Investigating the effect of pneumoperitoneum with lower pressure on postoperative shoulder pain in gynecologic laparoscopy surgeries accompanied by application of deep neuromuscular blockage

Aim: The aim of this study is to determine whether pneumoperitoneum with lower pressure (8-10 mmHg) and the application of deep neuromuscular blockage (NMB) will reduce the shoulder pain developed after laparoscopic hysterectomy surgery, when pneumoperitoneum with standard pressure (12-14 mmHg) and the application of modest neuromuscular blockage (NMB) were compared. Methods: Study is a randomized, controlled prospective clinic research. Study was included 49 patients for whom operations such as total laparoscopic hysterectomy (TLH) and bilateral salpingectomy/ total laparoscopic hysterectomy and bilateral salpingoopheroctomy (TLH and BSO) were planned due to benign reasons. Patients were divided into two groups. In 25 patients included in Group 1 (the lower pressure and deep NMB group), pneumoperitoneum with lower (8-10 mmHg) and deep neuromuscular blockage (rocuronium infusion 0.3-0.6 mg/kg/h) were studied during laparoscopy. For the 24 patients included in group 2, pneumoperitoneum with standard pressure (12-14 mmHg) was provided and modest neuromuscular blockage (fraction bolus rocuronium, if required) was applied. Optimization of surgical conditions related to deep neuromuscular blockage applied to patients in group 1 was carried out to provide sufficient intra-abdominal work area. In all patients standard therapy was applied for postoperative analgesia and if necessary additional analgesic was used and recorded At postoperative 1, 6, 36 and 48 hours shoulder and abdominal pains and other secondary results were recorded through NRS and VAS. The length of postoperative hospital stay was also recorded. Should pain was evaluated at postoperative day 7. In both groups the data of patients were compared between groups and within groups. Results: The mean length of operation was 148 min. in lower pressure group and 155 min. in standard pressure group. During follow-up there were no shoulder pains in 13 of 25 patients (group 1) and in 10 of 24 patients (group 2). According to 2 assessment scales (NRS and VAS), in all time frames (6, 24, 36 and 48 hours) a numeric reduction was found in shoulder pain in group 1 (lower pressure and deep NMB group) compared to group 2 (standard pressure and modest NMB group). However, there was no statistically significant difference between groups. Shoulder pain was not detected in any of the patients in postoperative 1st hour. A statistically significant difference was found when time-related shoulder pain was evaluated in both groups. Conclusion: In lower pressure and deep NMB group, the frequency and severity of shoulder pain was little numerically, but the statistical difference was found insignificant. It is thought that this result might have resulted from the paucity of patients included in study. A statistically significant difference was found when time-related shoulder pain was evaluated in both groups. It was observed in both groups that shoulder pain has appeared especially at 24th and 36th hours and it was more severe at these hours. But more severe abdominal pain was seen at the early postoperative period and it alleviated in time. A statistically significant difference was established between two groups in terms of operation process, indicating that pneumoperitoneum with lower pressure did not prolong the operation process. In addition, intraoperative PETCO2 value was also studied. PETCO2 value was found higher in the conditions of pneumoperitoneum with higher pressure (PETCO2 > 40mmHg). This indicated that the respiratory tract was influenced by pneumoperitoneum with higher pressure negatively. A shorter postoperative hospital stay was observed in lower pressure and deep NMB group. Key Words: pneumoperitoneum, neuromuscular blockage, post-laparoscopy shoulder pain