After the Laparoscopy:
“My Aching...Shoulder?"

By Heather Guidone, CEC Program Director

Everything you've heard is true…sometimes the shoulder pain following a laparoscopy can be even more painful than your abdomen!  But if work was done in the pelvis, why the shoulder pain? This article will address why this happens and what the CEC has been doing for years to help effectively diminish this pain in our patients.

During laparoscopy, C0₂ (carbon dioxide) gas is injected through a special needle inserted just below the navel. This is done to expand the abdomen and allow your surgeon a better view of your organs. After the laparoscopy, many women experience shoulder pain, which can range from mild to severe. Commonly, this is attributed to the C0₂ gas being trapped as it exits the body.  What you might not know is that the diaphragm and the shoulder also share some of the same nerves; predominantly, the Phrenic Nerve.

The Phrenic Nerve arises on each side of the neck, from the 3rd, 4th and 5th cervical spine roots.   It passes downward between the lungs and the heart to reach the diaphragm.  Impulses through this nerve from the brain bring about the regular contractions of the diaphragm during breathing.  When the C0₂ gas irritates the diaphragmatic nerves, that pain is referred upwards through the nerve connections, eventually landing in - and aggravating - the shoulder. Experiments with gases other than C0₂ (such as helium, nitrous oxide and argon) all produced the same or similar effect.⁽¹⁾

Why does the gas irritate the nerves, if it's just inflating the diaphragm? Because the gas does more than just inflate the abdominal cavity: it also affects the physiology of the surrounding peritoneal tissue.  It was once believed that the shoulder pain was due to a reaction of the gas combining with water.  However, recent work has determined that the actual cause of the nerve irritation is a result of the cellular death caused by the combination of a temperature change from the gas at 70^o F and the drying effect of the gas at .0002%.⁽²⁾  Heating and humidifying the gas during laparoscopy can prevent the cellular death and quite simply, result in less shoulder pain.⁽³⁾ The CEC has long practiced Insuflow™ technology to confer improved pain control and reduced need for opioid analgesics (painkillers) and antiemetics (to help with nausea and vomiting) in our patient's postoperative period; an effective practice supported by numerous studies, including the small sampling below:

 
Beste TM; Daucher JA; Holbert D, Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, East Carolina University Brody School of Medicine, Greenville, NC 27834, USA.  Humidified compared with dry, heated carbon dioxide at laparoscopy to reduce pain.  Obstet Gynecol.  2006; 107(2 Pt 1):263-8 (ISSN: 0029-7844).  Last accessed 02 May 06 from: http://www.medscape.com/medline/abstract/16449110

 
Glew PA; Campher MJ; Pearson K; Schofield JC; Davey AK, Department of Anesthesia, University of Otago, Dunedin, New Zealand.  Animal Study - The effect of warm humidified C0₂ on the dissipation of residual gas following laparoscopy in piglets.  J Am Assoc Gynecol Laparosc.  2004; 11(2):204-10 (ISSN: 1074-3804).  Last accessed 02 May 06 from:
http://www.medscape.com/medline/medredirect?pmidParam=15200776

Demco L, Department of Obstetrics and Gynecology, University of Calgary, Alberta, Canada.  Effect of heating and humidifying gas on patients undergoing awake laparoscopy.  J Am Assoc Gynecol Laparosc.  2001; 8(2):247-51 (ISSN: 1074-3804). Last accessed 02 May 06 from: http://www.medscape.com/medline/publicationbrowser/123?pmid=11342732

 
The shoulder pain phenomenon can be significantly reduced through the effective techniques we practice, such as removing the C0₂ before the end of the procedure and heating and humidifying the C0₂.  At the Center for Endometriosis Care, patient comfort is our paramount concern; as such, we always utilize the latest technology and surgical practice to minimize pain and recovery time.

Glossary:
cellular death – a regular process by the body to deliberately get rid of unwanted cells

C0₂ – a colorless, odorless gas comprised of one carbon and two oxygen atoms; commonly used during laparoscopy to inflate the abdominal cavity
laparoscopy - a minimally invasive surgical procedure used to diagnose and treat Endometriosis (among other disorders)
peritoneal tissue – the membrane that forms the lining of the abdominal cavity
phrenic Nerve – provides innervation to the diaphragm and is responsible for, among other functions, breathing
 
References:
1 “How Can Laparoscopy Be Less Painful?"  American Association of Gynecological Laparoscopists Conference, November 2000.  Interview footage, Drs. Hugo Verhoeven & Larry Demco.  Last accessed 02 May 06 from the OBGYN.net website: http://www.obgyn.net/avtranscripts/aagl2000_demco_verhoeven.htm

(2) & (3)  Journal of the International Society for Gynecologic Endoscopy, February, 2001 Volume 7 Issue 1

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