A Simple Maneuver Greatly Reduces Laparoscopy Shoulder Pain

A new study describes a simple clinical maneuver to fully evacuate the carbon dioxide (CO2) used for insufflation during laparoscopy that can greatly reduce the shoulder pain (as well as the nausea and vomiting) that is often seen after this surgery.

Researchers at the Southwest Healthcare System (Murrieta, CA, USA) studied 116 female outpatients who were scheduled for elective gynecologic laparoscopic surgery. The patients were randomly allocated to either the control group, which received the current standard procedure to remove CO2, passive deflation through the abdominal cannula, or to an intervention group. In this group, CO2 was removed by means of the Trendelenburg position (30 degrees) and a pulmonary recruitment maneuver consisting of five manual inflations of the lung. Postoperative shoulder pain was assessed before discharge and 12, 24, 36, and 48 hours later using a visual analog scale (VAS, 0-100). In addition, positional characteristics of the shoulder pain and incidence of post-discharge nausea and vomiting were recorded until 48 hours after discharge.

The study results showed that visual analogue scores for shoulder pain at 12, 24, and 36 hours after discharge were all significantly lower in the group treated with the new technique. Moreover, use of the new technique reduced positional pain from 63% to 31% and cut the rate of nausea and vomiting from 56.5% to 20.4%. The study was published in the May 2008 issue of Obstetrics and Gynecology.

"This simple clinical maneuver at the end of surgery reduced shoulder pain as well as postoperative nausea and vomiting after laparoscopic surgery by more than half,” said lead author Christian Apfel, M.D., of the department of anesthesia. "It is easy enough to be implemented in daily clinical practice and might have additional benefits as well, such as reducing atelectasis induced by the laparoscopic technique.”

Post-laparoscopy shoulder pain is thought to result when carbon dioxide (CO2) used for insufflation during the procedure irritates the phrenic nerve, leading to referred pain at cervical spine level C4.


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