title: Prevention of postlaparoscopic shoulder and upper abdominal pain: a randomized controlled trial.
abstract: OBJECTIVE
  To estimate the effectiveness of combined intervention with the pulmonary recruitment maneuver and intraperitoneal normal saline infusion to reduce postlaparoscopic shoulder and upper abdominal pain.
  
  
  METHODS
  Patients were randomly assigned to undergo the combined intervention (n=50) or to a control group (n=50). Postlaparoscopic shoulder pain and upper abdominal pain were evaluated at 12, 24, and 48 hours postoperatively.
  
  
  RESULTS
  At 12, 24, and 48 hours, the incidence of laparoscopic-induced shoulder pain was lower in the intervention group (54%, 46%, and 30%, respectively) than in the control group (72%, 70%, and 50%, respectively; P=.008, P=.001, and P=.004, respectively). The number needed to treat for benefit to reduce shoulder pain incidence was six (95% confidence interval [CI], 4-21) at 12 hours, five (95% CI, 3-10) at 24 hours, and five (95% CI, 4-15) at 48 hours. The incidence of laparoscopic-induced upper abdominal pain also was lower in the intervention group (78%, 72%, and 58%, respectively) than in the control group (92%, 90%, and 70%, respectively) at 12, 24, and 48 hours postoperatively (P=.006, P=.001, and P=.077, respectively). The number needed to treat for benefit to reduce upper abdominal pain incidence was eight (95% CI, 5-24) at 12 hours and six (95% CI, 4-14) at 24 hours.
  
