shoulder pain (p<0.001), opioid and analgesic consumption (p<0.001) and the incidence of nausea (p=0.002) and vomiting (p=0.012) during the first 24 hours after surgery were significantly lower in group D. No complications related to dexamethasone administration were noted.

Conclusion

intraperitoneal dexamethasone reduces postoperative pain after laparoscopic cholecystectomy.

Effect of Low or High Pressure Alveolar Recruitment Maneuver on Postoperative Pain and Quality of Recovery in Patients with Obesity Undergoing Laparoscopic Sleeve Gastrectomy

Background: This study aimed to evaluate whether a low- or high-pressure alveolar recruitment maneuver (ARM) might reduce postoperative pain and improve the quality of recovery after laparoscopic bariatric surgery. Methods: 90 patients with a body mass index > 30 kg/m2 scheduled for laparoscopic sleeve gastrectomy were randomly assigned to control (n = 30), low ARM (n = 30), or high ARM groups (n = 30). For the low and high ARM groups, ARM was repeated five times to hold the peak airway pressure at 30 cmH2O and 60 cmH2O for 5 s, respectively, before removal of the trocar. Conventional methods to reduce post-laparoscopic pain, such as intraperitoneal saline irrigation, hemovac drainage, and gentle abdominal compression were performed in all patients, regardless of the assigned group. Results: Shoulder and surgical site pain scores 24 h postoperatively and rescue meperidine requirement were similar between the groups (p = 0.141, 0.101, and 0.82, respectively). The quality of recovery 40 (QoR40) score 24 h postoperatively was similar between the groups (p = 0.755). Postoperative pulmonary complications were similar between the groups (p = 0.124). Conclusion: Application of a low- or high-pressure ARM in addition to conventional methods to remove remnant peritoneal CO2 gas did not reduce postoperative shoulder or surgical site pain or improve the quality of recovery after laparoscopic sleeve gastrectomy.

Effects of intraperitoneal bupivacaine injection in laparoscopic appendectomy in children on post-operative pain: A controlled randomized double-blinded study

BACKGROUND

The aim of this study is to determine the effects of local anesthetics administered intraperitoneally in laparoscopic appendectomy.

METHODS

Patients who underwent laparoscopic appendectomy due to acute appendicitis were enrolled in the study. The children were divided into two groups. Intraperitoneal bupivacaine injection to appendectomy site and subdiaphragmatic area was performed after resection of appendix and aspirastion of intraperitoneal reactive fluid in Group 1 while Group 2 did not receive this therapy. The children were questioned by a nurse at postoperative 1st, 6th, 12th, and 24th h. Pain scores (PS) (abdominal), abdominal wall incisional pain (IP), shoulder pain (SP), and first need for analgesics were recorded.

RESULTS

One hundred and twenty children were enrolled to the study. There was no significant difference in PS values and IP values between the two groups (p>0.05). SP values at 12th and 24th h were significantly lower in Group 1 (p<0.05). There was a statistically significant reduce in analgesic need in Group 1 (p=0.007).

CONCLUSION

Intraperitoneal bupivacaine instillation to surgery site and subdiaphragmatic area seems to reduce the SP post-opera-tive and also reduce post-operative analgesic need. More meaningful results can be obtained with an increase in the number of patients.

Systematic Review and Meta-Analysis of Perioperative Administration of Acetazolamide for Management of Postoperative Pain after Laparoscopy

Background and Objective

To perform a systematic review and meta-analysis to evaluate the efficacy of perioperative acetazolamide (ACTZ) administration with laparoscopy for reducing postoperative referred pain.

Methods

The following databases were searched from inception to March 1, 2020: Cochrane, PubMed, PubMed Central, Ovid, and Embase. Electronic search used: Acetazolamide AND (laparoscopy OR laparoscopic OR Celioscopy OR Celioscopies OR Peritoneoscopy OR Peritoneoscopies). No limits or filters were used. We included only studies of patients who underwent abdominal laparoscopy (LSC), had a pain assessment at approximately 24 hours postoperatively, and included a treatment with ACTZ group and a no-treatment or minimal-treatment comparison group.

Results

Five studies met inclusion criteria, with a combined total of 253 participants, 116 in the ACTZ group and 137 in the control group. A Bayesian hierarchical model was assumed for the study specific treatment effects. Posterior sampling was conducted via Markov Chain Monte Carlo methods, and posterior inference carried out on the hierarchical treatment effect. ACTZ significantly decreased average pain scores compared to control group by -0.726 points (95% confidence interval -1.175-0.264). The posterior probability that ACTZ decreases mean pain scores by ≥ 0.5 was 0.846.

