Page 16 - World Journal of Laparoscopic Surgery

Muzzafar Zaman et al

Table 1: Frequency of occurrence of shoulder tip pain was significantly higher in group B
Group A Group B
Number Percentage Number Percentage
patient having shoulder tip pain 2 8 8 32
patient not having shoulder tip pain 23 92 17 68
Total 25 100 25 100

Table 2: Comparison of mean VAS among two groups resulting in release of inflammatory mediators that
Groups Mean SD elicits referred pain to shoulder. 3,8 Another theory is
A 0.92 3.19 based on pockets of residual CO gas left in the abdomen
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B 5.72 8.59 after surgery. The last theory is based on the assump­
p-value 0.012 tion that CO gas is converted to carbonic acid on the
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moist surface of peritoneum which irritates diaphragm
Classical four port laparoscopic cholecystectomy leading to shoulder tip pain.
was done in all the 50 cases. Randomization of cases In our study, the frequency of shoulder tip pain
was done according to randomization chart and stan­ was significantly lower in the group that underwent
dard statistical methods were used for analyzing the laparoscopic cholecystectomy with low pressure pneu­
outcome of the study p-value < 0.05 showed statistically moperitoneum compared to standard pressure pneu­
significant value. moperitoneum. Only two patients (8%) in group A and
eight patients (32%) in group B suffered shoulder tip pain
oBSERVATion And RESuLTS which is statistically significant with p < 0.05. Our find­
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ings are similar to Khetri, Kandil, Barczynski et al. 6
The study was conducted at MMU Medical College and
Hospital, solan. Fifty patients were admitted having gall The intensity of shoulder tip pain was significantly
stone disease and 25 patients (group A) underwent lapa­ lower in group A at 8, 12, 24, 48 hours than group B as
roscopic cholecystectomy with low pressure pneumope­ recorded on VAS. In group A, the mean analgesic con­
ritoneum (10 mm Hg) and another 25 patients (group B) sumption was 123 mg as compared to group B which
underwent the same surgery with standard pressure was 195 mg with p­valve of 0.04 which is statistically
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pneumoperitoneum (14 mm Hg). They were followed­ significant. Joshipura et al, Kandil, Barczynski et al
up for postoperative shoulder tip pain, operative time, showed similar findings.
analgesic consumption, postoperative hospital course
and complication rates (Tables 1 and 2). ConCLuSion
Comparison of shoulder tip pain in two groups. This study demonstrates that the use of simple expedient
Comparison of mean visual analog score (VAS) of reducing the pressure of the pneumoperitoneum to
among two groups. 10 mm Hg results in significant reduction in both the
Visual analog score was significantly higher in intensity and frequency of postoperative shoulder tip
group B. pain, had shorter hospital stay, early recovery, and
Our findings are similar to the study carried out by hence better outcome. On the basis of these results, the
Khetri et al. 4 widespread use of low pressure pneumoperitoneum
can be used as a standard pressure for uncomplicated
diSCuSSion gallstone disease.

The advent of laparoscopic cholecystectomy is a mile­
stone achieved in the treatment of gallstones. Though REFEREnCES
there have been obvious advantages of laparoscopic 1. Tsimayiannis ECg, Lekkas ET, Siakas P, Jabarian M, Tzorou H.
cholecystectomy but postoperative shoulder tip pain Intraperitoneal normal saline and bupivacaine infusion for
is still a very common and distressing complaint. The reduction of postoperative pain after laparoscopic cholecys­
tectomy. Surg Laparosc Endosc 1998:8:416-420.
origin of referred pain to shoulder after laparoscopic 2. Cunnife MG, McAnena OJ, Dar MA, Flyn CJ. Prospective
cholecystectomy is poorly understood. The tissue randomized trial of intraoperative bupivacaine irrigation for
trauma theory is based on stretching of the peritoneum the management of shoulder tip pain following laparoscopy.
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and diaphragm secondary to pneumoperitoneum Am J 1997:84:455-458.

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