Effects of delayed suprapubic port removal on post-laparoscopic shoulder pain: A randomized controlled trial

Abstract

Background: One of the major drawbacks of gynecologic laparoscopy is post-laparoscopic shoulder pain (PLSP) that is believed to result from intra-abdominal CO2 retention leading to peritoneal and diaphragmatic stretching and causing referred pain in C4 dermatome. Several interventions have been applied to prevent and reduce its incidence and severity, with contradictory results. Only pulmonary recruitment maneuver, extended assisted ventilation, and active intra-abdominal gas aspiration have been mentioned to be effective interventions for CO2 evacuation. However, in our experience, an alternative technique of delayed suprapubic port removal (DSPR) was found to be an effective method in CO2 expulsion. Therefore, we conducted this randomized trial to determine the effectiveness of the DSPR technique in reducing the incidence and severity of PLSP. The trial was conducted at a single, tertiary hospital between May 2015 and May 2016. Having complied with the criteria, 220 patients scheduled for elective gynecological laparoscopy were randomly allocated into 2 groups after giving informed consent. Laparoscopic procedures were performed through 10-mm umbilical port and at least 2 ancillary, including suprapubic, ports. In conventional group, ancillary ports were removed at the end of surgery leaving only opened umbilical cannula for pneumoperitoneum deflation. Abdominal compression from periphery towards umbilicus was performed to further expel CO2 before removing the umbilical cannula. In DSPR group, both umbilical and suprapubic cannulas were retained. Two-step abdominal compression was undertaken, primarily towards umbilicus and secondarily towards pelvic cavity, before sequentially removing the umbilical and the suprapubic cannulas. Postoperatively, each patient was asked to rate PLSP level on 100-mm VAS during 0–6, 6–12, 12–24, and 24–48 h, respectively. Statistical analysis was performed to determine both incidence and severity of PLSP during 24-and 48-h post-laparoscopy. Results: Patients in DSPR group demonstrated significantly lower incidence of PLSP within 24 h (43.8% vs 59.0%; p = 0.027) and 48 h (43.8% vs 60.0%; p = 0.019), and expressed apparently lower pain scores (0 (0–0) vs 0 (0–8); p = 0.020) during 24–48 h post-surgery. Conclusion: DSPR is an effective CO2 expulsion technique, resulting in significant reduction of both incidence and severity of PLSP within 24–48 h post-laparoscopy.