Pulmonary Recruitment Maneuver Research Articles

Multi-Modal Analgesic Technique for Pain Control in Patients Undergoing Diagnostic Gynecological Laparoscopy: Randomized Controlled Clinical Trial.

BACKGROUND:Advancement in minimally invasive laparoscopic surgeries make it one of the best choices for both the surgeon and the patient. The anesthesiologist had to improve the techniques used to control post-operative pain.AIM:In this study, we hyposethized that multi-modal analgesic technique which is a combination of two simple techniques (intraperitoneal lidocaine and pulmonary recruitment) allow better result than using only one of them.PATIENTS AND METHOD:This randomised controlled, double-blind study was conducted in Kasr-Alainy hospital, faculty of medicine, Cairo University, Egypt from September 2017 till February 2018. Fifty female patients, scheduled for diagnostic gynecologic laparoscopy were included in the study. Patients were randomly allocated using random computer allocation with numbered closed opaque envelopes into four study group. GM (n = 12): Patients received pulmonary recruitment maneuver and intra-peritoneal Lidocaine, GL (n = 13): Patients received intra-peritoneal Lidocaine, GP (n = 13): Patients received Pulmonary Recruitment Maneuver, GC (n = 12): Patients received passive exsufflation through the port site. In the ward, patients were asked to fulfil a questionnaire about pain severity using (VAS) at 1, 3, 6-hour post-operative both the patients and the anesthesiologist that assess the (VAS) were blind of the patient groupRESULTS:Regarding pain score between groups VAS 1 (the primary outcome) was lowest in GM {4.5 (3-5)} in comparison with other groups (P value = 0.015), while VAS 3 & VAS 6 wasn’t statistically significant between groups. Regarding Time of first rescue analgesia; GM {3 (1.75-4)} showed the longest time in between groups (P-value = 0.042). As regard nausea and vomiting; there was no statistically significant difference in in-between groups.CONCLUSION:Application of Multi-modal analgesic technique allows better analgesia for a longer duration than the use of the sole technique for control of abdominal pain in patients undergoing diagnostic gynaecological laparoscopy.

Assessment of a Combination of Clinical Maneuvers in Evaluation of Post-Laparoscopic Pain: A Randomized Clinical Trial.

To assess the efficacy of the combined maneuvers in evaluation of post-laparoscopic pain. A randomized controlled study was conducted. Sixty-four women were included in the study and were randomly divided into two groups. Intervention group received combined maneuvers such as intraperitoneal normal saline infusion, pulmonary recruitment maneuver and local bupivacaine instillation at port sites after laparoscopic surgery. Control group received routine care. Upper abdominal pain, shoulder pain and incision site pain were noted in both groups at 3, 6, 12, 24 and 48h postoperatively. The median interquartile range (in centiles) of upper abdominal pain score 3, 6 and 12h postoperatively in the intervention group was 1.0 (0.25-1.0), 1.0 (0.0-1.0) and 0.50 (0.0-1.0), and in the control group, the values were 2.0 (2.0-1.0), 2.0 (2.0-1.0) and 1.0 (0-1.0) at 3, 6 and 12h, respectively (p < 0.000). The median interquartile range of shoulder pain score 3, 6 and 12h postoperatively in the intervention group was 0.0 (0.0-1.0), 0.0 (0.0-0.75) and 0.0 (0.0-1.0), and in the control group, the values were 1.0 (0.0-2.0), 1.0 (0.0-1.75) and 1.0 (0-1.0) at 3, 6, and 12h. The upper abdominal pain and shoulder pain relief was significantly more in the intervention group than in the control group in the first 12h of surgery. Combined maneuvers could significantly reduce post-laparoscopic upper abdominal and shoulder pain.Clinical Trial CTRI Registration Number-CTRI/2017/07/0089, web address of CTRI-http://ctri.nic.in.

Semi-Fowler positioning in addition to the pulmonary recruitment manoeuvre reduces shoulder pain following gynaecologic laparoscopic surgery.

