"Oh, My Aching...Shoulder?"
Yes, everything you've heard is true. Sometimes the shoulder pain following a laparoscopy is more painful than your incisions or your abdomen!
During the lap, C02 (Carbon Dioxide) gas is injected through a special needle inserted just below the navel.(1) This is done in order to insufflate the pelvic cavity and allow the surgeon a better view of the reproductive organs. After the lap, most people experience shoulder pain, ranging from mild to severe. But if the work was done in the pelvis, why the shoulder pain?
The diaphragm and the shoulder share some of the same nerves - predominantly the Phrenic Nerve. The Phrenic Nerve arises on each side of the neck, from the 3rd, 4th and 5th cervical spine roots and passes downwards between the lungs and the heart to reach the diaphragm. Impulses through the nerves from the brain bring about the regular contractions of the diaphragm during breathing. When the C02 gas irritates the diaphragmatic nerves, that pain is then referred upwards through the nerve connections, eventually landing in - and aggravating - the shoulder.
Why does the gas irritate the nerves, if it's just inflating the diaphragm? Because the gas does more than just inflate the abdominal cavity: it also effects the physiology of the surrounding peritoneal tissue. Previously, some surgeons believed that the shoulder pain was due to a reaction of the C02 combining with water. However, recent work has determined that the actual cause of the nerve irritation is a result of the cellular death caused by the combination of a temperature change from the gas at 21c and the drying effect of the gas at .0002%.(2) Dr. Larry Demco, a renowned laparoscopic pioneer and Associate Clinical Professor of Obstetrics & Gynecology at the University of Calgary (Alberta, Canada), refers to to this event in the following manner:
"...Just as the cold dry wind of a Canadian winter causes exposed skin to freeze in less than a minute, the same cold, dry gas of laparoscopy kills the peritoneal cells - resulting in the shoulder pain. Just as the Canadians flock to the warm, moist air of Florida to escape the pain of frostbite of a Canadian winter, heating and humidifying the gas during laparoscopy can prevent the cellular death of the peritoneum and result in less shoulder pain. Without shoulder pain, the patient's recovery is markedly affected. There is little need for pain medication and a shorter post-op recovery time." (3)
No matter what the medium of insufflation, the effects of the gas temperature remain the same. Experiments with gases other than C02 (such as helium, nitrous oxide and argon) all produced the same or similar effect. (4)
This phenomenon can be almost completely avoided through several means, but unfortunately, not many surgeons practice such techniques as removing the C02 before the end of the procedure, heating and humidifying the C02, injecting local anesthetics, or performing what is known as "gasless laparoscopy."
Gasless laparoscopy is a recent development in minimally invasive surgery, having been utilized by endoscopic experts for approximately a decade. Performed without the use of C02 insufflation, gasless laps instead utilize a special lift system ("LaparoLift" or "AbdoLift") to view the surgical field. The Lift is inserted into the abdominal cavity via a small cut in the lower umbilicus. It in turn raises the abdominal wall mechanically and allows a similar view into the cavity as that afforded by use of C02.(5) Use of the Lift not only affords the patient better recovery time and less pain, but also markedly decreases risks brought about by the use of the C02, including the potential physiologic, immunologic, cardiovascular, pulmonary and renal implications of the C02 effects.
We have come a long way since the days of using the more invasive laparotomy as the standard of care for Endometriosis and other pelvic disorders. Finding the right surgeon who is skilled in the latest techniques can offer the patient not only less pain during and after surgery, but the best long-term results as well.
For more information on the basic laparoscopy and post-op tips, visit the ERC's website , email their offices at EndoFL@aol.com or phone them toll free at 800/239-7280 and reference "Laparoscopy Fact Sheet."
References
(1) "Laparoscopy: What Can You Expect?"
by Dr. Mark Perloe / http://www.ivf.com/laprscpy.html
(2) & (3) International
Society for Gynecologic Endoscopy, February, 2001 Volume 7 Issue 1
(4) "How Can Laparoscopy Be Less
Painful?" American Association of Gynecological Laparoscopists Conference,
November 2000. Interview footage, Drs. Hugo Verhoeven &
Larry Demco / http://www.obgyn.net/avtranscripts/aagl2000_demco_verhoeven.htm
(5) "Gasless Laparoscopy," a publication
of the Institute for Endoscopic Gynaecology, University Witten, Herdecke,
Germany / http://www.gasless-laparoscopy.com