Surgical Endoscopy

, Volume 24, Issue 8, pp 2002–2007 | Cite as

The effect of mechanical ventilation tidal volume during pneumoperitoneum on shoulder pain after a laparoscopic appendectomy

  • Hwa-Yong Shin
  • Seong-Hyop Kim
  • Yeong-Ju Lee
  • Duk-Kyung KimEmail author



Postlaparoscopic shoulder pain (PLSP) frequently occurs after various laparoscopic surgical procedures. Its mechanism is commonly assumed to be overstretching of the diaphragmatic muscle fibers due to the pressure of a pneumoperitoneum, which causes phrenic nerve-mediated referred pain to the shoulder. Based on this hypothesis, we speculated that during inspiration, the lung could squeeze out the phrenic nerve with carbon dioxide gas against the constantly pressurized abdominal cavity with increasing tidal volume (VT). Thus, we examined whether mechanical ventilation with a low VT (LTV, VT 7 ml/kg) during a pneumoperitoneum might reduce PLSP in patients undergoing laparoscopic appendectomy compared with ventilation with the traditional VT (TTV, VT 10 ml/kg).


In a prospective trial, 64 adult patients undergoing laparoscopic appendectomy were randomly assigned to two groups of 32 each (LTV and TTV groups). Intravenous ketorolac was used as a postoperative rescue analgesic. The 2-, 4-, 24-, and 48-h postoperative incidence and severity of PLSP, severity of surgical pain, and need for rescue analgesia was assessed.


The overall incidence of PLSP was similar in both groups (57.1% in the LTV group vs. 65.5% in the TTV group). Compared with the TTV group, the incidence and PLSP verbal rating scale (VRS) did not decrease in the LTV group throughout the study period. No statistically significant differences were observed in the VRS surgical pain score, the cumulative ketorolac consumption at each time point, or the time to first rescue analgesia.


Mechanical ventilation with a reduced 7 ml/kg VT during a pneumoperitoneum does not reduce the frequency and severity of PLSP after laparoscopic appendectomy compared with ventilation with the traditional VT (10 ml/kg).


Laparoscopic surgery Postoperative pain Mechanical ventilation Tidal volume 



Drs. Hwa-Yong Shin, Seong-Hyop Kim, Yeong-Ju Lee, and Duk-Kyung Kim have no conflicts of interest or financial ties to disclose.


  1. 1.
    Semm K (1983) Endoscopic appendectomy. Endoscopy 15:59–64CrossRefPubMedGoogle Scholar
  2. 2.
    Garbutt JM, Soper NJ, Shannon WD, Botero A, Littenburg B (1999) Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc 9:17–26CrossRefPubMedGoogle Scholar
  3. 3.
    Chung RS, Rowland DY, Li P, Diaz J (1999) A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg 177:250–256CrossRefPubMedGoogle Scholar
  4. 4.
    Golub R, Siddiqui F, Pohl D (1998) Laparoscopic versus open appendectomy: a metaanalysis. J Am Coll Surg 186:545–553CrossRefPubMedGoogle Scholar
  5. 5.
    Dixon JB, Reuben Y, Halket C, O’Brien PE (2005) Shoulder pain is a common problem following laparoscopic adjustable gastric band surgery. Obes Surg 15:1111–1117CrossRefPubMedGoogle Scholar
  6. 6.
    Mouton WG, Bessell JR, Otten KT, Maddern GJ (1999) Pain after laparoscopy. Surg Endosc 13:445–448CrossRefPubMedGoogle Scholar
  7. 7.
    Berberoglu M, Dilek ON, Ercan F, Kati I, Ozmen M (1998) The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain. J Laparoendsc Adv Surg Tech A8:273–277CrossRefGoogle Scholar
  8. 8.
    Sarli L, Costi R, Sansebastiano G, Trivelli M, Roncoroni L (2000) Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy. Br J Surg 87:1161–1165CrossRefPubMedGoogle Scholar
  9. 9.
    Chang SH, Lee HW, Kim HK, Kim SH, Kim DK (2009) An evaluation of perioperative pregabalin for prevention and attenuation of postoperative shoulder pain after laparoscopic cholecystectomy. Anesth Analg 109:1284–1286CrossRefPubMedGoogle Scholar
  10. 10.
    Phelps P, Cakmakkaya OS, Apfel CC, Radke OC (2008) A simple clinical maneuver to reduce laparoscopy-induced shoulder pain: a randomized controlled trial. Obstet Gynecol 111:1155–1160PubMedGoogle Scholar
  11. 11.
    Matsui K, Yoshida M, Maemura Y, Ichihara Y, Yamagami M, Kikuchi H (1994) Significance of phrenic nerve block in the anesthetic management of laparoscopic cholecystectomy. Masui 43:1718–1721PubMedGoogle Scholar
  12. 12.
    Dogan R, Sahin D, Isbilen C (2008) Laparoscopic cholecystectomy under spinal anesthesia with right phrenic nerve block. Acta Anaesthesiol Scand 52:445–446PubMedCrossRefGoogle Scholar
  13. 13.
    Tiel RL, Kline DG (1996) Peripheral nerve trauma. In: Bradley WG (ed) Neurology in clinical practice. Butterworth-Heinemann, Boston, pp 980–981Google Scholar
  14. 14.
    Song C, Alijani A, Frank T, Hanna GB, Cuschieri A (2006) Mechanical properties of the human abdominal wall measured in vivo during insufflation for laparoscopic surgery. Surg Endosc 20:987–990CrossRefPubMedGoogle Scholar
  15. 15.
    Nyerges A (1994) Pain mechanisms in laparoscopic surgery. Semin Laparosc Surg 1:215–218PubMedGoogle Scholar
  16. 16.
    Aitola P, Airo I, Kaukinen S, Ylitalo P (1998) Comparison of N2O and CO2 pneumoperitoneum during laparoscopic cholecystectomy with special reference to postoperative pain. Surg Laparosc Endosc 8:140–144CrossRefPubMedGoogle Scholar
  17. 17.
    Abbott J, Hawe J, Srivastava P, Hunter D, Garry R (2001) Intraperitoneal gas drain to reduce pain after laparoscopy: randomized masked trial. Obstet Gynecol 98:97–100CrossRefPubMedGoogle Scholar
  18. 18.
    Cai H, Gong H, Zhang L, Wang Y, Tian Y (2007) Effect of low tidal volume ventilation on atelectasis in patients during general anesthesia: a computed tomographic scan. J Clin Anesth 19:125–129CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Hwa-Yong Shin
    • 1
  • Seong-Hyop Kim
    • 1
  • Yeong-Ju Lee
    • 2
  • Duk-Kyung Kim
    • 1
    Email author
  1. 1.Department of Anesthesiology and Pain MedicineKonkuk University School of MedicineSeoulSouth Korea
  2. 2.Department of Anesthesiology and Pain MedicineNational Police HospitalSeoulSouth Korea

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