IntroductionThe semi-Fowler position, defined as a body position at 30° head-of-bed elevation, has been shown to increase intra-abdominal pressure.AimTo investigate the impact of semi-Fowler positioning in addition to the pulmonary recruitment manoeuvre (PRM) on post-laparoscopic shoulder pain.Material and methodsOne hundred and six patients (mean age: 43 ±12 years) undergoing gynaecologic laparoscopic surgery (LS) were included. The patients were divided into three groups: group 1 consisted of patients receiving PRM in the neutral position, group 2 comprised patients receiving PRM in the semi-Fowler position, and patients in the control group received neither PRM nor additional positioning. Information concerning wound and shoulder pain (post-laparoscopic shoulder pain – PLSP) at postoperative 6, 12 and 24 h was recorded using a visual analogue scale (VAS) for each patient.ResultsThe PLSP scores at postoperative 6 h (5.71 ±0.86, 5.28 ±0.84 and 6.61 ±0.91, respectively, p < 0.001), 12 h (4.41 ±0.83, 4.01 ±0.82 and 5.32 ±0.97, respectively, p < 0.001), and 24 h (3.24 ±0.78, 2.44 ±0.73 and 4.34 ±0.85, respectively, p < 0.001) were significantly different among the groups, the lowest being in those who received PRM in addition to semi-Fowler positioning.ConclusionsSemi-Fowler positioning in addition to PRM significantly reduces post-laparoscopic shoulder pain. We assume that the benefit gained using the semi-Fowler positioning is mainly derived from its potential to better evacuate the remaining abdominal gas following LS.

Effect of Low-pressure Pulmonary Recruitment Maneuver on Postlaparoscopic Shoulder Pain: Randomized Controlled Trial

Study ObjectivePostlaparoscopic shoulder pain (PLSP) is effectively reduced by a pulmonary recruitment maneuver (PRM). The goal of this study is to assess the efficacy of a PRM using maximal inspiratory pressure of 30 cm H2O, which is lower than previously studied pressure for reducing PLSP. DesignRandomized controlled trial. SettingUniversity hospital. PatientsEighty-four patients who were undergoing elective gynecologic laparoscopy. InterventionsPatients were randomly assigned to the control (n = 42) or the PRM (n = 42) group. Measurements and Main ResultsThe primary outcome was the intensity of the shoulder pain using the visual analog scale (VAS). The VAS score of shoulder pain (median [interquartile range]) was significantly lower in the PRM group than in the control group at 24 hours (0 [0–0] vs 1.5 [0–4.0], p <.001) and 48 hours (0 [0–0] vs 1.0 [0–2.0], p <.001) after surgery. Other variables, including surgical pain score and vital signs, were similar between the 2 groups. ConclusionThe PRM with 30 cm H2O can be a simple method to reduce PLSP. Therefore, it would be helpful to perform the PRM with 30 cm H2O routinely.

Interventions to reduce shoulder pain following gynaecological laparoscopic procedures.

Interventions to reduce shoulder pain following gynaecological laparoscopic procedures.

Comparison of Impacts of Intraperitoneal Saline Instillation with and without Pulmonary Recruitment Maneuver on Post-Laparoscopic Shoulder Pain Prevention: A Randomized Controlled Trial

Objective: The most plausible mechanism of post-laparoscopic shoulder pain (PLSP) is the referred pain to the shoulder by retained carbon dioxide in the peritoneal cavity. Intraperitoneal isotonic saline instillation (SI) and pulmonary recruitment maneuver (RM) were indicated to alleviate PLSP effectively. However, as SI and RM act through a similar mechanism of removing residual carbon dioxide from the peritoneal cavity, it is debatable whether the combined use of both interventions is superior to using either of them individually in reducing PLSP. This study was designed to compare the single strategy using SI alone with the combined strategy using SI and RM.

