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.

Effects of delayed suprapubic port removal on post-laparoscopic shoulder pain: a randomized controlled trial

Background One of the major drawbacks of gynecologic laparoscopy is post-laparoscopic shoulder pain (PLSP) that is believed to result from intra-abdominal CO2 retention leading to peritoneal and diaphragmatic stretching and causing referred pain in C4 dermatome. Several interventions have been applied to prevent and reduce its incidence and severity, with contradictory results. Only pulmonary recruitment maneuver, extended assisted ventilation, and active intra-abdominal gas aspiration have been mentioned to be effective interventions for CO2 evacuation. However, in our experience, an alternative technique of delayed suprapubic port removal (DSPR) was found to be an effective method in CO2 expulsion. Therefore, we conducted this randomized trial to determine the effectiveness of the DSPR technique in reducing the incidence and severity of PLSP. The trial was conducted at a single, tertiary hospital between May 2015 and May 2016. Having complied with the criteria, 220 patients scheduled for elective gynecological laparoscopy were randomly allocated into 2 groups after giving informed consent. Laparoscopic procedures were performed through 10-mm umbilical port and at least 2 ancillary, including suprapubic, ports. In conventional group, ancillary ports were removed at the end of surgery leaving only opened umbilical cannula for pneumoperitoneum deflation. Abdominal compression from periphery towards umbilicus was performed to further expel CO2 before removing the umbilical cannula. In DSPR group, both umbilical and suprapubic cannulas were retained. Two-step abdominal compression was undertaken, primarily towards umbilicus and secondarily towards pelvic cavity, before sequentially removing the umbilical and the suprapubic cannulas. Postoperatively, each patient was asked to rate PLSP level on 100-mm VAS during 0–6, 6–12, 12–24, and 24–48 h, respectively. Statistical analysis was performed to determine both incidence and severity of PLSP during 24- and 48-h post-laparoscopy. Results Patients in DSPR group demonstrated significantly lower incidence of PLSP within 24 h (43.8% vs 59.0%; p = 0.027) and 48 h (43.8% vs 60.0%; p = 0.019), and expressed apparently lower pain scores (0 (0–0) vs 0 (0–8); p = 0.020) during 24–48 h post-surgery. Conclusion DSPR is an effective CO2 expulsion technique, resulting in significant reduction of both incidence and severity of PLSP within 24–48 h post-laparoscopy. Trial registration Thai Clinical Trials Registry, TCTR20160208003. Registered 8 February 2016 — retrospectively registered; http://www.thaiclinicaltrials.org/

Effects of Delayed Suprapubic Port Removal on Post-laparoscopic Shoulder Pain: A Randomized Controlled Trial

Background: One of the major drawbacks of gynecologic laparoscopy is post-laparoscopic shoulder pain (PLSP) that is believed to result from intra-abdominal CO2 retention leading to peritoneal and diaphragmatic stretching and causing referred pain in C4 dermatome. Several interventions have been applied to prevent and reduce its incidence and severity, with contradictory results. Only pulmonary recruitment maneuver, extended assisted ventilation and active intra-abdominal gas aspiration have been mentioned to be effective interventions for CO2 evacuation. However, in our experience, an alternative technique of delayed suprapubic port removal (DSPR) was found to be an effective method in CO2 expulsion. Therefore, we conducted this randomized trial to determine the effectiveness of the DSPR technique in reducing the incidence and severity of PLSP. The trial was conducted at a single, tertiary hospital between May 2015 and May 2016. Having complied with the criteria, 220 patients scheduled for elective gynecological laparoscopy were randomly allocated into 2 groups after giving informed consent. Laparoscopic procedures were performed through 10-mm umbilical port and at least 2 ancillary, including suprapubic, ports. In conventional group, ancillary ports were removed at the end of surgery leaving only opened umbilical cannula for pneumoperitoneum deflation. Abdominal compression from periphery towards umbilicus was performed to further expel CO2 before removing the umbilical cannula. In DSPR group, both umbilical and suprapubic cannulas were retained. Two-step abdominal compression was undertaken, primarily towards umbilicus and secondarily towards pelvic cavity, before sequentially removing the umbilical and the suprapubic cannulas. Postoperatively, each patient was asked to rate PLSP level on 100–mm VAS during 0-6, 6-12, 12-24, and 24-48 hours respectively. Statistical analysis was performed to determine both incidence and severity of PLSP during 24- and 48-hours post-laparoscopy.Results: Patients in DSPR group demonstrated significantly lower incidence of PLSP within 24 hours (43.8% vs 59.0%; p=0.027) and 48 hours (43.8% vs 60.0%; p=0.019), and expressed apparently lower pain scores (0(0-0) vs 0(0-8); p=0.020) during 24-48 hours post-surgery.Conclusion: DSPR is an effective CO2 expulsion technique, resulting in significant reduction of both incidence and severity of PLSP within 24-48 hours post-laparoscopy.Trial registration: Thai Clinical Trials Registry; TCTR20160208003; Registered 8 February 2016 - Retrospectively registered; http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=1715

