Research progress on post-laparoscopic shoulder pain after gynecologic surgery

Abstract

Shoulder pain after gynecological laparoscopic surgery is increasingly being regarded as a serious clinical problem. The main risk factors are excessively high CO₂ pressure during pneumoperitoneum, a very rapid CO₂ insufflation rate, and excessive residual CO₂ under the diaphragm. The mechanisms underlying the development of shoulder pain include mechanical stimulation, chemical stimulation, and the relationship with the intraoperative body position. On the basis of these risk factors and mechanisms, preventive measures can be implemented from three perspectives: surgery, nursing, and medication. In terms of surgical interventions, prevention involves limiting the pneumoperitoneum pressure and CO₂ insufflation rate and removing as much residual CO₂ gas as possible at the end of the surgery. From the nursing viewpoint, diverse interventions are implemented from multiple perspectives throughout the perioperative period. Additionally, preventive measures involving medications are being studied. This article reviewed the clinical characteristics, mechanisms, risk factors, and preventive measures for shoulder pain after laparoscopic gynecological surgery, with the aim of providing a reference for effective prevention strategies.

Introduction

Continuous advancements in gynecological laparoscopic techniques have largely replaced traditional open abdominal surgeries. Compared with open abdominal surgeries, gynecological laparoscopic surgeries offer remarkable advantages, such as less intraoperative bleeding, better exposure of the surgical field, shorter treatment duration, minimal scarring, lower incidence of intra-abdominal adhesions, rapid recovery of intestinal function, fewer postoperative complications, quicker resumption of daily activities and work, and minimal trauma.^1,2 Recent studies have confirmed that laparoscopic surgery can effectively reduce the risk of postoperative infections, shorten hospital stays, and enhance patients’ quality of life. However, research has also indicated that post-laparoscopic shoulder pain (PLSP) in gynecological patients may be more distressing than abdominal incision pain and visceral pain. Recent reports show that the incidence of PLSP is as high as 90%.^3–5 Postoperative shoulder pain mainly occurs in the right shoulder.^6,7 Studies have shown that >50% of women experience more severe right shoulder pain. ⁸ Persistent postoperative shoulder pain exacerbates patients’ discomfort, increases postoperative complications, delays the rehabilitation process, imposes clear psychological and mental burdens on patients, significantly reduces patient satisfaction, and markedly increases nursing costs. These adverse effects counter the original intention of performing gynecological laparoscopic surgeries. Therefore, PLSP is increasingly regarded as a serious clinical problem.

Although PLSP is frequently reported, there are significant limitations in the preventive and management measures used in clinical practice. A thorough analysis of the underlying mechanisms and risk factors for PLSP can provide valuable information for the development of more effective preventive and therapeutic strategies. Therefore, this narrative review comprehensively summarizes the research progress on PLSP and explores the existing challenges in detail to provide valuable references for lowering the incidence of PLSP.

We chose the narrative review format because it is best suited to discuss a wide range of issues from different perspectives. We followed the expert-defined quality criteria for narrative reviews and quantified them using the “Scale for the Quality Assessment of Narrative Review Articles (SANRA).” ⁹ Relevant publications were identified by systematically querying the following sources supplemented by reference lists: PubMed, Google Scholar, Cochrane Library, and China National Knowledge Infrastructure (CNKI). We used a combination of the search terms “post-laparoscopic shoulder pain,” “shoulder pain,” “gynecologic surgery,” “gynecological surgery,” and “gynecologic operation.” References were finally selected after reading the full text. We studied all types of publications (original research, systematic reviews, meta-analyses, narrative reviews, and case reports). When multiple studies reported similar results, we selected the most recent studies that represented the highest methodological quality. No language restrictions were applied.

Clinical features of PLSP in gynecological patients

Shoulder pain is a relatively common complication of gynecological laparoscopic surgery, and its clinical characteristics are distinct from those of other conditions. In terms of the temporal pattern, a large amount of clinical data indicates that up to 95% of patients start to experience shoulder pain symptoms on postoperative day 1, with symptoms rarely beginning on the day of the surgery. In the initial stage following laparoscopic surgery, visceral pain dominates for the first 24 h. The intensity of this pain rapidly peaks but then subsides quickly. ¹⁰ In stark contrast, shoulder pain is typically mild on the day of the surgery and is often overlooked. However, by postoperative day 2, shoulder pain significantly intensifies and becomes very apparent.

