Abstract
Background
Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholecystolithiasis. Despite the many advantages over open surgery, many patients complain about referred pain to the shoulder during the postoperative course. The purpose of this review was to evaluate different intraoperative surgical methods to minimize shoulder pain (SP).
Methods
A search of the literature was conducted using PubMed, Excerpta Medica Database (EMBASE), and Cochrane database of systematic reviews. Eligibility criteria were: randomized clinical trials or meta-analysis evaluating intraoperative surgical methods applied to minimize incidence or severity of SP after LC. Only papers published in English were included. Data extracted were year of publication, number of participants and allocation, nonsignificant or significant effect on incidence or severity of SP.
Results
A total of 31 papers where included in the review. Seven, 8, and 12 papers investigated the effect of drains, abdominal wall lift (AWL), and low-pressure pneumoperitoneum respectively. Four papers investigated drain suction, active gas aspiration, low insufflation flow or N2O insufflation respectively. The interventions that overall showed a significant reduction on either the incidence or severity of SP were low-pressure pneumoperitoneum, low insufflation rate, and active gas aspiration.
Conclusions
Drainage and AWL are not recommended to reduce SP after LC. Low-pressure pneumoperitoneum with carbon dioxide is the best documented intraoperative surgical method to minimize both the incidence and severity of SP after LC.
Similar content being viewed by others
References
Keus F, Gooszen HG, van Laarhoven CJ (2010) Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev 1:CD008318. doi:10.1002/14651858.CD008318
Bisgaard T, Kehlet H, Rosenberg J (2001) Pain and convalescence after laparoscopic cholecystectomy. Eur J Surg 167:84–96
Jensen K, Kehlet H, Lund CM (2009) Postoperative recovery profile after elective abdominal hysterectomy: a prospective, observational study of a multimodal anaesthetic regime. Eur J Anaesthesiol 26:382–388
Paulson J, Mellinger J, Baguley W (2003) The use of intraperitoneal bupivacaine to decrease the length of stay in elective laparoscopic cholecystectomy patients. Am Surg 69:275–278
Kandil TS, El Hefnawy E (2010) Shoulder pain following laparoscopic cholecystectomy: factors affecting the incidence and severity. J Laparoendosc Adv Surg Tech A 20:677–682
Sandhu T, Yamada S, Ariyakachon V, Chakrabandhu T, Chongruksut W, Ko-iam W (2009) Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial. Surg Endosc 23:1044–1047
Tsimoyiannis EC, Siakas P, Tassis A, Lekkas ET, Tzourou H, Kambili M (1998) Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy. World J Surg 22:824–828
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700. doi:10.1136/bmj.b2700
Kahokehr A, Sammour T, Shoshtari KZ, Taylor M, Hill AG (2011) Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial. Ann Surg 254:28–38
Kahokehr A, Sammour T, Soop M, Hill AG (2011) Intraperitoneal local anaesthetic in abdominal surgery—a systematic review. ANZ J Surg 81:237–245
Georgiou C, Demetriou N, Pallaris T, Theodosopoulos T, Katsouyanni K, Polymeneas G (2011) Is the routine use of drainage after elective laparoscopic cholecystectomy justified? A randomized trial. J Laparoendosc Adv Surg Tech A 21:119–123
Hawasli A, Brown E (1994) The effect of drains in laparoscopic cholecystectomy. J Laparoendosc Surg 4:393–398
Mrozowicz A, Rucinski P, Polkowski WP (2006) Routine drainage of the subhepatic area after laparoscopic cholecystectomy. Prospective, controlled study with random patient selection. Polski Przeglad Chirurgiczny 78:597–609
Mrsic V, Nesek-Adam V, Budinscak I, Smiljanic A, Cala Z, Rasic Z (1997) Effect of abdominal drainage on postoperative shoulder pain in laparoscopic cholecystectomy. Croat J Gastroenterol Hepatol 6:41–44