Comparison of impacts of intraperitoneal saline instillation with and without pulmonary recruitment maneuver on post-laparoscopic shoulder pain prevention: a randomized controlled trial.

Intraperitoneal isotonic saline instillation (SI) and pulmonary recruitment maneuver (RM) were indicated to alleviate post-laparoscopic shoulder pain (PLSP) effectively. The aim of this study was to compare the effects of the single strategy using SI alone and the combined strategy using SI and RM on PLSP reduction. Subjects undergoing elective gynecologic laparoscopy were randomly allocated to a control group (no intervention, n = 48) and two intervention groups (single strategy of SI alone, n = 48; combined strategy of SI and RM, n = 48). In the control group, carbon dioxide was removed only via passive evacuation through the port sites at the completion of the laparoscopic procedure. In the saline instillation group, 20-mL/kg of body weight SI was performed. In the combined strategy group, RM using five pulmonary inflations was performed, in addition to SI. The PLSP scores, which were the primary outcome, were recorded using a visual analog scale postoperatively. The PLSP scores 24 and 48h after surgery were significantly lower in the two intervention groups than in the control group (P = 0.014 and P = 0.001, respectively), while no significant differences were observed between the two intervention groups. The single strategy using SI alone is as effective as the combined strategy of SI and RM for removing residual carbon dioxide and consequently preventing PLSP. Therefore, considering the potential risks of pulmonary or hemodynamic complications associated with RM, the single strategy using SI alone might be a better choice than the combined strategy.

Randomised controlled trial to estimate reduction in pain after laparoscopic surgery when using a combination therapy of intraperitoneal normal saline and the pulmonary recruitment manoeuvre.

To evaluate the effect of two manoeuvres at the end of gynaecological laparoscopy on postoperative pain. Randomised controlled trial. One teaching and one university hospital in the Netherlands. Women aged between 18 and 65 years, with American Society of Anaesthesiologists (ASA) classification I-II, scheduled for an elective laparoscopic procedure for a benign gynaecological indication. Women were randomly allocated to two groups. In the intervention group, carbon dioxide was removed from the abdomen by a combination treatment of intraperitoneal warm saline and performing a pulmonary recruitment manoeuvre. In the control group, carbon dioxide was removed with gentle abdominal pressure. Frequency and intensity of post-laparoscopic shoulder pain and pain in the upper abdomen at 8, 24, and 48 hours after surgery. A total of 200 women participated, with 100 in each group. No difference was observed in the occurrence of post-laparoscopic shoulder pain during the first 48 hours after surgery between the intervention group (46%) and the control group (55%). The incidence of abdominal pain was not significantly different between the two groups. The mean visual analogue scale (VAS) scores of participants who reported shoulder pain were not statistically different between the groups. The mean VAS score for abdominal pain at 8 hours after surgery was significantly lower in the intervention group compared with the control group (3.2 versus 4.2, P = 0.02). No difference in pain medication between the groups was observed, nor was there any difference in nausea or vomiting. Combined intervention of intraperitoneal saline and the pulmonary recruitment manoeuvre does not lower post-laparoscopic shoulder pain. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. PRM with intraperitoneal saline does not influence the incidence and intensity of post-laparoscopic shoulder pain.

Effect of the pulmonary recruitment maneuver on pain after laparoscopic gynecological oncologic surgery: a prospective randomized trial.