PLSP in gynecological patients mainly manifests as dull rather than sharp pain. Moreover, the pain site is vague and difficult to locate accurately. In daily life, shoulder pain intensifies when patients change their body position, such as when they transition from lying down to standing. Conversely, when patients remain at rest and reduce their physical activity, the pain can be alleviated to a certain extent. Notably, among the numerous patients who have undergone gynecological laparoscopic surgery, the PLSP severity often far exceeds that of incision pain and visceral pain. Clinical statistics show that up to 72% of patients do not use opioid drugs for relief from relatively intense PLSP. ³ This may be attributed to various factors, such as patients’ concerns about the adverse effects of opioid drugs or differences in their pain tolerance.

In addition, the temporal characteristics of PLSP differ significantly from those of abdominal pain. Conventional prevention and treatment regimens for incision pain and visceral pain usually involve adjustment of the drug administration timing and dose according to the pain occurrence pattern. However, owing to the unique temporal characteristics of PLSP, the use of a conventional regimen will inevitably lead to a situation where the peak plasma concentration does not coincide with the peak PLSP. ¹⁰ This inconsistency prevents the drug from exerting its optimal therapeutic effect when PLSP is most severe, making it difficult for conventional intervention measures to eff?show $146#?>ectively alleviate PLSP. This has become a key challenge that urgently needs to be addressed in clinical treatment.

Pathogenesis of PLSP in gynecological patients

Despite continuous and in-depth exploration of this subject, the exact pathogenesis of PLSP has not been fully elucidated. At this stage, the most widely accepted theories in the academic community include the following:

Theory of tissue trauma

During the crucial stage of establishing pneumoperitoneum in gynecological laparoscopic surgery, the intra-abdominal pressure increases sharply and extremely quickly. This sudden change in pressure causes the diaphragm to rise as though it has been pushed upward by a powerful force. Simultaneously, the subphrenic dome area passively expands. During this series of mechanical changes, the peritoneum and the diaphragm bear the brunt of the force and are subjected to significant stretching. This intense stretching may trigger a series of complex and interrelated pathophysiological changes.

From a vascular perspective, excessive stretching can damage the structure of the blood vessel wall and cause vascular tearing. If blood vessels are torn, local blood circulation is disrupted, and the normally smooth blood supply is blocked, resulting in tissue ischemia and hypoxia, which affect the normal metabolic function of cells and activate a series of damage-related signaling pathways.

Moreover, tissue damage triggers the body's innate immune response, causing inflammatory cells such as macrophages and neutrophils to rapidly accumulate at the damage site. Once activated, these inflammatory cells release large amounts of inflammatory mediators, such as prostaglandins, bradykinin, and histamine. Of these, prostaglandins lower the threshold of pain receptors, increasing the sensitivity of nerve endings to pain stimuli, while bradykinin directly stimulates nerve endings to produce pain and increase vascular permeability, leading to local tissue edema and further compression of the surrounding nerves, resulting in greater pain. These inflammatory mediators work synergistically on nerve endings, significantly intensifying pain. Finally, nerve conduction can lead to shoulder pain.^1,4,11

Theory of CO₂ stimulation

After laparoscopic surgery, a certain amount of CO₂ that has been used to establish pneumoperitoneum typically remains in the body. Over time, this residual CO₂ is gradually absorbed by the bloodstream through the peritoneum. CO₂ has unique chemical properties and can react with water molecules in the blood to form carbonic acid. The direct consequence of this chemical reaction is a significant decrease in the pH of the local microenvironment of the peritoneum, transforming the initially neutral peritoneal environment into an acidic environment. ¹²