Nursal TZ, Yildirim S, Tarim A, Noyan T, Poyraz P, Tuna N, Haberal M (2003) Effect of drainage on postoperative nausea, vomiting, and pain after laparoscopic cholecystectomy. Langenbecks Arch Surg 388:95–100
Gurusamy Kurinchi S, Samraj K, Mullerat P, Davidson Brian R (2007) Routine abdominal drainage for uncomplicated laparoscopic cholecystectomy. Cochrane Database Syst Rev. doi:10.1002/14651858.CD006004.pub3
Barczynski M, Herman RM (2003) A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy. Surg Endosc 17:533–538
Beqiri AI, Domi RQ, Sula HH, Zaimi EQ, Petrela EY (2012) The combination of infiltrative bupivacaine with low-pressure laparoscopy reduces postcholecystectomy pain. A prospective randomized controlled study. Saudi Med J 33:134–138
Chok KS, Yuen WK, Lau H, Fan ST (2006) Prospective randomized trial on low-pressure versus standard-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 16:383–386
Esmat ME, Elsebae MM, Nasr MM, Elsebaie SB (2006) Combined low pressure pneumoperitoneum and intraperitoneal infusion of normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy. World J Surg 30:1969–1973
Ibraheim OA, Samarkandi AH, Alshehry H, Faden A, Farouk EO (2006) Lactate and acid base changes during laparoscopic cholecystectomy. Middle East J Anesthesiol 18:757–768
Kanwer DB, Kaman L, Nedounsejiane M, Medhi B, Verma GR, Bala I (2009) Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy—a randomised controlled trial. Trop Gastroenterol 30:171–174
Perrakis E, Vezakis A, Velimezis G, Savanis G, Deverakis S, Antoniades J, Sagkana E (2003) Randomized comparison between different insufflation pressures for laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 13:245–249
Sarli L, Costi R, Sansebastiano G, Trivelli M, Roncoroni L (2000) Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy. Br J Surg 87:1161–1165
Yasir M, Mehta KS, Banday VH, Aiman A, Masood I, Iqbal B (2012) Evaluation of post operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparoscopic cholecystectomy. Surgeon 10:71–74
Gurusamy KS, Samraj K, Davidson BR (2009) Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database Syst Rev 15:CD006930. doi:10.1002/14651858.CD006930.pub2
Koivusalo AM, Kellokumpu I, Lindgren L (1996) Gasless laparoscopic cholecystectomy: comparison of postoperative recovery with conventional technique. Br J Anaesth 77:576–580
Larsen JF, Ejstrud P, Kristensen JU, Svendsen F, Redke F, Pedersen V (2001) Randomized comparison of conventional and gasless laparoscopic cholecystectomy: operative technique, postoperative course, and recovery. J Gastrointest Surg 5:330–335
Lindgren L, Koivusalo AM, Kellokumpu I (1995) Conventional pneumoperitoneum compared with abdominal wall lift for laparoscopic cholecystectomy. Br J Anaesth 75:567–572
Talwar N, Pusuluri R, Arora MP, Pawar M (2006) Randomized controlled trial of conventional carbon dioxide pneumoperitoneum versus gasless technique for laparoscopic cholecystectomy. JK Sci 8:73–78
Uen YH, Chen Y, Kuo CY, Wen KC, Koay LB (2007) Randomized trial of low-pressure carbon dioxide-elicited pneumoperitoneum versus abdominal wall lifting for laparoscopic cholecystectomy. J Chin Med Assoc 70:324–330
Uen YH, Liang AI, Lee HH (2002) Randomized comparison of conventional carbon dioxide insufflation and abdominal wall lifting for laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 12:7–14
Vezakis A, Davides D, Gibson JS, Moore MR, Shah H, Larvin M, McMahon MJ (1999) Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy. Surg Endosc 13:890–893
Gurusamy Kurinchi S, Samraj K, Davidson Brian R (2008) Abdominal lift for laparoscopic cholecystectomy. Cochrane Database Syst Rev. doi:10.1002/14651858.CD006574.pub2
Jorgensen JO, Gillies RB, Hunt DR, Caplehorn JR, Lumley T (1995) A simple and effective way to reduce postoperative pain after laparoscopic cholecystectomy. Aust N Z J Surg 65:466–469
