Effect Of Trendelenburg Position, Warm Pad Application and Deep Breathing Exercise on Shoulder Pain and Post Gynecologic Laparoscopic Recovery
Phase: NA
Conditions: Gynecologic Nursing, Postoperative Pain
Sponsor: Alexandria University

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,, 
 
 
 
 
Faculty of Nursing 
Obstetrics& Gynecologic Nursing Department
Protocol for postdoctoral research  
In Obstetric& Gynecologic Nursing 
Academic Year 2020-2021 
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Title: 
 In English: 
Effect Of Trendelenburg Position, Warm Pad Application and Deep Breathing 
Exercise on Shoulder Pain and Post Gynecologic Laparoscopic Recovery 
 
 
 
 
 
 
 
 
 
 
 
Keywords: Trendelenburg position, Warm Pad, Breathing exercise, Gynecologic 
laparoscopy, shoulder pain, postoperative recovery. 
 
 
 
 
 

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INTRODUCTION 
Laparoscopic gynecologic surgery has evolved from a limited surgical procedure used only 
for diagnostic purposes to a major surgical approach for treating a multitude of malignant 
and non-malignant pathologies. It is currently considered one of the most common surgical 
procedures performed by gynecologists.( Zeein et al., 2020) . Laparoscopic surgery, has 
become widely recognized as a viable alternative to traditional laparotomy in treatment of 
different gynecologic diseases (Hsuan et al., 2019). The advantages of laparoscopic surgery 
over traditional laparotomy include a smaller surgical wound, less postoperative pain, a 
shorter hospital stay, faster recovery, and a better cosmetic result. (chen et al., 2011). 
However, post-laparoscopic shoulder pain (PLSP), is a prevalent complaint following 
laparoscopic surgery with an incidence as high as 80%.  The pain can be severe and is 
usually relieved in 24–48h, but rarely persists for over 72h after surgery. It has also been 
found that PLSP is less responsive to treatment than incision and visceral pain (Kiyak, 
2019).  
 
The precise mechanism of post-laparoscopic shoulder pain remains unclear. Carbon dioxide 
accumulation and phrenic nerve irritation as a result of diaphragmatic stretching are the most 
accepted explanations( Phelps, 2008). A number of techniques that are proposed to diminish 
shoulder pain as intraperitoneal instillation of local anesthetics, pulmonary recruitment 
maneuver, warm and humidified dioxide, low pressure  pneumoperitoneum and 
intraperitoneal normal saline  infusion. Unfortunately, these interventions have often found 
quite varied and sometimes even conflicting results regarding their effectiveness (Tian, 
2021). 
 
Optimal pain management is imperative for the success of immediate and long term 
rehabilitation. Therefore, relieving PLSP is a problem that can no longer be ignored. 
Effective pain control is best achieved through a combination of both pharmaceutical and 
non-pharmaceutical therapies.  Non pharmacological methods increase women/Patient 
control of her feeling, improve the activity level and functional capacity and reduce dosage 
of analgesic drugs thus decreasing the side effects of treatment (Metawie et al.,2015).  

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One of the popular non-pharmacological techniques is heat therapy, it is easy to use, 
inexpensive, require no prior practice, and have minimal side effects when used properly. In 
addition to being used for pain relief, heat is used to relieve chills or trembling, decrease 
joint stiffness, reduce muscle spasm, and increase connective tissue extensibility (Mohamed 
& Elhady, 2016).  
 
Also, one of the recommended non-pharmacological actions is to use deep breathing 
relaxation techniques. The technique of breathing relaxation itself is an act of nursing care, 
which in this case the nurse teaches the patients how to do deep breathing techniques, slow 
breathing (hold inspiration to the maximum) and how to exhale slowly. In addition to 
reducing pain intensity, deep breathing relaxation techniques can also improve lung 
ventilation and increase blood oxygenation (Asman & Maifita, 2019 ).  
 