  
  CONCLUSIONS
  Combined intervention with the pulmonary recruitment maneuver and intraperitoneal normal saline infusion is easy to implement in daily clinical practice to significantly reduce postlaparoscopic shoulder and upper abdominal pain.
authors: Department of Obstetrics and Gynecology, the Immunology Center, and the Department of Emergency Medicine, Taipei Veterans General Hospital, and the School of Medicine, the Institute of Clinical Medicine, and the Infection and Immunity Research Center, National Yang-Ming University, Taipei, Taiwan.
authors: Hsiao-Wen
authors: HW
authors: Tsai
authors: Peng-Hui
authors: PH
authors: Wang
authors: Ming-Shyen
authors: MS
authors: Yen
authors: Kuan-Chong
authors: KC
authors: Chao
authors: Teh-Fu
authors: TF
authors: Hsu
authors: Yi-Jen
authors: YJ
authors: Chen
mesh_terms: D015746:Abdominal Pain / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D007274:Injections, Intraperitoneal; D010535:Laparoscopy / Q000009:adverse effects*; D008614:Meperidine / Q000008:administration & dosage; D008875:Middle Aged; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D020069:Shoulder Pain / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D012965:Sodium Chloride / Q000008:administration & dosage*; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D012965:Sodium Chloride; D008614:Meperidine
references: Kluivers KB, Johnson NP, Chien P, Vierhout ME, Bongers M, Mol BW. Comparison of laparoscopic and abdominal hysterectomy in terms of quality of life: a systematic review. Eur J Obstet Gynecol Reprod Biol 2008;136:3–8.
references: Tsai HW, Chen YJ, Ho CM, Hseu SS, Chao KC, Tsai SK, et al.. Maneuvers to decrease laparoscopy-induced shoulder and upper abdominal pain: a randomized controlled study. Arch Surg 2011;146:1360–6.
references: Dixon JB, Reuben Y, Halket C, O'Brien PE. Shoulder pain is a common problem following laparoscopic adjustable gastric band surgery. Obes Surg 2005;15:1111–7.
references: Korell M, Schmaus F, Strowitzki T, Schneeweiss SG, Hepp H. Pain intensity following laparoscopy. Surg Laparosc Endosc 1996;6:375–9.
references: Alexander JI. Pain after laparoscopy. Br J Anaesth 1997;79:369–78.
references: Madsen MR, Jensen KE. Postoperative pain and nausea after laparoscopic cholecystectomy. Surg Laparosc Endosc 1992;2:303–5.
references: Jackson SA, Laurence AS, Hill JC. Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia 1996;51:485–7.
references: Fredman B, Jedeikin R, Olsfanger D, Flor P, Gruzman A. Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy. Anesth Analg 1994;79:152–4.
references: Coventry DM. Anaesthesia for laparoscopic surgery. J R Coll Surg Edinb 1995;40:151–60.
references: Phelps P, Cakmakkaya OS, Apfel CC, Radke OC. A simple clinical maneuver to reduce laparoscopy-induced shoulder pain: a randomized controlled trial. Obstet Gynecol 2008;111:1155–60.
references: Nyerges A. Pain mechanisms in laparoscopic surgery. Semin Laparosc Surg 1994;1:215–8.
references: Jabbour-Khoury SI, Dabbous AS, Gerges FJ, Azar MS, Ayoub CM, Khoury GS. Intraperitoneal and intravenous routes for pain relief in laparoscopic cholecystectomy. JSLS 2005;9:316–21.
references: Kissin I. Preemptive analgesia. Why its effect is not always obvious. Anesthesiology 1996;84:1015–9.
references: Tsimoyiannis EC, Siakas P, Tassis A, Lekkas ET, Tzourou H, Kambili M. Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy. World J Surg 1998;22:824–8.
references: Chen YJ, Wang PH, Ocampo EJ, Twu NF, Yen MS, Chao KC. Single-port compared with conventional laparoscopic-assisted vaginal hysterectomy: a randomized controlled trial. Obstet Gynecol 2011;117:906–12.
references: Ghezzi F, Cromi A, Colombo G, Uccella S, Bergamini V, Serati M, et al.. Minimizing ancillary ports size in gynecologic laparoscopy: a randomized trial. J Minim Invasive Gynecol 2005;12:480–5.
references: Tsimoyiannis EC, Glantzounis G, Lekkas ET, Siakas P, Jabarin M, Tzourou H. Intraperitoneal normal saline and bupivacaine infusion for reduction of postoperative pain after laparoscopic cholecystectomy. Surg Laparosc Endosc 1998;8:416–20.
references: Revill SI, Robinson JO, Rosen M, Hogg MI. The reliability of a linear analogue for evaluating pain. Anaesthesia 1976;31:1191–8.
references: Jensen MP, Turner JA, Romano JM, Fisher LD. Comparative reliability and validity of chronic pain intensity measures. Pain 1999;83:157–62.
references: Zmora O, Hashavia E, Munz Y, Khaikin M, Shabtai M, Ayalon A, et al.. Laparoscopic colectomy is associated with decreased postoperative gastrointestinal dysfunction. Surg Endosc 2009;23:87–9.
references: Esmat ME, Elsebae MM, Nasr MM, Elsebaie SB. Combined low pressure pneumoperitoneum and intraperitoneal infusion of normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy. World J Surg 2006;30:1969–73.
references: Ricard JD. Barotrauma during mechanical ventilation: why aren't we seeing any more? Intensive Care Med 2004;30:533–5.
references: Magnusson L, Tenling A, Lemoine R, Hogman M, Tyden H, Hedenstierna G. The safety of one, or repeated, vital capacity maneuvers during general anesthesia. Anesth Analg 2000;91:702–7.
references: diZerega GS, Verco SJ, Young P, Kettel M, Kobak W, Martin D, et al.. A randomized, controlled pilot study of the safety and efficacy of 4% icodextrin solution in the reduction of adhesions following laparoscopic gynaecological surgery. Hum Reprod 2002;17:1031–8.
references: Muzii L, Bellati F, Manci N, Zullo MA, Angioli R, Panici PB. Ringer's lactate solution remains in the peritoneal cavity after laparoscopy longer than expected. Fertil Steril 2005;84:148–53.
references: Brown CB, Luciano AA, Martin D, Peers E, Scrimgeour A, diZerega GS. Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study. Fertil Steril 2007;88:1413–26.
references: Trout SW, Kemmann E. Vulvar edema as a complication of laparoscopic surgery. J Am Assoc Gynecol Laparosc 1996;4:81–3.