Shoulder pain after laparoscopic surgery has been thought to be due to the irritation of the phrenic nerve, which may be mainly caused by insufflated carbon dioxide . However, shoulder pain can be caused by stretching of the shoulder, which is constrained by many muscles and ligaments . We investigated postoperative shoulder pain in 72 patients who underwent gynaecological laparoscopy by the gasless, wall-lift method. In 56 patients, the right arm, with attached intravenous catheter, was abducted 80-90 degrees from the trunk while the left arm remained at the patient's side, with the head in a neutral position with a slight turn to the right side. In 16 patients, both arms were anteriorly flexed at the shoulder and the elbow with both hands on the forehead. On inquiry, one day after operation, shoulder pain was reported by 19% of the patients with flexed arms, significantly less often than by the patients with an abducted arm (59%) (Table 1).
During gynaecological laparoscopy, patients are placed in a head-down position. Despite previous warnings  and a report of brachial plexus injury , the arm is often abducted in the Trendelenburg position for the safety of the intravenous catheter. The surgeon operates using his instruments, through the abdominal puncture, towards the pelvic cavity by watching the television screen, set beside the patient's leg. Therefore, arm abduction may damage shoulder muscles, ligaments or nerves because of the head-down positioning and direct compression by the surgeon's hip .
We assume that most of the shoulder pain we detected was caused by stretching of the shoulder muscles, ligaments or nerves - brachial plexus neuropathy can be manifested as shoulder pain without paralysis  - consistent with its late onset and varying severity. Although none of the previous reports of shoulder pain after gynaecological laparoscopy contains specific information about arm positioning, some of the postoperative pain reported in those studies might have been related to the position of the arm.
Department of Anesthesiology; Suwa Red Cross Hospital; Suwa City, Nagano, Japan
Department of Anesthesiology and Resuscitology; Shinshu University School of Medicine; Matsumoto, Nagano, Japan
1. Alexander JI. Pain after laparoscopy. Br J Anaesth
2. Morrey BF, Itoi E, An K-N. Biomechanics of the shoulder. In: Rockwood Jr CA, Matsen III FA, eds. The Shoulder,
2nd edn. Philadelphia, USA: WB Saunders, 1998: 233-276.
3. Britt BA, Joy N, Mackay MB. Anesthesia-related trauma caused by patient malpositioning. In: Gravenstein N, Kirby RR, eds. Complications in Anesthesiology,
2nd edn. Philadelphia, USA: Lippincott-Raven Publication, 1996: 365-389.
4. Gagnon J, Poulin EC. Beware of the Trendelenburg position during prolonged laparoscopic procedures. Can J Surg
5. Warner MA, Martin JT. Patient positioning. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical Anesthesia,
4th edn. Philadelphia, USA: Lippincott Williams & Wilkins, 2001: 639-665.