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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 27  |  Issue : 2  |  Page : 132-137

Intraperitoneal saline instillation in reducing shoulder tip pain after laparoscopic surgeries


Department of General Surgery, Azeezia Institute of Medical Science and Research, Kollam, Kerala, India

Date of Submission30-Jul-2021
Date of Decision05-Sep-2021
Date of Acceptance06-Sep-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. R Anjali
Department of General Surgery, Azeezia Institute of Medical Science and Research, Kollam - 691 537, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_41_21

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  Abstract 


Introduction: The incidence of shoulder pain after laparoscopic surgery ranges from 35 to 80%. Objectives: The objective of the study was to find the proportion of shoulder tip pain after laparoscopic surgeries with and without intraperitoneal subdiaphragmatic saline instillation and to compare the frequency of post-operative analgesics usage in both groups. Methods: A longitudinal comparative study was conducted on 56 patients undergoing laparoscopic surgeries. Twenty-eight subjects in the study group received intraperitoneal subdiaphragmatic saline wash at the end of the procedure and the control group received no wash. Post-operative shoulder pain was assessed by a visual analogue scale at fixed time intervals. Post-operative use of analgesics, length of stay in the hospital and early mobilisation and discharge from the hospital were also considered. Results and Discussion: Among the 56 patients, there was a statistically significant reduction in the shoulder tip pain postoperatively at 6, 12, 24 and 48 h. Additional analgesic requirement was less in the Wash group, statistically significant at 6, 12, 24 and 48 h post surgery. This significance in outcome was also reflected in the length of the hospital stay, smooth recovery, early discharge, better quality of life and early return to work. Conclusion: Intraperitoneal subdiaphragmatic normal saline wash significantly improved the surgical outcome after laparoscopic surgery by diminishing the shoulder tip pain, minimising analgesic requirements in the post-operative period, thus enhancing early mobilisation and discharge.

Keywords: Carbon dioxide, intraperitoneal saline instillation, length of hospital stay, phrenic nerve, post-operative analgesics, shoulder tip pain, visual analogue scale


How to cite this article:
Anjali R, Salim J M. Intraperitoneal saline instillation in reducing shoulder tip pain after laparoscopic surgeries. Kerala Surg J 2021;27:132-7

How to cite this URL:
Anjali R, Salim J M. Intraperitoneal saline instillation in reducing shoulder tip pain after laparoscopic surgeries. Kerala Surg J [serial online] 2021 [cited 2021 Nov 29];27:132-7. Available from: http://www.keralasurgj.com/text.asp?2021/27/2/132/330405




  Introduction Top


With the expanding role of ambulatory surgery and the need for earlier hospital discharge, reducing post-operative pain has obtained increasing importance.[1] Post-operative pain delays resumption of normal activities.[2] Hence, post-operative pain control is one of the most important factors in patient convalescence and safe discharge from a surgical facility.[3],[4]

Pain after laparoscopic surgery on the 1st day may be a visceral or parietal pain.[5] Shoulder tip pain is an example of parietal pain, the incidence ranging from 35% to 80%.[6] The reasons for shoulder pain may be due to CO2 introduced in the abdomen causing phrenic nerve irritation.[7] It may be transient or persistent for up to 3 days after laparoscopic surgeries.[8]

Perioperative analgesia has been provided by opioid analgesics, extensive use of which is associated with a variety of perioperative side effects leading to decreased patient satisfaction.[1] Therefore, anaesthesiologists and surgeons are turning to non-conventional techniques to minimise the pain.[9]

To reduce post-laparoscopic pain after laparoscopic surgery, two promising strategies are mentioned in the literature;[10] the first is the pulmonary recruitment manoeuvre[11] and the second is the use of intraperitoneal normal saline infusion through the port sites.[12] Our study was designed to analyse the effectiveness of intraperitoneal subdiaphragmatic instillation of normal saline in reducing the shoulder tip pain and reducing the frequency of analgesics postoperatively following laparoscopic surgeries by comparing the proportion of shoulder tip pain between both groups and the frequency of post-operative analgesics usage in the groups.