ObjectiveTo evaluate the effectiveness of the pulmonary recruitment maneuver (PRM) at the end of the operation to decrease laparoscopy-induced abdominal or shoulder pain after gynecological oncologic surgery.MethodsIn total, 113 women undergoing laparoscopic surgery for malignant or premalignant gynecological lesions were assigned randomly to two groups: the PRM group (the patient was placed in the Trendelenburg position (30°) and the PRM, consisting of two manual pulmonary inflations to a maximum pressure of 40 cmH2O) (n=54) and the control group (n=52). Postoperative shoulder and abdominal pain was assessed 12, 24, and 48 hours later using a visual analog scale (0–10). In addition, the incidence of post-discharge nausea and vomiting was recorded until 48 hours after discharge.ResultsPostoperative shoulder pain at 12 and 24 hours was significantly less severe in the PRM group (2.2±0.5 and 2.0±0.4) than in the control group (4.0±0.5 and 3.9±0.4; both p<0.001). The PRM significantly reduced the severity of upper abdominal pain at 12 and 24 h compared with the control group (3.1±0.4 and 2.9±0.4 vs. 5.9±0.5 and 4.9±0.5; both p<0.001). The analgesic requirement during the postoperative period was similar in the two groups (control group, 78.8%; PRM group, 75.9%; p=0.719).ConclusionThe PRM effectively and safely reduced postoperative shoulder and upper abdominal pain levels in patients undergoing laparoscopic gynecological oncologic surgery. Trial registry at ClinicalTrials.gov, NCT01940042.

Pulmonary recruitment maneuver reduces pain after laparoscopic bariatric surgery: a randomized controlled clinical trial

BackgroundPulmonary recruitment maneuver (PRM) at the end of laparoscopic gynecologic surgery has been shown to reduce postoperative pain. This prospective, randomized, controlled clinical trial aimed to investigate postoperative pain (primary endpoint) and nausea when performing a ventilator-piloted PRM at the end of laparoscopic bariatric surgery. SettingsA secondary-level public hospital in Sweden. MethodsAfter giving written consent, patients undergoing elective laparoscopic bariatric surgery were randomized to receive routine exsufflation (control group) or a ventilator-piloted PRM to remove residual carbon dioxide from the abdomen at the end of surgery. Pain and nausea intensities were recorded at 4, 12, 24, 36, and 48 hours after surgery using a questionnaire with numeric rating scales. Postoperative consumption of analgesics and antiemetics was also evaluated. ResultsThere were 150 randomly assigned patients recruited, 79 to PRM intervention and 71 controls. Pain intensity was significantly lower in the PRM group than in the control group 24 hours postoperatively (numeric rating scale 2 [1–3] versus 3 [2–5]; P = .002). Pain during the first 24 hours did not increase in the PRM group as it did in the control group (P = .045). Opioid requirements were significantly lower in the PRM group than in the control group (5.0 mg [2–10] versus 9.0 mg [5–15]; P = .025). The PRM did not affect incidence or intensity of nausea and vomiting. ConclusionsA ventilator-piloted PRM reduced postoperative pain intensity and opioid requirement after laparoscopic bariatric surgery. The heterogeneity of the study population and the large number of hospital staff involved indicate good generalizability of the results.

POstLAparoscopic Reduction of pain By combining intraperitoneal normal salinE And the pulmonary Recruitment maneuver (POLAR BEAR trial). RCT to estimate reduction in pain after laparoscopic surgery when using a combination therapy of intraperitoneal normal saline and the pulmonary recruitment maneuver

