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 . 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 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 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:
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, which could be the cause of pelvic discomfort and hematoma, a solid swelling of clotted blood within the tissues. We control every site of oozing. 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.
Patients feel exceptionally well if these steps are followed.
Medically reviewed by Tamer Seckin, MD on October 5, 2019
I’ve seen many obgyns over the years explaining my monthly symptoms during my period...but eventually it became a daily struggle with these pain. It feels like a poke here and there near my right pelvic region. I was given birth control pills for the past ten years but honestly, it didn’t help at all. I was in bed whenever I had my period. I was previously sent to GI doctors for possible appendicitis but it was ruled out from imagings…
Dr.Seckin is so much more than a surgeon. His passion for helping endometriosis sufferers and determination to improve the quality of life in all of his patients is undeniable. I remember when my gynecologist first told me I needed a laparoscopy. Her exact words were "I can do the surgery, but if you were MY daughter- I'd send you to him." From the first day I met him he took the time to explain endometriosis to me since I knew…
I was there for hysterectomy but then I found out that I also had endometriosis.My both surgeries went excellent and I feel great!.I am so thankful to Dr.Seckin and all his team for making my journey smooth!
I am a physician who suffered from deep infiltrative endometriosis. I needed laparoscopic surgery, so I went to see my former gynaecologist and he performed the procedure (a surgery which he supposedly does hundreds of times a year) last November. I had severe pain again when I had my period in January and was advised to go on taking a low hormone dose anticoncipient pill. My symptoms came back quickly and got worse in a few months’ time. I went…
After years of excessively painful periods, a serious loss of quality of life, and a series of uninformed and uninterested doctors, Dr. Seckin and Dr. Goldstein turned my life around. I was told I woke up from my surgery almost a year ago with a smile on my face, and I haven't stopped since. Before I heard of Dr. Seckin, I was experiencing almost daily terrible pain to the point where I had difficulty walking, inability to eat, inexplicable weight…
Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well. They were all caring, kind, patient, and took the time to listen to me and explain anything I needed to…
Dr. Seckin and his staff spared me from years and years of heavy periods and unbearable endometriosis pain. After having surgery with him (my first) I can now function like a regular human. No more eating NSAIDs like candy and calling out sick from work. Thank you, Dr. Seckin!