  Materials and Methods Top


It was a longitudinal comparative study conducted in the department of general surgery of a tertiary care hospital from 2018 to 2020 on patients undergoing laparoscopic surgeries. All patients undergoing laparoscopic surgery above 18 years and below 70 years were included. Patients with American Society of Anaesthesiologist (ASA) criteria 3, 4 and 5, gross peritonitis and diaphragmatic abnormalities and surgeries that involve irritation of diaphragm in any form, previous midline laparotomies and patients allergic or intolerant to analgesics were excluded. Sample size was calculated using the formula.



where

α = 5%, ƍ = 0.5, Z1-α/2 = 1.96

1− β = 80%, m = 5, Z1-β =0.842

The sample size was calculated as n = 28 for each group making a total of 56 patients. Convenience sampling method was adopted. After getting written informed consent, patients of both sexes having an physical status classification ASA – 1 and 2 and undergoing laparoscopic surgeries [Figure 1] were randomly divided into two groups of 28 subjects each, after obtaining the approval from the Ethical and Scientific Committee of our Institution. For Group A (Intervention group), intraperitoneal subdiaphragmatic saline wash with 0.9% normal saline was given [Figure 2] after removing blood clot and debris and visualising the phrenic nerve [Figure 3]. For Group B (Control group), routine treatment (removal of carbon dioxide via passive exsufflation through port sites) without intraperitoneal subdiaphragmatic saline wash, but removing all blood clots and debris was given.
Figure 1: Laparoscopic Surgery – after port placement

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Figure 2: Subdiaphragmatic Intraperitoneal saline instillation

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Figure 3: Saline in the subdiaphragmatic space

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The study was blinded for patients, nurses and house officers on the ward, but only the surgical team was aware of the allocation. Both the groups received perioperative local infiltration of the wound (periportal sites) with ropivacaine or bupivacaine to mask the incisional wound pain in the post-operative period. All patients received alprazolam 0.5 mg orally and ranitidine 150 mg orally the night before surgery. All were operated under general anaesthesia with pre-oxygenation for few minutes with 100% oxygen. Induction was done with injection glycopyrrolate (0.1 mg) i/v, injection fentanyl 2 mcg/kg/iv and propofol (1–1.5 mg/kg) i/v. Endotracheal intubation was done after giving succinylcholine, intermittent positive pressure ventilation was continued with Bain's circuit through anaesthesia workstation. Maintenance was done with oxygen, N2O, isoflurane, injection atracurium and injection fentanyl. Residual effect of atracurium reserved with neostigmine and glycopyrrolate. Standard ports were placed, and laparoscopic surgeries were done in a standard fashion by experienced laparoscopic surgeons. Carbon dioxide was used as distension medium, introduced either as closed technique (through a Veress needle placed infraumbilically/Palmer's point) or via the open technique, depending upon feasibility. At the end of surgery, the intervention group (Wash group) received thorough intraperitoneal saline wash after removing all blood clots and debris with 0.9% normal saline till clear fluid is seen in the cavity. Control group (No Wash group) did not receive any wash except for removing blood clot and debris with suction. After surgery, the participants reported the primary outcomes of shoulder tip pain at 1, 6, 12, 24 and 48 h after surgery using 10-point visual analogue scale (VAS) [Figure 4]. Secondary outcomes were post-operative use of analgesics, length of stay in the hospital and early mobilisation and discharge from the hospital.
Figure 4: Visual Analogue Scale

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0 mark indicated no pain, 1–3 mild pain, 4–7 moderate pain and 8–10 severe pain. Injection paracetamol was given to patients with VAS score of 1–3, injection diclofenac for score 4–7 or to those patients who demanded stronger analgesics and injection tramadol + injection Emeset for score 8–10. Data collected were tabulated in a Microsoft excel sheet and analysed using SPSS version 22.0 software (IBM SPSS Statistics, Software version 22.0, USA, 2020). The categorical variables are expressed as proportions and continuous variables as mean and standard deviation. Chi-square test was used to find the significance of association between categorical variables. A difference with a significant level <0.05 was considered statistically significant.