BackgroundShoulder pain and pain in the upper abdomen are common complaints after laparoscopy, sometimes surpassing the pain at incision sites. The incidence of shoulder pain ranges from 35 to 80%. Post-laparoscopic pain is caused by retention of carbon dioxide in the abdomen, which irritates the phrenic nerve and diaphragm, causing referred pain in the shoulder and in the upper abdomen. A promising strategy to reduce this post-laparoscopic pain is the pulmonary recruitment maneuver, which indirectly increases intraperitoneal pressure and thereby facilitates removal of residual carbon dioxide. An alternative strategy is the infusion of intraperitoneal normal saline. With normal saline infusion, carbon dioxide rises and escapes through the port sites. In addition, normal saline offers a physiologic buffer system to dissolve excess carbon dioxide.Methods/DesignThis multicenter randomized controlled trial is conducted in two teaching hospitals in the Netherlands. Women between 18 and 65 years of age, with an ASA classification of I-II who are scheduled to undergo an elective laparoscopic procedure with benign gynecologic indication can participate. Following informed consent, participants are randomly allocated into two groups at the end of the surgical procedure. In the intervention group, the upper abdomen is filled with normal saline infusion with the patient in the Trendelenburg position. Then the anesthesiologist performs a standardized pulmonary recruitment maneuver with a pressure of 40 cm H2O. The trocar sleeve valves will be left open, so carbon dioxide can escape the abdominal cavity. With the patient in a neutral position the instruments are removed from the abdomen. In the control group, carbon dioxide is removed from the abdominal cavity at the end of surgery, with gentle abdominal pressure and passive exsufflation through the port sites, with open sleeve valves.The primary outcomes are the incidence and intensity of post-laparoscopic pain in the shoulder, upper abdomen and at the operation sites, at 8, 24 and 48 h after surgery. Secondary outcomes are postoperative use of analgesics, nausea, vomiting and pulmonary complications.DiscussionThis study may reduce post-laparoscopic pain in women undergoing laparoscopy.Trial registrationDutch trial register, number NTR4812.

The impact of a pulmonary recruitment maneuver to reduce post-laparoscopic shoulder pain: A randomized controlled trial

ObjectiveA pulmonary recruitment maneuver (PRM) can effectively reduce post-laparoscopic shoulder pain (PLSP). However, a high-pressure PRM may cause pulmonary barotrauma. This study aimed to evaluate the efficacy and safety of a PRM using two different maximum inspiratory pressures (40 and 60cmH2O) for reducing PLSP. Study designPatients undergoing gynecologic laparoscopy were randomly allocated to a control group (n=30), a 40 cmH2O PRM group (n=30), and a 60 cmH2O PRM group (n=30). In the control group, residual carbon dioxide was removed by passive exsufflation through the port site. In the two intervention groups, the PRM consisting of five manual pulmonary inflations was performed at the end of surgery with a maximum pressure of 40 cmH2O or 60 cmH2O, respectively. Shoulder pain and wound pain were recorded using a visual analogue scale at 24 and 48h postoperatively. ResultsWound pain scores at 24 and 48h post-surgery were not different between the three groups. The PLSP scores in the two intervention groups were significantly lower than that seen in the control group at 24 and 48h postoperatively (P=0.006 and P<0.001, respectively). However, there were no statistically significant differences in the PLSP scores between the two intervention groups. ConclusionA low-pressure PRM (40cmH2O) is as effective as a high-pressure PRM (60cmH2O) for removing residual gas from the peritoneal cavity. PRM using a maximal inspiratory pressure of 40cmH2O is safe and efficacious for the reduction of PLSP.

Simple Clinical Maneuver for Reducing Shoulder Pain Following Gynecologic Laparoscopic Surgery at Maharat Nakhonratchasima Hospital: A Randomized Controlled Trial

Objective: To assess the efficacy of simple clinical maneuver to reduce shoulder pain after gynecologic laparoscopic surgery. Study design: Randomized controlled trial. Method: One hundred and four patients who were scheduled for elective gynecologic laparoscopic surgery were randomly allocated to either the current standard as a control group or to additional efforts to remove residual CO 2 at the end of surgery groups. For 54 patients in control group, CO 2 was removed by passive deflation of the abdominal cavity through the cannula. While in 50 patients in the intervention group, CO 2 was removed by means of Trendelenbrerg position (30 degrees) and a pulmonary recruitment maneuver consisting of 5 manual inflations of lung . Postoperative shoulder pain was recorded on a verbal rating scale (VRS 1-6) at 24, 48 hours after operation. Result: There are no significant differences in age, time of surgery, type of surgery, body mass index between 2 groups except for the postoperative hospital stay (mean,SD) which are 2.5 + 0.57 days in the control group compared to 2.1 + 0.47 days in the intervention group (p < 0.001). Postoperative shoulder pain (VRS 2-6) in first 48 hrs was evaluated. The significant pain is found in11 in 50 patients (22%) in the intervention group compared with34 in 54 patients (63%) in the control group (p < 0.001). Conclusion: This simple clinical maneuver can reduce the number of patients complaining of shoulder pain after Gynecologic laparoscopic surgery with statistical significance.