Conclusion

Current available evidence demonstrates that perioperative ACTZ may provide a modest improvement in postoperative referred pain following LSC.

Post Laparoscopy Pain Reduction Project I (POLYPREP I): intraperitoneal normal saline instillation-a randomised controlled trial

OBJECTIVES

To evaluate the effect of intraperitoneal normal saline instillation (INSI) of 15 mL/kg body weight on postoperative pain after a gynaecological laparoscopic procedure.

DESIGN

Randomised controlled trial.

SETTING

University Hospital in Kuala Lumpur, Malaysia.

PARTICIPANTS

Patients aged 18-55 years, with American Society of Anaesthesiologists (ASA) classification I-II, scheduled for an elective gynaecological laparoscopic procedure for a benign cause.

INTERVENTION

The patients were randomly allocated to two groups. In the intervention group, 15 mL/kg body weight of normal saline was instilled intraperitoneally, while the control group received the conventional combination of open laparoscopic trocar valves with gentle abdominal pressure to remove the retained carbon dioxide.

MAIN OUTCOME MEASURES

The outcomes measured were the mean pain scores for shoulder and upper abdominal pain at 24 h, 48 h, and 72 h postoperatively.

RESULTS

A total of 68 women completed the study, including 34 women in each group. There was no difference in the shoulder pain score at 24 h, 48 h, and 72 h postoperatively. However, a significant improvement in the upper abdominal pain score after 48 h (95% confidence interval [CI] 0.34-1.52, p = 0.019) and 72 h (95% CI 0.19-0.26, p = 0.007) postoperatively were observed.

CONCLUSIONS

INSI of 15 mL/kg body weight does not lower postoperative shoulder pain compared to no fluid instillation. A modest pain score improvement was observed in the upper abdominal area at 48 h and 72 h after surgery. An INSI of up to 30 mL/kg body weight may be required to eliminate shoulder pain. Care must be taken before administering a higher amount of INSI, considering the potential risk of peritoneal adhesions. Clinical registration ISRCTN Identifier: 87898051 (Date: 26 June 2019) https://doi.org/10.1186/ISRCTN87898051.

Safety considerations in laparoscopic surgery: A narrative review

Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.

Sodium Bicarbonate Sub-Diaphragmatic Irrigation Relieves Shoulder Pain After Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study Objective

To determine whether sub-diaphragmatic irrigation with sodium bicarbonate would relieve post-laparoscopic shoulder pain (PLSP) after total laparoscopic hysterectomy.

Design

Randomized double-blinded trial.

Setting

Teaching hospital.

Patients

Seventy patients undergoing total laparoscopic hysterectomy (TLH) for benign indications.

Intervention

We randomly allocated patients to intervention or control groups where sodium bicarbonate containing flushing liquid or normal saline was irrigated sub-diaphragm before sewing.

Measurement & Main Results

The primary outcome was PLSP following surgery measured by a numerical rating scale (NRS) (0 = no pain; 10 = worst pain imaginable). Secondary outcomes were abdominal incisional and visceral pain, analgesic use, and sodium bicarbonate related side effects. The incidence of PLSP in intervention group was significantly lower than that in control group (P < 0.05). Contrarily, incisional and visceral pain was similar in both groups (P = 0.1). The consumption of rescue analgesics in the intervention group was lower than that in the control group. Side effects were comparable in both study groups.

Conclusion

Sub-diaphragmatic irrigation with sodium bicarbonate could effectively reduce shoulder pain, but not abdominal incisional and visceral pain, in patients undergoing TLH without an increase in side effects.

Registration information

Clinical trial registry number: http://www.chictr.org.cn/ (ChiCTR2100041765).

Registration findings

http://www.chictr.org.cn/showproj.aspx?proj=66721 Link to clinical trial page and data repository: http://www.medresman.org.cn/pub/cn/proj/projectshshow.aspx?proj=2992.

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review

Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.

To drain or not to drain: the association between residual intraperitoneal gas and post-laparoscopic shoulder pain for laparoscopic cholecystectomy

Residual intra-peritoneal gas may be associated with post-laparoscopic shoulder pain (PLSP), which is a frequently and disturbance compliant after surgery. Herein, we aimed to examine whether expiring residual gas via a surgical drain reduces the frequency and intensity of PLSP in the first day after laparoscopic cholecystectomy. 448 participants were enrolled in this prospective cohort study. The incidence and severity of PLSP after surgery were recorded. Of these, the cumulative incidence of PLSP in the drain group was lower particularly at the 12th postoperative hour (18.3% vs. 27.6%; P = 0.022), 24th postoperative hour (28.8% vs. 38.1%; P = 0.039), and throughout the first postoperative day (P = 0.035). The drain group had less severe PLSP (crude Odds ratio, 0.66; P = .036). After adjustment using inverse probability of treatment weighting, the drain group also had a significant lower PLSP incidence (adjusted hazard ratio = 0.61, P < 0.001), and less severe PLSP (adjusted odds ratio = 0.56, P < 0.001). In conclusion, the maneuver about passive force to expel residual gas, surgical drain use, contributes to reduce the incidence and severity of PLSP, suggesting that to minimize residual gas at the end of surgery is useful to attenuate PLSP.