The membrane potential of phrenic nerve cells, which are highly sensitive to pH changes, undergoes noticeable changes upon alterations in the local environment of the peritoneum. This change in potential excites nerve fibers, triggering nerve impulses. In particular, the sensory innervation of the central diaphragmatic pleura and mediastinal pleura in the human body originates primarily from the phrenic nerve (C3–5), while the supraclavicular nerve (C3–4) is responsible for transmitting sensory information from the acromial process area. Owing to some overlap in the spinal cord segments between the phrenic and supraclavicular nerves, when the phrenic nerve is stimulated by the acidic environment and nerve impulses are generated, these impulses travel upward along the nerve conduction pathway to the spinal cord. Owing to the correlation of innervation areas at the spinal cord level, this impulse can be misinterpreted as a sensory signal from the acromial process area. Thus, patients experience pain in the neck or scapular region.^13–15

Risk factors for PLSP in gynecological patients

Through clinical research and practice, numerous risk factors for PLSP in gynecological patients have been identified. The leading causes include the following:

Excessively high CO₂ pressure during pneumoperitoneum

CO₂ pneumoperitoneum must be established during gynecological laparoscopic surgery to ensure a clear surgical field. However, if the pneumoperitoneum pressure is too high, it significantly impacts the tension of the diaphragm. However, the Trendelenburg position (head-down or feet-up) is often adopted during gynecological laparoscopic surgery. In this position, the gravitational force on the diaphragm is superimposed on the pneumoperitoneum pressure, resulting in marked increase in the tension exerted on the diaphragm. Studies have shown that excessively high pneumoperitoneum pressure increases the risk of mechanical damage to the diaphragm, stimulating nerve fibers distributed in the diaphragm area and ultimately increasing the probability of PLSP.^16,17

Excessively rapid CO₂ insufflation rate

When pneumoperitoneum is established, if the CO₂ insufflation rate is too high, a large amount of CO₂ rapidly enters the abdominal cavity, directly and powerfully stimulating the phrenic nerve. This stimulation triggers pain in the neck and shoulders through nerve reflexes. ¹⁸ From a physiological perspective, the diaphragm of women is weaker than that of men. When exposed to a high CO₂ concentration caused by rapid insufflation, the phrenic nerve is more likely to be affected in women than in men. Therefore, female patients are more likely to develop PLSP after laparoscopic gynecological surgery, consistent with the pathogenesis of PLSP. ¹⁹

Excessive residual CO₂ under the diaphragm

After laparoscopic surgery, residual CO₂ gas in the body is another critical risk factor influencing PLSP development.^20,21 Postoperatively, this residual CO₂ gas accumulates near the abdominal wall. When a patient changes their body position, for example, from the supine position to standing, the CO₂ gas shifts under the diaphragm due to gravity and accumulates there, exerting tension on the diaphragm. Moreover, CO₂ has unique chemical properties that allow it to dissolve in water to form carbonic acid, which acidifies the local environment. The phrenic nerve is highly sensitive to pH changes, and stimulation by an acidic environment causes the phrenic nerve to become excited, triggering shoulder pain. ¹⁷ In clinical practice, gynecological patients usually get out of bed and move on postoperative day 2. At this time, the change in body position causes the gas that originally accumulated under the anterior abdominal wall to shift to the lower part of the diaphragm, thereby stimulating the phrenic nerve and triggering PLSP. This finding is consistent with the clinical characteristics of PLSP; pain worsens on postoperative day 2 and is related to changes in body position. ¹

Preventive measures for PLSP in gynecological patients

Surgical prevention

The surgical measures for the prevention and reduction of PLSP occurrence are primarily based on the management of the identified PLSP risk factors, including limiting the pneumoperitoneum pressure and maintaining the CO₂ insufflation rate during the establishment of pneumoperitoneum and removing as much residual CO₂ gas as possible at the end of the operation.^16,22

Using gases as CO₂ substitutes for insufflation

The ideal gas for establishing pneumoperitoneum should meet the following conditions; it should be inexpensive, easily accessible, colorless, nonflammable, nonexplosive, easily excreted, and completely nontoxic. Many gases, such as CO₂, helium, argon, nitrogen, and nitrous oxide, can be used to establish pneumoperitoneum. ²³ CO₂ is already used in gynecological laparoscopic surgery, indicating that it possesses the required qualities such as easy solubility and absorption by the peritoneum, resulting in a relatively low risk of venous or arterial air embolism. Other gases are less soluble than CO₂ and require more time for absorption. Most importantly, the safety of these alternative gases has remained a concern. ¹⁶