Pulmonary Recruitment Maneuver for Reducing Postoperative Shoulder Pain Incidence After Laparoscopic Gynecologic Surgery: A Prospective Randomized Controlled Trial

Pulmonary Recruitment Maneuver for Reducing Postoperative Shoulder Pain Incidence After Laparoscopic Gynecologic Surgery: A Prospective Randomized Controlled Trial

Pulmonary recruitment maneuver to reduce pain after laparoscopy: a meta-analysis of randomized controlled trials.

We investigated the impact of pulmonary recruitment maneuver in reducing shoulder pain after laparoscopic procedure. We conducted a systematic review of the literature using Medline (1966-2014), Scopus (2004-2014), Popline (1974-2014), www.ClinicalTrials.gov (2008-2014), and Google Scholar (2004-2014) along with reference lists of electronically retrieved studies. Statistical meta-analysis was performed using the RevMan 5.1 software. Six studies were included in the present systematic review, involving 571 patients. Among them, 291 (51 %) were offered a pulmonary recruitment maneuver, and 280 patients (49 %) were treated with conventional evacuation of pneumoperitoneum that included either passive evacuation or gentle pressing of the abdominal walls with the trocar ports open. The introduction of a pulmonary recruitment maneuver significantly decreased postoperative shoulder pain 12 h (435 patients, REM, MD -1.55, 95 % CI -2.01, -1.10), 24 h (435 patients, REM, MD -1.59, 95 % CI -2.00, -1.18), and 48 h post-operatively (335 patients, REM, MD -0.93, 95 % CI -1.37, -0.50). We also identified evidence of a potential beneficial effect in the reduction of postoperative upper abdominal pain. However, discrepancies in the interpretation of abdominal pain among the included studies precluded meta-analysis of this index. According to the results of our meta-analysis, pulmonary recruitment maneuver seems to be an easily performed, potentially preventive measure of post-laparoscopic shoulder pain. Further research is mandated, however, in the field, because firm results are precluded by the small number of included studies.

ABSTRACT 390

Background and aims: Mechanical ventilation using protective strategy is used to minimize the ventilator-induced lung injury, however prone positioning and pulmonary recruitment maneuver are necessary in some cases. Aims: To describe a case report of a child acute respiratory distress syndrome (ARDS). Methods: The information was obtained from medical charts after parents written autorization. Results: We reported the case of 11years old female child with mild asthma had admitted in PICU and because of dyspnea and hypoxemia, started noninvasive ventilation, but patient did not tolerate it, subsequently Heliox was unsuccessfull as well. 2ndday antibiotics started. Progressive worsening dyspnea /hypoxemia resulted in intubation. Afterwards, PaO2/FiO2 83 (Peep 13cmH2O FiO20,9), driving pressure 32cmH2O Vt 6mL/kg (pH7,20 PaCO2 62mmHg). On the 4thday CT demonstrated presence of regional lung attenuation of a dependent area (Figure 1), it was accomplished pulmonary recruitment maneuver (driving pressure 15cmH2O, IT2sec, RR10cpm, FiO21,0, Peep20, 25, 30,35,40cmH2O, 2minutes in each Peep level) (Figure 2). Decremental Peep titration was done, searching an ideal Peep 18cmH2O, enabling a decrease of the FiO20,45, SpO293%, driving pressure 15cmH2O, Vt6mL/kg associated prone positioning. 6th day there was a new clinical worsening episode (PaO2/FiO2 121), accomplished another pulmonary recruitment maneuver at the bedside (driving pressure 15cmH2O, PEEP 25cmHO), after 2hours PaO2/FiO2 185. On the two following days, the ventilatory parameters was decreased. 9thday extubation was done successfully, she was discharged home after 11days.FigureConclusions: This case report demonstrated the ventilatory protective strategy was insufficient to manage ARDS, so the pulmonary recruitment maneuver and prone positioning were the strategies that conduced a less harmful ventilation and improved the gas exchange.

