Reply to: postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum.

3 to 4), good operation conditions and reduction of shoulder pain could also be achieved by using low-pressure pneumoperitoneum (<10 mmHg). In contrast to Madsen et al., a trial in laparascopic cholecystectomy demonstrated a success rate of just 60% in finishing surgical procedures with low-pressure pneumoperitoneum (8 mmHg) and deep neuromuscular block (posttetanic count 1). They found no significant difference in outcome parameters (postoperative pain, oxycodone consumption, time delay to normal activity, nausea). The authors concluded that deep versus moderate neuromuscular block (actually shallow neuromuscular block in the study) improved surgical space conditions just marginally during low-pressure laparoscopic cholecystectomy. In accordance with these results, Madsen et al. also identified no difference in the area under the curve of visual analogue scale ratings of shoulder pain, incisional pain, lower abdominal pain and overall pain for 4 and 14 days. Furthermore, opioid use and other recovery parameters were not different between deep neuromuscular blockade with low-pressure pneumoperitoneum and moderate neuromuscular blockade with standard-pressure pneumoperitoneum. They found only a significant reduction in the incidence of shoulder pain during the 14 days after laparoscopic hysterectomy in the group with low-pressure pneumoperitoneum. The authors judged the pain ratings of less than 20/100 on the visual analogue scale as clinically not relevant. If the scaling of the mean shoulder pain ratings in Figure 2 is correct, the shoulder pain (mean visual analogue scale <14) would have been irrelevant across the whole observational period (14 days) in both the groups. Furthermore, it is unexpected that in the group with moderate neuromuscular blockade, an estimated 2 to 3% of the patients reported on shoulder pain on days 11 and 12 (see Figure 3 in the original article), on days 7 to 10 nobody indicated shoulder pain. Was there another origin of shoulder pain? For daily clinical practice, we should also recall the possible role of the duration of surgery in the development of postoperative shoulder pain after laparoscopic interventions and the possible prolongation of laparoscopies using low-pressure pneumoperitoneum in the hand of inexperienced surgeons.