Using low pneumoperitoneum pressure instead of standard pneumoperitoneum pressure

Reducing pneumoperitoneum pressure is a potentially effective method for preventing PLSP. ⁴ However, this approach can hinder the establishment and maintenance of the surgical operating space, leading to a poor surgical field, increased surgical difficulty, and possible prolongation of operation time, which can increase the risk of surgical complications. Therefore, low pneumoperitoneum pressure cannot become a standard method for preventing PLSP. ²⁴ Some studies have shown that using low-pressure pneumoperitoneum during gynecological laparoscopy results in a small improvement in pain scores and significantly affects the visualization of the surgical area; however, its safety needs to be determined. ²¹ Hsu et al. ¹⁹ reported that establishing pneumoperitoneum with a low flow rate can reduce PLSP severity but cannot not reduce its incidence.

Using heated or heated and humidified CO₂ gas

The typical temperature of CO₂ used in gynecological laparoscopic surgery is 21°C, with 0% relative humidity. This cold, dry gas may cause hypothermia and postoperative pain or fatigue. Therefore, some researchers have hypothesized that using heated and humidified gas instead of cold and dry gas reduces the PLSP risk. However, a meta-analysis ²¹ on the severity of PLSP after gynecological laparoscopy and the use of postoperative analgesics revealed no significant differences in the incidence, severity, or analgesic requirements of PLSP between patients treated with conventional gas and those treated with heated or heated and humidified gas.

Gasless gynecological laparoscopy

Related studies^16,23 have shown no statistically significant difference in PLSP scores between patients undergoing laparoscopic tubal ligation surgeries not involving gas and those undergoing surgery involving standard pneumoperitoneum pressure. However, compared with simple gas evacuation, active gas aspiration reduces the PLSP intensity, with significant differences noted at 6, 12, and 24 h postoperatively. These findings suggest that stimulation of the diaphragm and phrenic nerve by CO₂ gas is not the only cause of PLSP. It is speculated that PLSP occurrence is related to mechanical traction of the abdominal wall.

Active expulsion of CO₂ gas

To remove as much residual air from the abdominal cavity as possible, the air can be evacuated first with the patient in the Trendelenburg position (head-down and feet-up position) and then in the reverse Trendelenburg position (head-up and feet-down position). The remaining gas can be transferred to the subphrenic area and aspirated using a suction device. Although the results of these studies are inconsistent,^25,26 we still recommend removing as much gas as possible from the abdominal cavity to minimize the residual gas at the end of laparoscopic gynecological surgery. In addition, pressing the abdomen before it is closed to promote CO₂ expulsion from the abdominal cavity may reduce the PLSP severity. ²⁷

Abdominal drainage

Abdominal drainage can be used to effectively drain accumulated blood, fluid, and residual CO₂ gas from the abdominal cavity. However, its effectiveness in reducing PLSP remains controversial. An early meta-analyses ¹⁶ did not support the routine use of drainage tubes after gynecological laparoscopy, suggesting that drainage tubes do not prevent PLSP but increase the wound infection rate and incidence of postoperative abdominal pain. A recent meta-analysis ¹⁸ revealed that abdominal drainage at all time points after surgery is associated with a reduced incidence of PLSP; however, there is insufficient evidence to prove that it reduces the PLSP severity. ²⁴ Therefore, it remains unclear whether the placement of drainage tubes affects PLSP occurrence; more large-sample, multicenter studies are needed for further exploration.

Intraperitoneal fluid irrigation

Irrigation of the abdominal cavity with warm normal saline to remove CO₂ gas is based primarily on the ability of CO₂ to dissolve in water to form carbonic acid. Studies^4,14 have shown that irrigation of the subphrenic area with warm, normal saline can directly reduce the amount of residual CO₂ under the diaphragm and decrease the PLSP incidence in gynecological patients. However, some studies^4,14 have drawn opposite conclusions. Therefore, further in-depth research on this topic is needed.

