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Papers of the Week

2019 Nov

J Chin Med Assoc



Pain after laparoscopic surgery: Focus on shoulder-tip pain after gynecological laparoscopic surgery.


Sao C-H, Chan-Tiopianco M, Chung K-C, Chen Y-J, Horng H-C, Lee W-L, Wang P-H
J Chin Med Assoc. 2019 Nov; 82(11):819-826.
PMID: 31517775.


Laparoscopy, one of minimally invasive procedures, is a commonly used procedure in diagnosis and management of various kinds of clinical problems, including gynecologic organ-related diseases. Compared with conventional exploratory laparotomy, the benefits of laparoscopic surgery include reduction of surgical wound, decreasing in postoperative pain, shortening hospital stay, rapid recovery and a better cosmetic result. However, there are still up to 80% of patients after laparoscopic surgery complaining of high levels of pain and needing pain relief. Post-laparoscopic pain can be separated into distinct causes, such as surgical trauma- or incision wound-associated inflammatory change, and pneumoperitoneum (carbon dioxide)-related morphological and biochemical changes of peritoneum and diaphragm. The latter is secondary to irritation, stretching, and foreign body stimulation, leading to phrenic neuropraxia and subsequent shoulder-tip pain (STP). STP is the most typical unpleasant experience of patients after laparoscopic surgery. There are at least eleven strategies available to attempt to decrease post-laparoscopic STP, including (1) the use of an alternative insufflating gas in place of CO2, (2) the use of low-pressure pneumoperitoneum in place of standard-pressure pneumoperitoneum, (3) the use of warmed or warmed and humidified CO2, (4) gasless laparoscopy, (5) subdiaphragmatic intraperitoneal anesthesia, (6) local intraperitoneal anesthesia, (7) actively expelling out of gas, (8) intraperitoneal drainage, (9) fluid instillation, (10) pulmonary recruitment maneuvers, (11) others and combination. The present article is limited in discussing post-laparoscopic STP. We extensively review published articles to provide a better strategy to reduce post-laparoscopic STP.