Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum A randomised controlled trial

BACKGROUNDPostoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8mmHg).OBJECTIVEThe aim of this study was to investigate whether low-pressure pneumoperitoneum (8mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12mmHg) and moderate NMB (single bolus of rocuronium 0.3mgkg(-1) with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy.DESIGNA randomised, controlled, double-blinded study.SETTINGPrivate hospital in Denmark.PARTICIPANTSNinety-nine patients.INTERVENTIONSRandomisation to either deep NMB and 8mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days.MAIN OUTCOME MEASURESThe primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery.RESULTSShoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P=0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores.CONCLUSIONDeep NMB and low-pressure pneumoperitoneum (8mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12mmHg).