In addition, the trendelenburg position might decrease shoulder pain by reducing the 
mechanical pressure exerted by CO2 on the diaphragm and the upper abdominal muscles. 
CO2, known for its high solubility, would also be displaced to the pelvis that has a rich 
vasculature which in turn speeds up the resorption of pneumoperitoneum (Zeein et al., 
2020). However, evidence-based research is still needed in the area of pain relief after 
gynecologic laparoscopy and few studies have attempted to identify the effect of warm 
application and trendelenburg position versus deep breathing technique on PLSP.  So, the 
purpose of this study is to determine the effect of postoperative trendelenburg position, 
warm application, and deep breathing exercise on shoulder pain 
 
 
 
 
 
 
 

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AIM OF THE STUDY 
The present study aims to: 
 investigate the effect of postoperative trendelenburg position versus warm pad application  
and deep breathing technique on shoulder pain intensity  and post gynaecologic laparoscopic 
recovery  
Hypothesis
 
 Women who assume trendelenburg position after gynecological laparoscopic surgery 
exhibit less shoulder pain intensity and high quality postoperative recovery than those 
who receive warm application and who perform deep breathing technique. 
  
 Women who receive warm pad application after gynecological laparoscopic surgery 
exhibit less shoulder pain intensity and high-quality postoperative recovery than those 
who assume trendelenburg position and who perform deep breathing technique.  
 
 
 Women who perform deep breathing technique after gynecological laparoscopic 
surgery exhibit less shoulder pain intensity and high-quality postoperative recovery 
than those who assume trendelenburg position and who receive warm application.  
 
 
 
 
 
 
 
 
 
 
 
 

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PLAN OF THE STUDY 
MATERIALS AND METHOD 
 
Materials 
Research design: 
A comparative quasi-experimental research design will be utilized in this study, where the 
effect of three independent variables (Trendelenburg position, heating pad and deep 
breathing technique on two dependent variables (shoulder pain and post gynecologic 
laparoscopic recovery) will be examined in this study.  
Setting: 
 
This study will be conducted in the laparoscopic unit at El Shatby Maternity University 
Hospital in Alexandria Governorate, Egypt. This hospital was particularly chosen 
because the turnover of gynecologic laparoscopy is suitable for the study and the women 
attending this hospital have nearly the same socio-economic status which maintain 
homogeneity of the study sample 
Subjects: 
A convenient sample of 90 women attending the previously mentioned setting will be 
recruited. The Epi info 7 program version 10 was used to estimate the sample size using 
the following parameters; Population size= (1000) over 3months, Expected frequency 
50%, Acceptable error of 5%, and Confidence coefficient 95%. The minimum sample 
size 84 
women will be selected according to the following criteria: 
 Age from 18-70 years  
 who were scheduled for diagnostic or operative gynecological laparoscopic surgery 
for 
non-malignant 
pathologies 
(e.g., 
hysterectomy, 
myomectomy, 
ovarian 

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cystectomy) 
 Free from any medical or gynecological risk factors such as, morbid obesity (BMI > 
45). Medical history of deep vein thrombosis, rupture of ectopic pregnancy, rupture of 
an ovarian cyst, shoulder surgery and chronic shoulder pain.  
Sampling technique: The selected subjects were assigned to one of the following two 
groups: 
 Study group 1 included 30 women, who will assume the trendelenburg position.  
 Study group 2 involved 30 women, who will  receive the warm pad on shoulder   
 Study group 3 included 30 women who will perform deep breathing technique 
Tools: 
Three tools will be developed and used by researcher to collect the necessary data as 
following: 
 Tool (I): woman's Socio-demographic and Clinical Data Structured Interview 
Schedule 
   This tool will be developed by the researcher. It entails the following two sections: 
Part (I): Socio-demographic characteristics such as: the subjects' age, level of education and 
occupation. In addition to her marital status, residence, family type and income etc.-----. 
Part (II): Profile of current gynecologic surgery including: name, date, duration, reason 
for surgery and postoperative complaint.  
Tool (II): Postoperative Quality of Recovery scale(QoR40) 
This tool was originally developed by Myles (2000), (Myles et al., 2000) it is used to measure 
quality of recovery. It is consisted of 40 items, the items are grouped according to various 
aspects (dimensions) of recovery: emotional state (9items), physical comfort (12items), 
psychological support (7items), physical independence (5 items), and pain (7items). 
Subjects’ response to each item will vary according to a 5 point likert scale, it was scored for 
positive item as "1= none of the time, 2=some of the time, 3= usually,4=most of time, and 
5=all of the time. For negative items the scoring will be reversed.  
Total score of QoR scale will range from  (40- 200) scores, the total quality of recovery 
score was calculated as the following:-  

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Low quality of recovery--------------< 60% of total quality of recovery scores (< 120 scores). 
Moderate quality of recovery ------60-75% of total quality of recovery scores (< 120-150 
scores). High quality of recovery ------->75% of total quality of recovery scores (> 150- 
scores). 
 
