Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum

Madsen, Mia; Istre, Olav; Staehr‐Rye, A. K.; Springborg, Henrik Halvor; Rosenberg, Jacob; Lund, J.; Gätke, Mona Ring

doi:10.1097/eja.0000000000000360

Cited by 84 publications

(70 citation statements)

References 19 publications

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“…In our view, the study by Madsen et al 1 does not reveal whether lower referred pain scores after laparoscopy should be attributed to the use of deep neuromuscular blockade, low-pressure pneumoperitoneum or a combination of both. In the discussion section, Madsen et al 1 state that their results were mainly because of the lower insufflation pressure, as there seems no rational explanation for an analgesic effect of deep neuromuscular blockade or sugammadex.…”

Section: Editormentioning

confidence: 58%

“…In a recent issue of the European Journal of Anaesthesiology, Madsen et al 1 presented a randomised controlled trial, evaluating the effect of deep neuromuscular blockade and low-pressure pneumoperitoneum in laparoscopic hysterectomy. The authors concluded that deep neuromuscular blockade and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of postoperative shoulder pain as compared to standard pressure pneumoperitoneum (12 mmHg) with standard neuromuscular blockade.…”

Section: Editormentioning

confidence: 99%

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Does deep neuromuscular block affect pain after laparoscopic surgery?

Warlé

Dahan²

2017

European Journal of Anaesthesiology

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Editor,In a recent issue of the European Journal of Anaesthesiology, Madsen et al. 1 presented a randomised controlled trial, evaluating the effect of deep neuromuscular blockade and low-pressure pneumoperitoneum in laparoscopic hysterectomy. The authors concluded that deep neuromuscular blockade and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of postoperative shoulder pain as compared to standard pressure pneumoperitoneum (12 mmHg) with standard neuromuscular blockade. This finding is in accordance with a recent review and meta-analysis, showing that the use of lowpressure pneumoperitoneum correlates with clinically relevant, lower overall and referred shoulder pain scores. 2 In this meta-analysis, all included studies were performed with standard neuromuscular blockade regardless of the intraperitoneal pressure. Therefore, it seems reasonable to assume that the use of deep neuromuscular blockade does not influence postoperative pain scores and that it only facilitates the use of low-pressure pneumoperitoneum. However, in a recent study by Castro et al. 3 it was shown that sugammadex, in combination with deep neuromuscular blockade, reduced postoperative pain after laparoscopic bariatric surgery.Based on current evidence, postoperative pain scores may be reduced by the use of low-pressure pneumoperitoneum as well as the use of deep neuromuscular blockade. In our view, the study by Madsen et al. 1 does not reveal whether lower referred pain scores after laparoscopy should be attributed to the use of deep neuromuscular blockade, low-pressure pneumoperitoneum or a combination of both. In the discussion section, Madsen et al. 1 state that their results were mainly because of the lower insufflation pressure, as there seems no rational explanation for an analgesic effect of deep neuromuscular blockade or sugammadex. Although it remains speculative, deep neuromuscular blockade may in theory have an analgesic effect during laparoscopy. Deep neuromuscular blockade facilitates maximum stretching of abdominal wall muscle fibres during laparoscopy. This leads to an increased abdominal wall compliance that may reduce pressure-related postoperative pain.In conclusion, current evidence shows that the use of lowpressure pneumoperitoneum reduces pain scores after laparoscopy. The question of whether the use of deep neuromuscular blockade influences postoperative pain scores after laparoscopy remains unanswered. This issue should be pursued in future clinical trials.Acknowledgements relating to this article

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Section: Editormentioning

confidence: 58%

Section: Editormentioning

confidence: 99%

Does deep neuromuscular block affect pain after laparoscopic surgery?

Warlé

Dahan²

2017

European Journal of Anaesthesiology

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“…Bogani and colleagues64 compared low-pressure (8 mm Hg) versus standard-pressure (12 mm Hg) pneumoperitoneum and found that while abdominal pain was similar between groups, the incidence of shoulder tip pain in the early postoperative period was 36% in the standard and 5% in the low-pressure group. Madsen and colleagues65 demonstrated less shoulder tip pain with lower inflation pressure. When carbon dioxide (CO 2 ) was humidified and heated, postoperative shoulder tip pain scores, but not abdominal pain scores, were lower than when using control gases 66.…”

Section: Resultsmentioning

confidence: 98%

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations

Lirk

Thiry

Bonnet

et al. 2019

Reg Anesth Pain Med

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Background and objectivesLaparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.Strategy and selection criteriaRandomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.ResultsOf the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.ConclusionsThe baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.

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“…A randomized trial in laparoscopic cholecystectomy with no versus deep neuromuscular blockade showed fewer sudden contractions and inadequate visibility with deep versus no neuromuscular blockade during the operation [5]. In a study in patients undergoing laparoscopic hysterectomy where they were randomized to moderate versus deep neuromuscular blockade, the overall findings were the same that the occurrence of sudden contractions in the diaphragm or lateral abdominal muscles, the occurrence of insufflator alarms, and increased abdominal wall tension were significantly more frequent in patients undergoing moderate versus deep neuromuscular blockade during surgery [6]. Thus, a deep neuromuscular blockade during laparoscopic procedures will impair muscle contractions and give a better workspace for the surgeon.…”

Section: Optimized Surgical Exposurementioning

confidence: 98%