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

Abstract

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.

The Impact of Incentive Spirometry on Shoulder Tip Pain in Laparoscopic Cholecystectomy: A Randomized Clinical Trial

“…Other studies similarly found that LRM was followed by such complications as barotrauma and hemodynamic deterioration, 19 but IS in the present study indicated considerable efficiency and safety in relieving PLSP.…”

“…Thus, it reduced the patients' PLSP. Finally, Kietpeerakool et al 19 performed LRM with a pressure of 40 cm of H 2 O at the end of laparoscopic surgery and observed a significant reduction in the severity of patients' shoulder pain at 4, 12, 24, and 48 hours after surgery.…”

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review.

“…PLSP is a referred pain caused by chemical irritation of the phrenic nerve by CO 2 and by mechanical distention of the parietal peritoneum and liver capsule. PLSP usually lasts 1–3 (occasionally up to 7) days [ 120 , 121 ]. The main risk factor for developing PLSP is residual intraabdominal CO 2 ; therefore maneuvers improving its elimination at the end of surgery, such as gas suction and saline instillation before leaving the abdomen as well as the pulmonary recruitment maneuver, reduce the incidence and severity of PLSP [ 121 – 125 ].…”

Residual intraperitoneal carbon dioxide gas following laparoscopy for adnexal masses: Residual gas volume assessment and postoperative outcome analysis

“…[ 16 ] In a meta-analysis of randomized controlled trials, the authors concluded that a pulmonary recruitment maneuver with 40 cm H 2 O performed either alone or accompanied by intraperitoneal saline was a promising intervention for alleviating shoulder pain within 48 hours following gynecologic laparoscopy. [ 17 ] With these articles, it was suggested that free pneumoperitoneum is the cause of postoperative shoulder pain and that methods to decrease free air were a strategy for postoperative shoulder pain.…”