Tool (III): Numerical Pain Rating Scale (NRS) 
This tool will be adapted from the Clinical Manual for Nursing Practice (McCaffery, M. and 
Beebe, A. ,1993) (McCaffery& Beebe.,1993). It will be used to assess the severity of shoulder 
pain. Women will be instructed to choose a number from 0 to 10 that best describes their 
current pain.  0 means ''No pain" and 10 means sever pain'. It was scored as no pain (0), mild 
pain (1-3), moderate (4-7), and sever pain (8-10).  
 
METHOD 
The study will be accomplished according to the following steps: 
1. An official approval will be obtained from the Research Ethics Committee, 
Faculty of Nursing, Alexandria University. An official letters from the Faculty of 
Nursing, Alexandria University will be directed to the responsible authorities of 
the study settings to obtain the permission to collect data after explaining the study 
purpose. 
2. Tool (I) will be developed by the researcher after thorough review of recent& 
relevant literature. 
3. Tool (II, III) will be adapted and translate into Arabic language to suite Egypt 
culture. 
4. Tools will be tested for content validity by a jury of 5 experts in Obstetrics and 
Mental health fields. 
5. Tools will be tested for their reliability by using the appropriate test.   
6. A pilot study will be carried out on 9 women; to test the feasibility of the study as 
well as to ascertain the clarity and applicability of the tools in addition to calculate 
the time needed to complete them. (This number will be excluded from the study). 

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7. Each woman in the two groups will be individually interviewed during the 
preoperative period to collect basic data using tool I.  
8. Again, for women undergoing the present study, the researchers will reassure that 
they have the same technique of surgery, doses of anesthetic drugs, and intra-
operative measures to drain CO2 gas from the abdominal wall   . 
9. The subjects will be assigned to one of 3 groups as follows: 
 Group 1 (trendlenburg position group) in which the women will be positioned in a 
Trendelenburg position (20 °) once fully awake and cooperative in the recovery room 
and will remain in this posture for the first 24 hrs postoperatively. The maximum time 
allowed in a straight-up position will be three 15-min intervals over a 24-h period.  
 Group 2 (warm pad application group) in this group warm pad (38◦C -40◦C) will be 
applied on the shoulder after four hours postoperatively for a period of 5-10 minutes. 
Each woman will be asked to place heat pads when needed during the first 24 hours. 
 Group 3: (deep breathing group) the researcher will instruct women after the end of 
surgery and upon consciousness to take slowly deep breathing while observing her 
chest and hold her breath for about 5 seconds and then exhale slowly, repeating this 
deep breathing technique five times after full vigilance within the first 3 hours after 
surgery. Then, the process will be repeated 6, 12, and 24 h later.  The patient will be 
instructed about this type of breathing before surgery by researchers. 
10. Pain intensity will be evaluated for all groups 4 times: at arrival to recovery room, & 
4, 6, 12 and 24 hours postoperatively using tool III. 
11. postoperative recovery will be evaluated for all groups after 24 h postoperatively  
using tool II  
12. Comparison between all groups will be done to determine which intervention induces 
less shoulder pain and improve in postoperative recovery. 

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Ethical considerations: 
For each recruited subject the following issues will be considered: 
 Written informed consent will be obtained from women before data collection after 
explanation of the study aim. 
 Privacy of women will be maintained during data collection processes. 
 Confidentiality of data will be maintained during the execution of the study. 
 Women’s anonymity will be maintained during the execution of the study. 
 Women will be informed that their participation in the study is voluntary, and they 
can withdraw at any time. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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RESULTS 
 
       Analysis of data will be carried out by the researcher with the help of a statistical 
specialist. The collected data will be categorized, coded, computerized, tabulated and 
analyzed, using SPSS program. 
 
DISCUSSION 
       The obtained findings will be explained and compared to current related literature and 
recent researches in the field. 
 
CONCLUSION AND RECOMMENDATIONS 
        Conclusion and recommendations will be derived from the findings of the study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Li, X. Y., Tian, M., Li, A. Z., Han, C. L., & Li, K. Z. (2021). The risk of shoulder pain 
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 Zeeni, C., Chamsy, D., Khalil, A., Musa, A. A., Al Hassanieh, M., Shebbo, F., & 
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ISO 690 
 
 
 
 
 
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