by Tamer Seckin, MD | Posted on July 13, 2020
For first-time laparoscopic endometriosis surgery patients, post-operative shoulder pain can be an alarming symptom. But patients who have had multiple laparoscopic endo procedures know all too well that shoulder pain, and accompanying rib and chest pain, can be expected. Regardless of whether you're a first-timer, shoulder pain is common after laparoscopic surgery . Endometriosis surgery is could take long under anesthesia in the head-down position. Pre-op, your surgeon will prescribe Gas-X. Post-op, you'll be encouraged to walk around and get moving as much as you can, in hopes of minimizing this uncomfortable symptom.
Your endometriosis operation was concentrated in the pelvic area, so why are you feeling pain way up into your shoulder? Because of the CO2 gas that is used to inflate the abdomen before surgery. This gas can remain in the abdomen and irritate the diaphragm, which, in turn, can irritate the phrenic nerve (see illustration below), which has origins in the diaphragm and nerve endings in the shoulder .
Much of the gas will be removed towards the end of the procedure, but often residual gas can remain, causing pressure along with the diaphragm.
The phrenic nerve is a nerve that originates in the neck and goes down to the diaphragm . Irritation to the diaphragm may cause a person to feel pain in the shoulder area.
Around 35 to 80 percent of patients who undergo laparoscopic surgery for endometriosis experience shoulder pain post-op. The pain can last 2-3 days or longer depending on the pain medication the patient is on. At Seckin Endometriosis Center, we do not prescribe narcotics for this very reason. Narcotics slow bowel movements following surgery. The drugs can cause constipation, bloating, further trap gas, and can even cause an ileus (the temporary paralysis of intestines). We recommend avoiding narcotics, rotating Tylenol and ibuprofen along with Gas-x, a stool softener like Colace, and, if needed, a laxative.
During laparoscopy, surgeons make a small cut into the belly button, through which they insert a tube called a trocar to pump CO2 gas into the abdomen. Inflating the abdomen with CO2 gas allows the surgeon to have the best visibility possible throughout the abdomen. It also serves to put back pressure against the intestines and protect them during surgery.
Next, surgeons insert a laparoscope through the trocar. The laparoscope visualizes the inside of the abdomen. Surgical instruments are then inserted through other small incisions and port sites to remove any endometriotic lesions or perform any other procedures necessary.
Once the surgery is over, CO2 is released from the abdomen, and skin incisions are sewn together. However, despite our best efforts to suction out all of the gas, some CO2 often gets trapped inside the abdomen.
Gas pain in the shoulder following laparoscopic surgery can be reduced by:
Walking around, taking a hot shower, and lying on one's side
Drinking hot liquids like tea and soup as well as plenty of water and fluids with electrolytes
Using nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, diclofenac, and Tylenol instead of narcotics
Taking simethicone (Gas-X) and getting your first bowel movement going with stool softeners, hydration, and laxatives (if needed or advised)
Applying heat pads to the affected area
CO2 gas isn't the only source of shoulder pain after laparoscopic surgery. Excess fluid or blood clots trapped in the upper abdomen and between the diaphragm and right upper liver lobe could also be to blame. Therefore, before finishing the surgery, we make sure that we remove all gas, blood clots, and excess fluid, and we perform a secondary, surgical pause before closing the patient.
This pause is crucial as we finish the procedure. We do not close the skin incision immediately. Instead, we pause for five minutes. During this five-minute recess, the patient is placed in a flat, preferably reverse T-position that we call the “head up” position. This way, all the venous blood, and gas are brought through the pelvic cavity, which decreases the pressure inside the abdomen to its normal level. We also tell the anesthesiologist to lighten the anesthesia slightly, so the patient's blood pressure increases. We also check the excision sites for late oozing and bleeding.
After three to five minutes of recess, we re-fill the inner abdomen with gas again, and we check the excision surfaces for delayed bleeding. The cause of pelvic discomfort and hematoma, solid swelling of clotted blood within the tissues will be the cause of delayed bleeding. Excision surgeon controls every site of oozing during endometriosis surgery. We keep the excision surfaces completely dry, and then we suction all the excess fluid, as well as blood clots that have been accumulating. Finally, we keep the tip of our suction tube at the upper abdominal corners of the liver to decrease gas accumulation inside the peritoneum and shoulder pain following surgery. More importantly, suctioning the blood clots under the diaphragm prevents prolonged shoulder pain that would otherwise be caused by developing adhesions.
Patients feel exceptionally well if these steps are followed.
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