Comparison of outcomes of single incision robotic cholecystectomy and single incision laparoscopic cholecystectomy

Backgrounds/Aims

Multiport laparoscopic cholecystectomy is the standard surgical procedure for symptomatic gallbladder diseases. However, as a result of the ongoing trend toward minimally invasive laparoscopy, single-incision laparoscopic cholecystectomy (SILC) has evolved. Single-incision robotic cholecystectomy (SIRC) can overcome several limitations of manual SILC. The purpose of this study is to evaluate and compare the safety and feasibility of SIRC and SILC.

Methods

This study retrospectively reviewed data for all patients who underwent SIRC or SILC from March 2018 to July 2019 in a single institution. The following variables were analyzed: age, sex, body mass index, pain scale, length of stay, and complications. The data were analyzed using the Independent two sample t-test or the Fisher’s exact test.

Results

A total of 343 patients underwent SIRC or SILC during the study period. After excluding patients with acute cholecystitis, 197 SIRC and 103 SILC patients were analyzed in this study. The surgery time and postoperative hospital stay did not differ between SIRC and SILC. However, the SIRC patients experienced less bile spillage during the surgery than did the SILC patients (SIRC vs. SILC: 24 (23.3%) vs. 11 (5.6%) cases, respectively; p<0.001). Although there was no difference in the incidence of postoperative complications between procedures, additional pain control was administered more frequently in SILC patients (SILC 1.08±0.893, SIRC 0.58±0.795; p<0.001).

Conclusions

While both SILC and SIRC are effective for single-incision cholecystectomy, SIRC was superior to SILC in terms of technical stability. Moreover, it has the advantage of postoperative pain control.

The effect of subcutaneous and intraperitoneal anesthesia on post laparoscopic pain: a randomized controlled trial

A few modes of perioperative local analgesia have been studied in order to reduce postoperative pain after laparoscopy, including preemptive local anesthetics in the trocar sites and intraperitoneal anesthetics administration at the end of the surgery. However, the evidence regarding their efficacy are conflicting. In addition, the combination of both aforementioned methods has been rarely studied. Our aim was to evaluate whether subcutaneous trocar site and/or intraperitoneal analgesia reduce pain after gynecologic operative laparoscopy. This was a single-centered, randomized, controlled, double-blinded trial. The patients were randomly assigned to one of four equally sized groups: group 1-subcutaneous and intraperitoneal analgesia; group 2-subcutaneous analgesia and intraperitoneal placebo; group 3-subcutaneous placebo and intraperitoneal analgesia; Group 4-subcutaneous and intraperitoneal placebo. The patients, the surgeons, and the pain evaluators were all blinded to the patient's allocation. Included were patients who underwent elective operative laparoscopy. Exclusion criteria were: active infection, pregnancy, known sensitivity to Bupivacaine-Hydrochloride, chronic pelvic pain, surgeries with additional vaginal procedures, conversion to laparotomy, and malignancy. A total of 9 ml of Bupivacaine-Hydrochloride (Marcaine) 0.5%, or Sodium-Chloride 0.9%, as a placebo, were injected subcutaneously to the trocar sites (3 ml to each trocar site), prior to skin incision. In addition, 10 ml of Bupivacaine-Hydrochloride 0.5%, diluted with 40 ml of Sodium-Chloride 0.9% (a total of 50 ml solution), or 50 ml of Sodium-Chloride 0.9%, as a placebo, were injected intraperitoneally at the end of the surgery. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. The study was approved by the local Institutional Review Board and has been registered at clinicaltrials.gov. We conformed to the CONSORT recommendations. Between December 2016 and July 2019, a total of 119 patients were included in the study. Demographic and interventional characteristics were similar among the groups. The level of postoperative pain, either at rest or with change of position, was not significantly different between the groups, at all-time points. Application of subcutaneous and/or intraperitoneal analgesia is not effective in reducing pain after gynecologic operative laparoscopy.Clinical trial identification number: NCT02976571. Date of trial registration 11/29/2016. URL of the registration site: https://clinicaltrials.gov .

