Different Maneuvers for Reducing Post-laparoscopic Pain
Condition: Gynecologic Disease
MeSH terms: Genital Diseases, Female
Study type: Interventional

Summary: 
      -  Laparoscopic surgeries are becoming more attractive because of early recovery. However,
           post-laparoscopic shoulder and upper abdominal pain may cause more discomfort to the
           patient than the pain at the incision site

        -  Many strategies have been attempted, such as the use of nonsteroidal anti-inflammatory
           drugs; however, the effect is limited, and there are no reliable methods available yet.

        -  Recently, some techniques are introduced that can potentially alleviate various types of
           pain through different mechanisms in patients after laparoscopic surgery such as
           low-pressure pneumoperitoneum, intraperitoneal normal saline infusion, and pulmonary
           recruitment maneuvers.

        -  the investigators conduct this randomized controlled trial to evaluate the effectiveness
           of different strategies on reducing the intensity of post-laparoscopic shoulder and
           abdominal pain in patients undergoing laparoscopic gynecologic surgeries.
    

Detailed description: 
      Laparoscopic surgery is becoming more popular due to smaller incision, faster recovery, less
      postoperative pain, and earlier returns to normal activity . However post-laparoscopic
      shoulder and upper abdominal pain may upset the patient more than the pain at the incision
      site. The incidence of shoulder pain after laparoscopic gynecological surgery varies from 35%
      to 80% and could be so severe at 24 hours after laparoscopic hysterectomy as well.

      The mechanism of post laparoscopic shoulder and abdominal pain attributes to the insufflated
      co2 in the abdominal cavity and become entrapped between the liver and the right diaphragm
      causing irritation of the phrenic nerve, diaphragm and referred pain in the C4 dermatome. On
      the other hand, the prolonged exposure to residual CO2 dissolution leads to intra-abdominal
      acidosis and consequent peritoneal irritation and abdominal pain.

      As long as the retention of CO2 is the key factor in the laparoscopy-induced shoulder and
      abdominal pain, many strategies have been evolved to alleviate different types of pain in
      patients undergoing laparoscopic surgeries such as usage of low-pressure pneumoperitoneum
      (8-10 mmHg) that result in reducing the intensity of postoperative pain in comparison to
      standard high-pressure pneumoperitoneum (12-15 mmHg). Although this low pressure may impair
      visualization and jeopardize the surgeon's comfort during surgery, this method is proven to
      be safe and feasible.

      One of the maneuvers that have been proposed is an intraperitoneal normal saline infusion
      (IPS) that increases intraperitoneal pressure to enhance the removal of residual CO2, as well
      as offers a physiologic buffer system to wash out excess CO2.

      Pulmonary recruitment maneuvers (PRM) has also a potential beneficial effect on alleviating
      post-laparoscopic pain by mechanically increasing intraperitoneal pressure to accelerate the
      elimination of residual CO2.

      Because these variable techniques are mediated through different mechanisms, the
      investigators hypothesize that combination of two different maneuvers may be ideal and more
      effective in reducing post-laparoscopic shoulder and abdominal pain than any single or
      standard maneuver in patients undergoing laparoscopic gynecologic surgeries.
    

Intervention name(s): group C; Group L; Group LR; Group LS
Intervention type(s): Procedure; Procedure; Procedure; Procedure
Intervention description(s): laparoscopy will be performed with 14-16 mmHg intra-abdominal pressure. At the end of the procedure routine method for CO2 removal, passive exsufflation, will be used by applying gentle abdominal pressure to evacuate the residual gas through the port site.; laparoscopy will be performed with 8-10 mmHg intra-abdominal pressure and routine passive exsufflation will be applied for CO2 removal at the end of the procedure.; the intra-abdominal pressure will be kept at 8-10 mmHg during laparoscopy. At the end of the procedure pulmonary recruitment maneuver (PRM) will be done; which consists of five manual pulmonary inflations at a maximum pressure of 40 cm H2O and the fifth will be held for 5 seconds. During this procedure, the surgeon is instructed to keep the port sleeve valve fully opened to allow the CO2 to escape the abdominal cavity.; the intra-abdominal pressure will be kept at 8-10 mmHg during laparoscopy. At the end of the procedure, intraperitoneal normal saline (IPS) will be infused for removal of the intra-abdominal CO2; in which we fill the upper part of the abdominal cavity evenly and bilaterally with isotonic normal saline (15-20 mL/kg body weight)
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The patients will be divided randomly by a computer-generated randomization table into two equal groups
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Pulmonary recruitment maneuvers; low-pressure pneumoperitoneum; laparoscopic Shoulder and Abdominal Pain; laparoscopic gynecologic surgery; intraperitoneal saline infusion