Combined incisional ropivacaine infiltration and pulmonary recruitment manoeuvre for postoperative pain relief after diagnostic hysteroscopy and laparoscopy

Background Preoperative incisional local anaesthesia with ropivacaine is a common method of providing post-laparoscopy pain relief. The pulmonary recruitment manoeuvre also provides pain relief, but the combined effect of these two methods on pain following laparoscopic procedures has not been reported. We investigated the efficacy of combining local anaesthetic infiltration of ropivacaine with pulmonary recruitment manoeuvre on postoperative pain following diagnostic hysteroscopy and laparoscopy. Methods This prospective, randomized, controlled study involved 60 patients divided into two groups (n=30, each). Group 1 received 20 ml of 0.5% ropivacaine injected peri-incisionally preoperatively, with intra-abdominal carbon dioxide removed by passive deflation. Group 2 received 20 ml of 0.5% ropivacaine injected peri-incisionally with five manual inflations of the lungs with a positive-pressure ventilation of 40 cmH2O at the end of surgery. The last inflation was held for 5 seconds. The intensity of postoperative incisional and shoulder pain was evaluated using a numerical rating scale at 0, 2, 4, 8, 12, 24 and 48 hours postoperatively by an independent blinded anaesthesiologist. Tramadol was given postoperatively for analgesia. Results Compared with group 1, incisional ropivacaine infiltration combined with pulmonary recruitment manoeuvre significantly reduced dynamic pain at 0 hour, 4 hours, and 24 hours postoperatively (4.1 ± 2.2 vs. 2.1 ± 1.9, P=0.002; 2.7 ± 2.7 vs. 1.2 ± 1.3, P=0.035; and 3.5 ± 2.1 vs. 2.1 ± 1.8, P=0.03, respectively). Static incisional pain was significantly relieved at 0 hour, 2 hours, and 24 hours postoperatively (3.1 ± 1.7 vs. 1.6 ± 1.3, P=0.001; 1.4 ± 1.3 vs. 0.5 ± 0.8, P=0.012; and 2.3 ± 1.9 vs. 1.0 ± 1.5, P=0.038, respectively). Group 2 had more patients without shoulder pain (P&lt;0.05) and fewer requiring tramadol (P&lt;0.05). Conclusion Ropivacaine with pulmonary recruitment manoeuvre provided simple and effective pain relief after diagnostic hysteroscopy and laparoscopy.

Randomized clinical trial of a simple pulmonary recruitment manoeuvre to reduce pain after laparoscopy

Shoulder tip and abdominal pain following laparoscopic procedures are well recognized causes of postoperative morbidity. In this double-blind randomized clinical trial attempts were made to reduce postoperative pain in patients undergoing laparoscopic surgery by implementing a simple intraoperative technique. Patients undergoing elective laparoscopic cholecystectomy or laparoscopic transabdominal preperitoneal inguinal hernia repair were randomized to receive either the current standard treatment (control group) or an intervention to remove residual carbon dioxide. In the intervention group, the pneumoperitoneum was removed at the end of the operation by placing the patient in the Trendelenburg position and utilizing a pulmonary recruitment manoeuvre consisting of two manual inflations to a maximum pressure of 60 cmH2 O. In the control group, residual pneumoperitoneum was evacuated at the end of the procedure by passive decompression via the open operative ports. Seventy-six randomly assigned patients, 37 in the intervention group and 39 in the control group, were recruited. Overall postoperative pain scores were significantly lower in the intervention group (P = 0·001). Median (interquartile range) pain scores were significantly lower in the intervention group compared with the control group at both 12 h (3·5 versus 5; P < 0·010) and 24 h (3 versus 4·5; P < 0·010). Active evacuation of residual pneumoperitoneum following laparoscopic procedures, by means of two pulmonary recruitment manoeuvres in the Trendelenburg position, reduces postoperative pain significantly. This simple and safe technique can be implemented routinely after abdominal laparoscopy. NCT01720433 (http://www.clinical trials.gov).

