title: Impact of standard-pressure and low-pressure pneumoperitoneum on shoulder pain following laparoscopic cholecystectomy: a randomised controlled trial.
abstract: The incidence of shoulder pain (SP) following laparoscopic cholecystectomy (LC) varies between 21 and 80 %. A few randomised controlled trials and meta-analysis have shown lesser SP in LC performed under low-pressure carbon dioxide pneumoperitoneum (LPCP) than under standard-pressure carbon dioxide pneumoperitoneum (SPCP). However, the possible compromise in adequate exposure and effective working space during LPCP has negatively influenced its uniform adoption for LC.
  
  
  
  All consecutive patients undergoing elective LC for gallstone disease who met the inclusion and exclusion criteria were enroled. Fourty patients were randomised to SPCP group (pressure of 14 mmHg) and 40 to LPCP group (pressure of 9-10 mmHg). Primary outcome measured was incidence of SP and its severity on visual analogue scale (VAS) at 4, 8, 24 h and 7 days after LC. Secondary outcomes measured were procedural time, technical difficulty, surgeons' satisfaction score on exposure and working space, intra-operative changes in heart rate and blood pressure, abdominal pain and analgesic requirement. Analyses were performed using Stata software.
  
  
  
  There was no conversion to open surgery, bile duct injury or need to increase intra-abdominal pressure on either group. Twenty-three patients (57.5 %) in SPCP group and nine patients (22.5 %) in LPCP group had SP (p = 0.001). The severity of SP was significantly more in SPCP group at 8 and 24 h (p = 0.009 and 0.005, respectively). Both the groups had similar procedural time, surgeons' satisfaction score, intra-operative changes in heart rate and blood pressure.
  
  
  
  The incidence and severity of SP following LC performed at LPCP are significantly less compared to that in SPCP. The safety, efficacy and surgeons' satisfaction appear to be comparable in both the groups. Hence, a routine practice of low-pressure carbon dioxide pneumoperitoneum may be recommended in selected group of patients undergoing laparoscopic cholecystectomy.
  
  
  
  CTRI/2016/02/006590.
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Hemanga K
authors.initials: HK
authors.lastname: Bhattacharjee
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Azarudeen
authors.initials: A
authors.lastname: Jalaludeen
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India. drvkbansal@gmail.com.
authors.forename: Virinder
authors.initials: V
authors.lastname: Bansal
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Asuri
authors.initials: A
authors.lastname: Krishna
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Subodh
authors.initials: S
authors.lastname: Kumar
authors.affiliation: Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Rajeshwari
authors.initials: R
authors.lastname: Subramanium
authors.affiliation: Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Rashmi
authors.initials: R
authors.lastname: Ramachandran
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Misra
mesh_terms: D000328:Adult; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000517:prevention & control; D020069:Shoulder Pain / Q000209:etiology* / Q000517:prevention & control*; D064232:Visual Analog Scale
keywords: Laparoscopic cholecystectomy; Low-pressure pneumoperitoneum; Shoulder pain; Standard-pressure pneumoperitoneum; Surgeons’ satisfaction