  Results Top


Majority of the 56 patients belonged to the age group of 56–65 years, with the mean age of the patient being 46.32 ± 15.547 years [Figure 5]. Pearson Chi-square test found no statistical significance between the Wash group (Group A) and No Wash group (Group B) across all age brackets. There were an equal number of males and females in both arms of the study, incidentally. There was no outcome difference as far as gender of the patient is considered.
Figure 5: Age distribution of study subjects

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There was no statistical significance between the Wash group (Group A) and No Wash group (Group B) with relation to body mass index in the study subjects [Figure 6].
Figure 6: Body mass index of study subjects

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Although not significant statistically, at 1 h post surgery, 46.4% of patients in the No Wash group had shoulder tip pain (moderate pain) when compared to the Wash group (21.4%). At 6 h post surgery, 71.5% of the Wash group have no pain when compared to the No Wash group (35.7%). In the Wash group, 17.45% had mild pain and 10.7% had moderate pain when compared to the No Wash group with 7.1% mild pain and 57.1% moderate pain. Thus, it is statistically significant that the shoulder tip pain in the No Wash group is higher than the Wash group with a P = 0.001 [Figure 7].
Figure 7: Shoulder tip pain score (Visual Analogue Scale score) of study subjects at 6 h

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At 12 h, 78.6% of the study subjects in Wash group had no pain with respect to No wash group where 35.75% of subjects had no pain. There was statistical significance in reduction of shoulder tip pain in Wash group compared to No wash group [Figure 8] with a P = 0.04.
Figure 8: Shoulder tip pain score (Visual Analogue Scale score) of study subjects at 12 h

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At 24 h post surgery, 92.9% of the Wash group had no pain when compared to the No wash group (50% have no pain). In the Wash group, 7.1% had mild pain. In the No wash group, 28.6% had mild pain, 17.5% had moderate pain and 3.6% had severe pain. Thus, it is statistically significant that the shoulder tip pain in the Wash group is lower than the No wash group, with P = 0.001 [Figure 9].
Figure 9: Shoulder tip pain score (Visual Analogue Scale score) of study subjects at 24 h

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At 48 h, in the Wash group, 96.4% had no pain as compared to the No wash group (57.1%). Thus, it is statistically significant that the shoulder tip pain in the No wash group is higher than the Wash group with a P = 0.002 [Figure 10].
Figure 10: Shoulder tip pain score (Visual Analogue Scale score) of study subjects at 48 h

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On comparing the mean VAS Score at 1, 6, 12, 24 and 48 h between two groups, the wash group had a lesser mean VAS score. There was a significant difference in VAS score between the Wash and No Wash group with P < 0.05 during the first 48 h [Figure 11].
Figure 11: Mean Visual Analogue Scale score at 1, 6, 12, 24 and 48 h

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At 1 h, in the Wash group, only 15 (53.6%) patients required no analgesics in the 1st h as compared to the No Wash group. In the Wash group, 46.5% required analgesics (42.9% required one injection and 3.6% required two injections). In the No Wash group, 64.3% of patients required analgesics (50% required one injection and 14.3% required two injections), though statistically no significant reduction of shoulder tip pain was found in the Wash group as compared to the No Wash group. At 6 h, 67.9% of patients in Wash group and 35.7% in No Wash roup required no analgesia between 1 and 6 h. There is statistical significance in the reduction of shoulder tip pain in Wash Group with P = 0.021. Only 28.6% of patients in Wash roup required one pain killer as compared to 39.3% in the No Wash roup. About 3.6% in Wash roup required the second injection compared to 25% to the No Wash group [Figure 12].
Figure 12: Number of analgesic requirements at 6 h