Lung recruitment maneuver

The lung recruitment maneuver (parallel reaction monitoring (PRM)) involves increasing the positive end-expiratory pressure through manual lung inflation. PRM increases the intrathoracic pressure, which aids in the removal of CO₂ gas from the peritoneal cavity. It does not require additional equipment or drugs and is considered one of the most promising interventions for relieving PLSP. ²⁸ Taş et al. ²⁹ proposed PRM with a pressure of 40 cmH₂O as a simple, cost-effective method to alleviate shoulder pain after gynecological laparoscopy for benign diseases. Although PRM is simple to perform, it is associated with risks in patients with bullae or other severe lung diseases, and its effectiveness is controversial. Güngördük et al. ³⁰ reported that lung recruitment can significantly reduce the PLSP severity; however, some studies ⁴ have shown that PRM has no apparent ability to reduce the incidence or severity of PLSP.

Nursing-related preventive strategies

Relatively few nursing studies have focused on the prevention or alleviation of PLSP in gynecological patients. In contrast, domestic research on nursing is relatively abundant, and the recommended intervention methods are diverse, spanning the entire perioperative period. ³¹ During the preoperative stage, nursing care focuses on individualized psychological support. ³² By conducting in-depth communication with patients, obtaining an understanding of their psychological states, and providing targeted psychological support and counseling, the fear and anxiety of patients regarding surgery and postoperative pain can be alleviated, laying a good psychological foundation for postoperative rehabilitation.

Intraoperative nursing involves several key aspects. Attention is paid to improving the surgical position, and shoulder supports are appropriately used ³³ to relieve pressure from the patients’ shoulders caused by long-term fixation in the surgical position.^25,34 In addition, the nursing team actively cooperates with the doctor to minimize pneumoperitoneum pressure. Ensuring a clear surgical field helps minimize the potential adverse effects on patients caused by excessively high pneumoperitoneum pressure. In addition, nursing staff closely cooperate with the surgeon, accurately and efficiently transferring surgical instruments to shorten the operation time and reduce the body’s intraoperative stress response.

Postoperative nursing interventions are more diverse. In terms of exercise therapy, patients are encouraged to become ambulatory as early as possible. They are guided to perform exercises, such as breathing and rehabilitation exercises, and adopt the knee-chest and hip raising positions. These exercises help promote blood circulation and improve diaphragm function, which can alleviate postoperative shoulder pain to a certain extent.^35–37 Traditional Chinese medicine (TCM) therapies, such as massage, acupuncture, moxibustion, and auricular seed application, are also widely used. Employing the unique TCM theory of meridians and qi-blood, the qi-blood circulation of the human body can be regulated to help relieve pain. In Western medicine, analgesic measures such as dezocine directly act on the nervous system to relieve pain symptoms. Oxygen therapy, including long-term, short-term, and intermittent oxygen therapy, is implemented to increase the oxygen supply in the body and prevent the increase in pain sensitivity caused by factors such as hypoxia. In addition, comprehensive nursing interventions that combine exercise, TCM, and oxygen therapy use multiple approaches simultaneously to enhance the benefits of nursing care.

These nursing measures have been used to relieve postoperative shoulder pain to varying degrees, effectively improve the medical treatment experience, and prevent serious complications related to postoperative shoulder pain. However, these measures cannot fully alleviate PLSP. Cooperation among research groups and institutions is relatively weak in the field of nursing research. In the future, attention should be focused on research hotspots and cutting-edge trends, and active efforts should be made to strengthen cooperation among regions, research groups, institutions, and medical colleges. Multicenter studies can be performed to explore more effective nursing strategies to prevent PLSP and enhance the surgical treatment experience.

Drug prevention

Pharmacological drugs can ameliorate PLSP in gynecological patients, primarily by inhibiting the initiation and transmission of pain signals.

