Shoulder Pain and Post Gynecologic Laparoscopic Recovery
Condition: Gynecologic Nursing; Postoperative Pain
MeSH terms: Shoulder Pain
Study type: Interventional

Summary: 
      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
    

Detailed description: 
      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. Laparoscopic surgery, has become widely recognized as
      a viable alternative to traditional laparotomy in treatment of different gynecologic diseases
      . 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. 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.

      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. 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.

      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.

      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

      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.

      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 .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
    

Intervention name(s): Trendelenburg Position; Warm Pad Application; Deep Breathing Exercise
Intervention type(s): Other; Other; Behavioral
Intervention description(s): 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.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Supportive Care
Keywords: Shoulder Pain after Gynecologic Laparoscopic