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At 12 h post surgery, in the Wash group, 75% of patients required no analgesics when compared to the No Wash Group B. About 25% of patients in Wash group required only one injection. In the No Wash group, 42.9% required one injection, 8.9% required two injections and 1.8% of patients required three injections. It was found that a highly statistically significant reduction was made in the number of injections used in two groups (P = 0.011) [Figure 13].
Figure 13: Number of analgesic requirements at 12 h

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At 24 h, 10.7% of patients required one injection in the Wash Group, whereas in No Wash group, 35.7% required one injection, 10.7% required two injections and 3.6% required three injections. Hence, the analgesic requirement in the Wash group is less compared to No Wash group with a significant P = 0.012 [Figure 14].
Figure 14: Number of analgesic requirements at 24 h

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At 48 h, in the Wash group, 27 (96.4%) patients required no analgesics as compared to the No Wash group. Only 3.6% of patients required one injection in the Wash group. In the No Wash group, 60.7% of patients required one injection, 35.7% required two injections and 3.65% required three injections. There is a significant reduction in analgesic usage in the Wash group as compared with the No Wash group. P =0.005 [Figure 15].
Figure 15: Number of analgesic requirements at 48 h

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In the Wash Group (A), 89.3% of patients stayed in the hospital for 3 or less days and in the No Wash group (B), 88.9% of patients had to stay for 4 or more days probably due to shoulder tip pain [Figure 16].
Figure 16: Length of hospital stay

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  Discussion Top


In the era of daycare surgery, shoulder tip pain may delay discharge in 10%–20% of patients which is attributed to stretching of subdiaphragmatic fibres of phrenic nerve,[13] carbon dioxide retention, formation of carbonic acid,[14] diaphragmatic injury, etc., though the precise reason is unclear. Pain is a major part of the post-operative recovery process. Better pain management results in increased patient satisfaction and early return to normal activities. Effective pain management also leads to reduced hospitalisation duration, thereby decreasing costs for the healthcare providers. In a country like India where majority of the healthcare needs are met by the public healthcare systems, reduced healthcare costs will mean that the funds can be allocated towards more pressing needs.

Many different methods have been used successfully to diminish the intensity of pain after laparoscopic surgery, including a low-pressure pneumoperitoneum, a gasless technique for creating a working space, local wound anaesthetic infiltration, subarachnoid block, parenteral opioids/non-steroidal anti-inflammatory drugs (NSAIDs) and instillation of the subdiaphragmatic region with normal saline.[15] But till date, there are no standard guidelines available to reduce the incidence of shoulder tip pain.

Instillation of local anaesthetic solution intraperitoneally, as a mode of providing post-operative analgesia, has been studied extensively. It has the added advantage of early ambulation, reduced incidence of post-operative nausea, vomiting and reduces the use of parenteral opioids and NSAIDs, reduced length of hospital stay and early return to work. However, the results of the cited studies have been conflicting, with the majority demonstrating some benefit in terms of pain reduction, although the magnitude of this reduction and the duration of the effect have been limited.

In our study, all the groups were comparable with respect to the demographic data including age, sex, height, weight and body mass index. The incidence of shoulder tip pain did not significantly differ between the groups at 1 h post surgery. However, the number of patients having mild, moderate and severe pain was higher in the control group in all assessed hours after surgery compared to those in the intervention group. This shows that the incidence of post-operative shoulder tip pain was reduced by intraperitoneal normal saline wash as compared to the No Wash group. Furthermore, the number of analgesics required in the Wash group (intervention group) is very much less compared to the control group. Thus, it has been found that the length of hospital stay had reduced in the Wash group as compared to the No Wash group.

Different studies have revealed that intraperitoneal infusion of saline[16] resulted in a significant reduction in shoulder tip pain severity as compared to the control group.

