# Shoulder pain after laparoscopic antireflux surgery: a single-center, randomized, open-label trial

## TL;DR

This study found that injecting bupivacaine during antireflux surgery reduced postoperative shoulder pain and opioid use, while back massagers did not help.

## Contribution

The study introduces bupivacaine instillation as an effective strategy to reduce opioid use and postoperative shoulder pain after antireflux surgery.

## Key findings

- Bupivacaine instillation reduced opioid use compared to standard care and back massagers.
- Shoulder pain was most common in the first hour after surgery, with bupivacaine showing the lowest incidence.
- Back massagers did not significantly reduce pain or opioid use in postoperative patients.

## Abstract

Post-laparoscopic shoulder pain (PLSP) is a significant source of postoperative morbidity after hiatal hernia repair and antireflux surgery. We evaluated whether adjunctive pain relief strategies—instillation of 0.25% bupivacaine over the left hemidiaphragm or postoperative back massager use—reduced opioid use or pain severity after laparoscopic antireflux surgery (LARS).

This single-center, randomized, open-label trial included patients who underwent elective primary LARS between May 2021 and April 2024. Participants were randomly assigned (1:1:1) to one of three groups: A, standard medication regimen; B, standard + intraoperative instillation of 0.25% bupivacaine over the left hemidiaphragm; or C, standard + back massager use. Primary outcomes included overall pain and postoperative use of opioids. The secondary outcomes were pain frequency and severity by anatomical location. Assessments were performed 1, 3, 6, 24, 72, and 168 h after surgery. This trial was registered (ClinicalTrials.gov: NCT04936711) and is now complete.

Forty-three patients were randomized to groups A (n = 16), B (n = 10), and C (n = 17). One had a postoperative complication, and four were excluded (missing data: n = 2, incorrect massager use: n = 2), leaving 38 per-protocol patients (A: 16, B: 9, C: 13). The median age was 66 years (IQR 57–69), median BMI 28.4 kg/m2 (IQR 25.5–31.2), and 68.4% were female. Incidence of PLSP within 7 days was 97.6%. Overall, 84.2% required opioids with the lowest use in group B (A: 100%, B: 55.6%, C: 84.6%; p = 0.014). Group B also had lower rates of PLSP at 1 h (A: 75%, B: 44.4%, C: 88.2%; p = 0.025) as well as any pain at 3 h (A: 81.3%, B: 66.7%, C: 100%; p = 0.049).

PLSP is very common after LARS. Intraoperative bupivacaine instillation at the diaphragm reduced opioid use and pain severity in the immediate postoperative period, while back massagers provided no additional benefit.

The online version contains supplementary material available at 10.1007/s00464-025-11939-3.