Why do I have shoulder pain after endometriosis surgery?
For first-time laparoscopic endometriosis surgery patients, post-operative shoulder pain can be a downright alarming symptom. But patients who have had multiple laparoscopic endo procedures know all too well that shoulder pain, and accompanying rib pain and chest pain can be expected. No matter if you're a first-timer or not, shoulder pain is common after laparoscopic surgery . 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.
Where does this pain come from?
Your endometriosis operation was concentrated in the pelvic area, so why are you feeling pain way up into your shoulder?
CO2 gas that is used to inflate the abdomen before surgery is the culprit. It 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, which causes pressure along the diaphragm.
The phrenic nerve
The phrenic nerve is a nerve that originates in the neck and goes all the way down to the diaphragm . Irritation to the diaphragm may, therefore, cause a person to feel pain in the shoulder area.
How common is shoulder pain after surgery?
Around 35 to 80 percent of patients who undergo laparoscopic surgery experience shoulder pain post-op. The pain can last 2-3 days or longer depending on the pain medication the patient is on. Here at Seckin Endometriosis Center, we do not prescribe narcotics for this very reason. Narcotics slow the bowel or intestinal movement following surgery. The drugs can cause constipation, further gas trapping, bloating and even can cause an ileus, or 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.
How is laparoscopic surgery performed?
During laparoscopy, surgeons make a small cut in the umbilicus or 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 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 the skin incisions are sewn together. However, despite doing our best 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, and diclofenac and Tylenol rather than narcotics.
- Taking simethicone (Gas-X) and getting your first bowel movement going with stool softeners, hydration and laxative if needed or advised
- Applying heat pads on 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 the gas, blood clots and excess fluid, and we perform a secondary, surgical pause before closing the patient.
This 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. All the gas is removed from the abdomen. 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, which could be the cause of pelvic discomfort and hematoma, a solid swelling of clotted blood within the tissues. We control every oozing, to the last drop. We keep the excision surfaces bone 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.
These patients do exceptionally well if these steps are followed.
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