Anti-inflammatory drugs are widely used to inhibit the initiation of pain signals. They block the generation of pain signals by regulating the release of inflammatory mediators in the body. Moreover, local anesthetic drugs such as ropivacaine can be applied to the diaphragm surface where they act directly on nerve endings to inhibit the conduction of pain information. Intraperitoneal instillations of additional dexmedetomidine, clonidine, or bupivacaine can also exert local anesthetic effects and block the transmission of pain signals. Intraoperative levobupivacaine local infiltration anesthesia may exert postoperative analgesic effects comparable to those of transversus abdominis plane block in gynecologic laparoscopy. ³⁸ In addition, intraperitoneally administered hydrocortisone can effectively block pain signal transmission through local anti-inflammatory effects. Methods such as acupuncture combined with intravenous injection of parecoxib and intrathecal administration of drugs have also been explored as pharmacological treatments for PLSP prevention. These methods regulate the function of the nervous system through different pathways, increasing the pain threshold, and thereby relieving PLSP. These measures are often combined in practical applications to enhance the analgesic effect. Although analgesic drugs can relieve PLSP to a certain extent, compared with their analgesic effect on incision pain, their impact on PLSP is relatively limited. The effectiveness of these drugs in preventing and treating PLSP requires further in-depth research.^3,12,15,19 Moreover, although these drugs can relieve PLSP, they may also cause other postoperative complications, such as postoperative nausea and vomiting. These adverse effects have prompted researchers to actively explore nonpharmacological methods for PLSP treatment.^26,39

Kaloo et al. ⁴⁰ showed that the effect of pain relief for PLSP in patients undergoing gynecological laparoscopic surgeries at different sites varies depending on whether ropivacaine is administered as a local anesthetic at the trocar puncture site or sprayed intraperitoneally. Specifically, its effect in patients undergoing tubal–ovarian surgery was better than that in patients undergoing uterine surgery, with poor efficacy in patients undergoing gynecological laparoscopic surgeries involving pelvic ectopia. This highlights the limitations of this method. Therefore, further research is needed to conduct in-depth exploration on the pathogenesis of PLSP to aid the development of more precise and effective pharmacological prevention strategies.

We have summarized the quality and outcomes of various preventive measures in Table 1.

Table 1.

A summary of the quality and outcomes of various preventive measures.

Intervention categories	Specific measures	Level of evidence	Outcomes
Surgical prevention	Using gases as substitutes for CO2 for insufflation	High	The evidence is very uncertain regarding the effects of nitrous oxide, helium, and room air pneumoperitoneum compared with those of carbon dioxide pneumoperitoneum on any primary outcome, including cardiopulmonary complications, surgical morbidity, and serious adverse events. The safety of nitrous oxide, helium, and room air pneumoperitoneum has not been established, particularly in populations at higher anesthetic risk.
	Using low pneumoperitoneum pressure instead of standard pneumoperitoneum pressure	Medium	It may reduce the severity of PLSP; however, the effect on incidence rate is uncertain; low pressure may affect surgical field exposure.
	Gasless gynecological laparoscopy and active expulsion of CO2 gas	Medium	Although the results are inconsistent, we still advocate the removal of as much intraperitoneal gas as possible to minimize the amount of residual gas at the end of laparoscopic surgery.
	Abdominal drainage	Low	Early evidence suggests that it is ineffective and increases infection rates; recent analyses suggest that it reduces infection rates; however, the evidence remains weak. Its effect on pain severity is unclear.
	Intraperitoneal fluid irrigation	Low	Study conclusions are conflicting, and higher-quality research is needed to definitely determine its effectiveness.
	Lung recruitment maneuver	Low	The study conclusions are conflicting. Some suggest a reduction in severity, while others show no significant effect. The procedure is contraindicated (e.g. with bullae).
Nursing-related preventive strategies	Preoperative psychological support and education	Medium	It is widely believed to improve patients’ overall experience and pain perception; however its specific effects on PLSP are difficult to quantify.
	Intraoperative positioning optimization and shoulder support	Medium	Considered a good standard of practice and helpful in reducing posture-related shoulder pain.
	Early postoperative mobilization and positioning adjustments	Medium	Observational studies support its effectiveness, and it is part of primary postoperative care.
	TCM techniques (acupuncture, massage, and auricular acupuncture)	Medium	Systematic reviews suggest that it is effective; however, more rigorously designed international RCTs are needed to validate its effects and standardize the protocol.
Drug prevention	Local anesthetic (intraperitoneal spray/infiltration), NSAIDs, and other intraperitoneal drugs	Medium	The effects are inconsistent and may depend on the type of surgery. The effectiveness of drugs in preventing and treating PLSP need further research.