Patient reported experiences following laparoscopic prophylactic bilateral salpingo-oophorectomy or salpingectomy in an ambulatory care hospital

Women at risk of developing ovarian cancer because of a BRCA1 or BRCA2 pathogenic variant are candidates for prophylactic bilateral salpingo-oophorectomy (BSO). While BSO surgeries are routinely performed, to our knowledge there are no studies that have examined patient-reported experiences following laparoscopic BSO performed in an ambulatory care setting. The objective of this study was to examine whether women undergoing prophylactic laparoscopic BSO felt they were adequately informed about post-operative outcomes. A telephone interview was conducted among 46 women undergoing laparoscopic BSO to collect detailed information regarding surgical outcomes, complications, symptoms, and time to return to daily activities. The average age at surgery was 45.0 years (range 34-66) and 67% of women underwent BSO prior to age 50. The mean reported hospital stay was 7.2 h (range 4-12 h) and at time of discharge, 78% of the women felt well enough to go home. None of the women required a readmission to hospital. Forty-three percent (n = 20) of the women did not feel well informed about what to expect post-operatively. Most of the patient-reported outcomes (including pain, vaginal bleeding, and nausea/vomiting) were expected and patient-reported menopausal symptoms were more common among women who were premenopausal at surgery. In terms of returning to regular activities, premenopausal women (n = 36) resumed sexual activity on average at 43 days (range 2-365), which is later than postmenopausal women (n = 15) at 19 days (range 7-30). On average, women returned to full-time work in 16 days (range 1-56 days). Despite patients receiving pre-surgery counselling, our findings suggest that there is a need to provide supplemental, reinforcing patient materials in preparing patients for what to expect after surgery.

A double-blinded randomised controlled study to investigate the effect of intraperitoneal levobupivacaine on post laparoscopic pain

BACKGROUND

Laparoscopic surgery is the cornerstone of modern gynaecological surgery, with shorter hospital stays and a quicker return to normal activities. However postoperative pain remains problematic. No strategy to reduce phrenic nerve irritation, including heating or humidifying the insufflating gas, alternatives to CO₂, and intraperitoneal analgesics, has shown superiority.

METHODS

100 women undergoing laparoscopic surgery were randomly allocated, having either 40ml of 0.25% levobupivacaine or 40ml 0.9% sodium chloride solution administered into the peritoneal cavity following surgery. The patients and the main researcher were blinded. All women received standardised anaesthetic and laparoscopic technique, and postoperative pain control including nursing position and nature of analgesia. Postoperative pain was assessed 3 hours, 8 hours, day 1 and day 4/5 postoperatively.

RESULTS

100 patients were recruited undergoing surgery for benign causes aged 19-73(mean 40.3±13). There was no difference between the groups for age(p=0.64) or length of operation(p=0.56). There were no adverse events related to use of intraperitoneal instillation. There was a significant reduction in shoulder-tip pain scores in the levobupivacaine group at 3 hours(p=0.04). Furthermore, there was a significant reduction in wound-pain scores in the levobupivacaine group at 8hrs(p=0.04) and at day 4(p=0.04). No difference was found in pelvic pain between the two groups. No significant difference was found in the use of post-operative analgesia.

CONCLUSIONS

Intraperitoneal instillation of 40ml of levobupivacaine has some benefit in reducing postoperative pain and need for analgesia in the initial hours following gynaecological surgery. However, further well-designed randomised control trials are required to decide the optimum route and concentration of administering local anaesthetic.

Pulmonary Recruitment Maneuver for Reducing Shoulder Pain after Laparoscopic Gynecologic Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Background

Shoulder pain is a common symptom following laparoscopic surgery. This systematic review was undertaken to assess updated evidence regarding the effectiveness and complications of the pulmonary recruitment maneuver (PRM) for reducing shoulder pain after laparoscopic gynecologic surgery.

Methods

A number of databases for randomized controlled trials (RCTs) investigating PRM for reducing shoulder pain were searched up to June 2019. Two authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, and compared results. Network meta-analyses were employed to simultaneously compare multiple interventions. Effect measures were presented as pooled mean difference (MD) or risk ratio (RR) with corresponding 95% confidence intervals (CI).

Results

Of the 44 records that we identified as a result of the search (excluding duplicates), eleven RCTs involving 1111 participants were included. Three studies had an unclear risk of selection bias. PRM with a maximum pressure of 40 cm H₂O was most likely to result in the lowest shoulder pain intensity at 24 hours (MD −1.91; 95% CI −2.06 to −1.76) while PRM with a maximum pressure of 40 cm H₂O plus intraperitoneal saline (IPS) appeared to be the most efficient at 48 hours (MD −2.09; 95% CI −2.97 to −1.21). The estimated RRs for analgesia requirement, nausea/vomiting, and cardiopulmonary events were similar across the competing interventions.