Berberoglu M, Dilek ON, Ercan F, Kati I, Ozmen M (1998) The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain. J Laparoendosc Adv Surg Tech A 8:273–277
Aitola P, Airo I, Kaukinen S, Ylitalo P (1998) Comparison of N2O and CO2 pneumoperitoneums during laparoscopic cholecystectomy with special reference to postoperative pain. Surg Laparosc Endosc 8:140–144
Atak I, Ozbagriacik M, Akinci OF, Bildik N, Subasi IE, Ozdemir M, Ayta NI (2011) Active gas aspiration to reduce pain after laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 21:98–100
Wallace DH, Serpell MG, Baxter JN, O’Dwyer PJ (1997) Randomized trial of different insufflation pressures for laparoscopic cholecystectomy. Br J Surg 84:455–458
Al Shehri MY (1999) Radiological evaluation of patients after laparoscopic cholecystectomy. Saudi J Gastroenterol 5:23–26
Draper K, Jefson R, Jongeward R Jr, McLeod M (1997) Duration of postlaparoscopic pneumoperitoneum. Surg Endosc 11:809–811
Jackson SA, Laurence AS, Hill JC (1996) Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia 51:485–487
Tzovaras G, Liakou P, Fafoulakis F, Baloyiannis I, Zacharoulis D, Hatzitheofilou C (2009) Is there a role for drain use in elective laparoscopic cholecystectomy? A controlled randomized trial. Am J Surg 197:759–763
Uchiyama K, Tani M, Kawai M, Terasawa H, Hama T, Yamaue H (2007) Clinical significance of drainage tube insertion in laparoscopic cholecystectomy: a prospective randomized controlled trial. J Hepatobiliary Pancreat Surg 14:551–556
Fredman B, Jedeikin R, Olsfanger D, Flor P, Gruzman A (1994) Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy. Anesth Analg 79:152–154
Alijani A, Hanna GB, Cuschieri A (2004) Abdominal wall lift versus positive-pressure capnoperitoneum for laparoscopic cholecystectomy: randomized controlled trial. Ann Surg 239:388–394
Koivusalo AM, Kellokumpu I, Scheinin M, Tikkanen I, Makisalo H, Lindgren L (1998) A comparison of gasless mechanical and conventional carbon dioxide pneumoperitoneum methods for laparoscopic cholecystectomy. Anesth Analg 86:153–158
Ninomiya K, Kitano S, Yoshida T, Bandoh T, Baatar D, Matsumoto T (1998) Comparison of pneumoperitoneum and abdominal wall lifting as to hemodynamics and surgical stress response during laparoscopic cholecystectomy. Surg Endosc 12:124–128
Uemura N, Nomura M, Inoue S, Endo J, Kishi S, Saito K, Ito S, Nakaya Y (2002) Changes in hemodynamics and autonomic nervous activity in patients undergoing laparoscopic cholecystectomy: differences between the pneumoperitoneum and abdominal wall-lifting method. Endoscopy 34:643–650
Dexter SP, Vucevic M, Gibson J, McMahon MJ (1999) Hemodynamic consequences of high- and low-pressure capnoperitoneum during laparoscopic cholecystectomy. Surg Endosc 13:376–381
Gutt CN, Oniu T, Mehrabi A, Schemmer P, Kashfi A, Kraus T, Buchler MW (2004) Circulatory and respiratory complications of carbon dioxide insufflation. Dig Surg 21:95–105
Hasukic S (2005) Postoperative changes in liver function tests: randomized comparison of low- and high-pressure laparoscopic cholecystectomy. Surg Endosc 19:1451–1455
Di Massa A, Avella R, Gentili C (1996) Respiratory dysfunction related to diaphragmatic shoulder pain after abdominal and pelvic laparoscopy. Minerva Anestesiol 62:171–176
Schulz KF, Altman DG, Moher D (2011) CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Int J Surg 9:672–677
Disclosures
Anders Meller Donatsky, Flemming Bjerrum, and Ismail Gögenur have no conflict of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Donatsky, A.M., Bjerrum, F. & Gögenur, I. Surgical techniques to minimize shoulder pain after laparoscopic cholecystectomy. A systematic review. Surg Endosc 27, 2275–2282 (2013). https://doi.org/10.1007/s00464-012-2759-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-012-2759-5