Ventilation strategies and postoperative pain in laparoscopic cholecystectomy: pulmonary recruitment maneuver versus extended hyperventilation: a prospective randomized study

Objectives: Acidic milieu created by carbon dioxide is associated with post laparoscopic surgical pain. Gas washing techniques were used to reduce such effects. This trial compared pulmonary recruitment maneuver (PRM) versus extended hyperventilation technique (EHV) regarding postoperative pain profile in laparoscopic cholecystectomy patients. Methods: In a prospective, randomized controlled study, 90 patients, underwent laparoscopic cholecystectomy were divided into two equal groups; (PRM group) and (EHV group). Collected data included heart rate (HR), mean arterial blood pressure (MAP), visual analog score (VAS), the incidence of shoulder and sub-diaphragmatic pain, postoperative nausea, and vomiting (PONV). Results: The overall incidence of shoulder and sub-diaphragmatic pain, late VAS score (at 12, 24 hours) were lower in the EHV group, while hemodynamics, early VAS scores, rescue analgesic consumption, and PONV were comparable in both groups. Conclusion: Gas washing techniques improved safety and efficacy in improving pain profile following laparoscopic surgery. EHV provides less pain and more patients comfort than PRM, especially at delayed times.

Pulmonary Recruitment Maneuver for Reducing Shoulder Pain after Laparoscopic Gynecologic Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Background. Shoulder pain is a common symptom following laparoscopic surgery. This systematic review was undertaken to assess updated evidence regarding the effectiveness and complications of the pulmonary recruitment maneuver (PRM) for reducing shoulder pain after laparoscopic gynecologic surgery. Methods. A number of databases for randomized controlled trials (RCTs) investigating PRM for reducing shoulder pain were searched up to June 2019. Two authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, and compared results. Network meta-analyses were employed to simultaneously compare multiple interventions. Effect measures were presented as pooled mean difference (MD) or risk ratio (RR) with corresponding 95% confidence intervals (CI). Results. Of the 44 records that we identified as a result of the search (excluding duplicates), eleven RCTs involving 1111 participants were included. Three studies had an unclear risk of selection bias. PRM with a maximum pressure of 40 cm H2O was most likely to result in the lowest shoulder pain intensity at 24 hours (MD −1.91; 95% CI −2.06 to −1.76) while PRM with a maximum pressure of 40 cm H2O plus intraperitoneal saline (IPS) appeared to be the most efficient at 48 hours (MD −2.09; 95% CI −2.97 to −1.21). The estimated RRs for analgesia requirement, nausea/vomiting, and cardiopulmonary events were similar across the competing interventions. Conclusion. PRM with 40 cm H2O performed either alone or accompanied by IPS is a promising intervention for alleviating shoulder pain within 48 hours following gynecologic laparoscopy.

Perioperative Pain Control in Bariatric Surgeries, a Systematic Review

Introduction Research on adequate postoperative pain management is a current trend in post-anesthetic and surgical areas. Patient satisfaction is a parameter of medical quality. High pain scores increase the incidence of post-operative morbidity and lead to delayed recovery, prolonged hospital stay and increased healthcare costs.1 Bariatric Surgeries are surgeries performed for morbid obese patient to reduce patient’s weight through several methods and because morbid obese patients are at higher risk of complications after surgery2, Pain control during bariatric surgery is a major challenge3. Opioids play an important role in anesthesia practice; however, related complications like; sedation, airway obstruction, and respiratory depression are of concern in morbid obese patients .Therefore, opioids should be used sparingly. And newly safe methods better to be used for better perioperative pain control in bariatric surgeries. Objective To cover the gab of knowledge regarding the evidence of the safest and most efficient method to control perioperative pain in bariatric surgeries by reviewing the literature about this evidence through comparative systematic review study. Methodology Systematic review study discussed the results of 30 studies found in the literature related to perioperative pain control in bariatric surgeries according to the inclusion and exclusion criteria . Results and Discussion 30 different studies were discussed about the different methods of anesthesia in bariatric surgeries 6 of them about Transverses abdominis plane. ‘TAP’ block, 5 about Local anesthesia, 4 about Dexmedetomidine, 3 about spinal morphine, 3 about multi modal analgesia, 2 about preoperative medication, 2 about patient controlled analgesia ‘PCA', 1 about continuous infusion catheter, 1 about ibuprofen, 1 about Pulmonary recruitment maneuver, 1 about Sugammadex and 1 about non opioid anesthesia). Results are recorded about the efficacy of each method through the outcome measures. Conclusion It's found that the most effective method is multi modal analgesia represented in preoperative ultra sound guided TAP block, intraoperative port- sites and intraperitoneal infiltration with local anesthesia then recovery by sugammadex followed by postoperative IVI acetaminophen and PCA. Using preoperative clonidine, ketamine, pregabalin, epidural analgesia and pulmonary recruitment maneuver at the end of the surgery are also with low complication. Continuous infusion catheter, IV Ibuprofen, combined Dexmedetomidine and Acetaminophene, preoperative port-site infiltration and post operative intraperitoneal local anesthetic have no evidence based efficacy right now and it needs further studies.