Prevention of Postlaparoscopic Shoulder and Upper Abdominal Pain

Following laparoscopic surgery, residual carbon dioxide (CO2) trapped between the liver and the diaphragm induces phrenic nerve irritation and causes more patient discomfort than pain at the incision site. Although the pulmonary recruitment maneuver can mechanically remove residual CO2 and reduce pain, its effects occur only immediately after the operation and disappear later. Intraperitoneal normal saline infusion, another procedure, washes out CO2 with a physiologic buffer system and maintains longer pain relief. These 2 interventions are mediated through different mechanisms and act in different phases. This randomized controlled trial (RCT) tested the hypothesis that combining the pulmonary recruitment maneuver and intraperitoneal normal saline infusion would reduce postlaparoscopic shoulder and upper abdominal pain. Subjects were randomly assigned to the combined intervention or a control group receiving only passive deflation at the end of the procedure. Data for 100 patients were included in the analysis, 50 in the intervention group and 50 in the control group. The primary study end point was patient-reported postlaparoscopic upper abdominal pain and shoulder pain measured using a visual analog scale. Ratings for pain were obtained 12, 24, and 48 hours after surgery. The incidence of laparoscopic-induced shoulder pain at 12, 24, and 48 hours was lower in the intervention group (54%, 46%, and 30%, respectively) compared with the control group (72%, 70%, and 50%, respectively; P = 0.008, P = 0.001, and P = 0.004, respectively). To reduce the incidence of shoulder pain, the number needed to treat was 6 (95% confidence interval [CI], 4–21) at 12 hours, 5 (95% CI, 3–10) at 24 hours, and 5 (95% CI, 4–15) at 48 hours. At 12, 24, and 48 hours after surgery, the incidence of laparoscopic-induced upper abdominal pain also was lower in the intervention group (78%, 72%, and 58%, respectively) than that in the control group (92%, 90%, and 70%, respectively; P = 0.006, P = 0.001, and P = 0.077, respectively). These data show that the combined pulmonary recruitment maneuver and intraperitoneal normal saline infusion significantly reduce postlaparoscopic shoulder and upper abdominal pain. This intervention is inexpensive and easy to implement in daily clinical practice.

Techniques to reduce shoulder pain after laparoscopic surgery for benign gynaecological disease: a systematic review

Due to the well-known advantages of minimal invasive surgery, the majority of procedures for benign gynaecological diseases are performed by laparoscopy. Although laparoscopic surgery results in improved patient satisfaction, a considerable portion of patients have complaints of post-operative shoulder pain. This review presents an overview of the currently evaluated techniques to reduce shoulder pain after laparoscopic surgery for benign gynaecological disease. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using Medline, Embase and Cochrane databases. Randomised clinical trials reporting techniques to reduce shoulder pain after laparoscopic gynaecologic procedures for benign diseases were included. Eighty-eight articles were screened for inclusion. A total of 15 articles were included in the final review. The following studies described the techniques used to reduce shoulder pain: six studies evaluated the effect of local anaesthetics, three studies evaluated the effect of pulmonary recruitment manoeuvre and three studies evaluated the effect of intraperitoneal drainage. The remaining three studies evaluated the effect of saline installation, minilaparoscopy and gasless laparoscopy by using the Laprolift®. Overall, the pulmonary recruitment manoeuvre and intraperitoneal drainage were found to reduce the incidence and severity of shoulder pain (SP). Based on the current evidence, safety and possibility to implement the technique in daily practice, pulmonary recruitment manoeuvre can be recommended to reduce both the incidence and severity of SP.