NSAIDs: nonsteroidal anti-inflammatory drugs; RCTs: randomized controlled trials; PLSP: post-laparoscopic shoulder pain; TCM: traditional Chinese medicine.

Discussion

In gynecological patients, PLSP development is a common and non-negligible problem encountered in clinical practice, with a comprehensive and profound impact on the physical and mental health of patients. Physically, the pain caused by PLSP interferes with the normal activities of patients postoperatively and slows down the recovery of physical functions. Psychologically, persistent pain causes patients to experience negative emotions such as anxiety and irritability and may even trigger psychological stress responses, severely affecting their emotional states and psychological adjustment, thereby significantly reducing their postoperative quality of life.

The pathogenesis of PLSP has not yet been fully clarified. It is generally accepted in the academic community that multiple factors interact to jointly contribute to its development. In terms of tissue trauma, the sudden change in intra-abdominal pressure during pneumoperitoneum establishment causes the diaphragm to rise and the subphrenic dome to expand. This results in stretching of the peritoneum and diaphragm, triggering blood vessel tearing, nerve pulling, and release of inflammatory mediators, which generate pain signals. CO₂ stimulation is also a crucial factor. The postoperative residual CO₂ is absorbed into the blood to form carbonic acid, which reduces the pH of the peritoneum and stimulates the phrenic nerve. Overlap of the phrenic and supraclavicular nerves in the spinal cord segments eventually leads to shoulder pain. The surgical position should also be considered. The Trendelenburg position, which is commonly used in gynecological laparoscopic surgery, exerts greater tension on the diaphragm. Coupled with muscle relaxation under anesthesia, it is more likely to trigger PLSP. In addition, individual differences in patients, such as the relatively weaker diaphragm of women, increase their vulnerability to stimulation during pneumoperitoneum, raising the risk of PLSP.

Given the complex pathogenesis of PLSP, no single preventive or therapeutic measure is fully effective. Surgical prevention methods, such as limiting the pneumoperitoneum pressure, adjusting the CO₂ insufflation rate, using alternative gases, and actively expelling residual CO₂ gas, have been explored. However, these methods often involve disadvantages, such as their impact on the surgical field, uncertain safety of alternative gases, and unstable gas removal effect. Nursing interventions, ranging from preoperative individualized psychological care, intraoperative improvement of the surgical position, and shoulder support protection to postoperative exercise therapy, TCM therapies, oxygen therapy, and comprehensive nursing interventions, alleviate pain to a certain extent. However, they cannot eliminate the underlying causes. Pharmacological approaches include the use of anti-inflammatory, local anesthetic, and intra-abdominal drugs. However, the analgesic effect of these drugs on PLSP is weaker than that on incision pain, and they involve adverse effects such as postoperative nausea and vomiting.

Therefore, more medical researchers and practitioners need to urgently focus on PLSP. This review has certain limitations. It is necessary to perform more clinical trials; conduct multicenter, large-sample studies; accumulate more abundant data; and analyze the pathogenesis and factors influencing PLSP from different perspectives to clarify the interactive relationships among various factors. Furthermore, with the help of more advanced strategic algorithms, such as big data analysis and artificial intelligence models, the existing clinical data and patient characteristic data can be deeply mined and analyzed to explore more scientifically valid and reasonable management plans corresponding to the temporal characteristics of PLSP (such as pain onset time, pain peak time, and pain duration). This can facilitate the development of more effective preventive measures, help alleviate PLSP, allow rapid patient recovery, improve postoperative patient satisfaction, and provide strong support for further optimization and improvement of laparoscopic gynecological surgery.

Summary

We systematically reviewed the clinical characteristics, pathogenesis, risk factors, and multidimensional preventive measures for gynecological laparoscopic PLSP, covering all aspects from surgery and nursing care to pharmacological interventions. This comprehensive article offers clinical guidance; it not only emphasizes the significant impact of PLSP on patient recovery, psychological well-being, and quality of life but also, based on recent advances, introduces emerging interventions such as low-pressure pneumoperitoneum, lung recruitment maneuvers (PRM), and heated humidified gas, highlighting the value of implementing cutting-edge research to alleviate pain and improve patient quality of life in gynecological surgery.