Conclusion

PRM with 40 cm H₂O performed either alone or accompanied by IPS is a promising intervention for alleviating shoulder pain within 48 hours following gynecologic laparoscopy.

Less is more: clinical impact of decreasing pneumoperitoneum pressures during robotic surgery

The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8 mmHg. Continuous variables were compared using analysis of variance and χ² test was used for categorical variables. 598 patients were included in this study with no differences in age, BMI, race, prior abdominal surgeries, or specimen weight between the four cohorts. When comparing cohorts, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs. 3.8, p ≤ 0.001), and hospital length of stay (449 vs 467 vs 351 vs. 317 min, p ≤ 0.001). There were no differences in duration of surgery (p = 0.31) or blood loss (p = 0.09). Lower operating pressures were correlated with significantly lower peak inspiratory pressures (p < 0.001) and tidal volumes (p < 0.001). Surgery performed at lower-pressure pneumoperitoneum (≤ 10 mmHg) is associated with lower postoperative pain scores, shorter length of stay, and improved intraoperative respiratory parameters without increased duration of surgery or blood loss. Operating at lower insufflation pressures is a low-cost, reversible intervention that should be implemented during robotic surgery as it results in the improved pain scores and shorter hospital stays.

Combination of a pulmonary recruitment maneuver and intraperitoneal bupivacaine for the reduction of postoperative shoulder pain in gynecologic laparoscopy: a randomized, controlled trial

Objective

To compare the efficacy of a pulmonary recruitment maneuver using lower airway pressure (30 cm H₂O) and intraperitoneal bupivacaine, alone or in combination, for reducing shoulder pain after gynecologic laparoscopy.

Methods

A prospective controlled study was performed in a teaching hospital with patients who underwent elective gynecologic laparoscopic surgery. Two hundred eighty-seven patients were randomized into 1 of 4 groups: group A, placebo; group B, intraperitoneal instillation of bupivacaine; group C, CO₂ removal by a pulmonary recruitment maneuver; group D, combination of intraperitoneal bupivacaine and pulmonary recruitment maneuver. The interventions were performed at the end of surgery. Shoulder pain was recorded on a visual analog scale (VAS) at 1, 6, 12, and 24 hours postoperatively.

Results

The overall incidence of shoulder pain was 49.8% and the incidence tended to gradually decrease from group A to group D (59.0% in group A, 54.8% in group B, 44.4% in group C, and 41.5% in group D; P=0.026). In addition, the VAS scores gradually decreased from group A to D, although a statistically significant difference was only found at 6 hours postoperatively (P=0.03). There were no complications related to the interventions.

Conclusion

The combination of a pulmonary recruitment maneuver with intraperitoneal bupivacaine significantly reduced shoulder pain after gynecologic laparoscopy.

Trial Registration

ClinicalTrials.gov Identifier: NCT01039441

Comparison of Intraperitoneal Normal Saline Infusion with Pulmonary Recruitment Maneuver in Reducing Shoulder and Upper Abdomen Pain Following Gynecologic Laparoscopic Procedures: A Randomized, Controlled, Triple-Blind Trial

Objectives

The current study aimed at evaluating the effect of intraperitoneal infusion of normal saline (NS) and pulmonary recruitment maneuver (PRM) on the reduction of pain in shoulder, upper abdomen, and incision site after elective laparoscopic gynecologic surgery.

Methods

Totally, 280 patients (mean age: 30.5 years) that underwent laparoscopic gynecologic surgery from October 2013 to August 2015 were randomly and equally allocated into four groups. Group A received intraperitoneal infusion of NS 1.5 - 2 mL/kg of body weight; group B received PRM with five manual pulmonary inflations at a maximum pressure of 60 cm H₂O; group C simultaneously received two former interventions; and finally the control group D received routine method of gentle abdominal pressure. All patients were assessed in the first 24 hours after surgery.

Results

There was an unsteady pattern for pain in shoulder, upper abdomen, and incision site at different time points across the studied groups over the trial. Patients in group B showed significantly lower shoulder pain 24 hours after laparoscopic gynecologic surgery (P = 0.01), while patients in group D had significantly lower incision site pain (P < 0.001).

Conclusions

PRM was superior to intraperitoneal infusion of NS for reducing pain in the first 24 hours after laparoscopic gynecologic surgery.