For relief of shoulder tip pain, intraperitoneal infusion of normal saline at body temperature until the liver is submerged without fluid suction after deflation of pneumoperitoneum was first reported by Perry and Trambello and these results were confirmed by Duchene with encouraging results.[17]

In another study by Ahmed et al. states that the analgesic consumption was lower in the subdiaphragmatic saline wash group.[16]

Sandblom studied the effects of intra-abdominally instilled isotonic saline on pain, recovery and health-related quality of life following laparoscopic cholecystectomy and supported using isotonic saline in reducing the shoulder tip pain.[18]

Our findings were also consistent were with the findings of Tsiomoyiannis et al., whose studies confirmed that saline wash at body temperature reduces post-laparoscopy abdominal and shoulder tip pain.[19]


  Conclusion Top


This study concludes that intraperitoneal subdiaphragmatic normal saline wash significantly improved the surgical outcome after laparoscopic surgery by diminishing the shoulder tip pain in the first 48 h post surgery. There is a statistically significant reduction in the shoulder tip pain postoperatively especially at 6, 12, 24 and 48 h. It may be recommended as a simple, safe and cost-effective procedure. Additional analgesic requirement was less in the Wash group. At 6, 12, 24 and 48 h post surgery, the analgesic requirements were less in the Wash group and it is statistically very much significant as compared to the No Wash group. This significance in outcome was also reflected in the length of the hospital stay, early mobilisation, smooth recovery, early discharge, better quality of life and early return to work and decreasing the medical expenditure. Intraperitoneal subdiaphragmatic normal saline instillation may be recommended to all patients following laparoscopic procedures, as it is a simple, safe and cost-effective method.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Suginami R, Taniguchi F, Suginami H. Prevention of postlaparoscopic shoulder pain by forced evacuation of residual CO (2). JSLS 2009;13:56-9.  Back to cited text no. 12
    
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Sarac AM, Aktan AO, Baykan N, Yegen C, Yalin R. The effect and timing of local anesthesia in laparoscopic cholecystectomy. Surg Laparosc Endosc 1996;6:362-6.  Back to cited text no. 13
    
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Tsai HW, Chen YJ, Ho CM, Hseu SS, Chao KC, Tsai SK, et al. Maneuvers to decrease laparoscopy-induced shoulder and upper abdominal pain: A randomized controlled study. Arch Surg 2011;146:1360-6.  Back to cited text no. 14
    
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Narchi P, Benhamou D, Fernandez H. Intraperitoneal local anaesthetic for shoulder pain after day-case laparoscopy. Lancet 1991;338:1569-70.  Back to cited text no. 15
    
16.
Barazanchi AW, MacFater WS, Rahiri JL, Tutone S, Hill AG, Joshi GP, et al. Evidence-based management of pain after laparoscopic cholecystectomy: A prospect review update. Br J Anaesth 2018;121:787-803.  Back to cited text no. 16
    
17.
Tsimoyiannis EC, Siakas P, Tassis A, Lekkas ET, Tzourou H, Kambili M. Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy World J Surg 1998 Aug;22(8):824-8. doi: 10.1007/s002689900477.  Back to cited text no. 17
    
18.
Barthelsson C, Sandblom G, Ljesevic-Nikoletic S, Hammarqvist F. Effects of Intra-abdominally Instilled Isotonic Saline on Pain, Recovery, and Health-Related Quality-of-Life Following Laparoscopic Cholecystectomy: A Randomized Prospective Double-Blind Controlled Study. World Journal of Surgery. 2015 39(6). DOI:10.1007/s00268-015-2978-8.  Back to cited text no. 18
    
19.
Tsimoyiannis EC, Siakas P, Tassis A, Lekkas ET, Tzourou H, Kambili M. Intraperitoneal normal saline infusion for postoperative pain after laparoscopic cholecystectomy. World J Surg 1998;22:824-8.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]



 

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