Semi-Fowler positioning in addition to the pulmonary recruitment manoeuvre reduces shoulder pain following gynaecologic laparoscopic surgery

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.

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.

Pulmonary Recruitment Maneuver Reduces Shoulder Pain and Nausea After Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Background

Pain and nausea are common after laparoscopic surgery. This prospective, randomized, controlled trial aimed to investigate postoperative pain and as a secondary endpoint nausea, when performing a ventilator-piloted Pulmonary Recruitment Maneuvre (PRM) at the end of laparoscopic cholecystectomy.

Method

Patients having elective laparoscopic cholecystectomy were randomized to either ordinary exsufflation or ventilator-piloted PRM, to evacuate intra-abdominal carbon dioxide (CO₂) before abdominal closure. A questionnaire with numeric rating scales (NRS) was utilized to evaluate pain and nausea at five occasions during 48 h following surgery. Analgesic and antiemetic treatment was also analyzed.

Results

147 patients were analyzed, 76 receiving PRM and 71 controls. Overall pain was well controlled, with no significant difference between the groups regarding incidence (P=0.149) nor intensity (P=0.739). Incidence of shoulder pain was lower in the PRM group during the 48 postoperative hours, 44.7% versus 63.4% (P=0.023). The number needed to treat (NNT) to reduce shoulder pain was 6 (95% Confidence Interval, CI, 2.9–35.5) for the 48-h period. Incidence of nausea was lower in the PRM group during the 48-h period, 51.3% versus 70.4% (P=0.018). NNT was 6 (95% CI 2.9–27.4) for the 48-h period. Nausea intensity was lower in the PRM group during the 48 h (P=0.025). Fewer in the PRM population required antiemetics, 25.0% versus 42.3% (P=0.027).

Conclusion

A ventilator-piloted PRM at the end of laparoscopic cholecystectomy reduced incidence of shoulder pain, and incidence and intensity of nausea. Clinical trial registrationwww.clinicaltrials.gov. Identifier: NCT03026543.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06262-6.

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.

Low-pressure pulmonary recruitment maneuver: equal to or worse than moderate-pressure pulmonary recruitment maneuver in preventing postlaparoscopic shoulder pain? A randomized controlled trial of 72 patients

Introduction

The pulmonary recruitment maneuver (PRM) has emerged as an effective way of reducing post-laparoscopic shoulder pain (PLSP). However, the optimal lower pressure level for a PRM to reduce PLSP has not yet been investigated.

Aim

To compare the efficacy of the low-pressure PRM with moderate-pressure PRM in preventing PLSP.

Material and methods

Seventy-two ASA I-II patients who were scheduled for gynecologic LS for non-malignant conditions were enrolled in this study. Group 1 included patients who received the PRM at a maximum pressure of 30-40 cm H₂O in a semi-Fowler position and group 2 included patients who received the PRM at a maximum pressure of 15 cm H₂O in a semi-Fowler position. The primary outcome of the study was the difference in PLSP between the two groups.

Results

There were no significant differences in PLSP and wound pain VAS scores between patients receiving the PRM at 30 cm H₂O and 15 cm H₂O during postoperative pain monitoring (p < 0.05). The groups were also similar with respect to ambulation time (p = 0.215), length of hospital stay (p = 0.556) and the height of the pneumoperitoneum measured on chest X-ray (p = 0.151).

Conclusions

The low-pressure PRM (15 cm H₂O pressure) provides similar efficacy as the moderate-pressure PRM (30-40 cm H₂O) in terms of PLSP, wound pain, height of pneumoperitoneum, time of ambulation and length of hospital stay. We suggest that lower maximal inspiratory pressure of 15 cm H₂O might be preferred to avoid the potential complications of the PRM with higher pressures.