© FD-Communications Inc. Obesity Surgery, 15, 2005 1
Obesity Surgery, 15, pp-pp
Background: Shoulder-tip pain is commonly reported
following laparoscopic adjustable gastric band (LAGB)
placement.The incidence, nature and factors that may
increase the risk of pain have not been explored.
Methods: A prospective extensive collection of
patient characteristics and operative details was
obtained from consecutive patients having band
placement for severe obesity. Postoperatively, the
presence and characteristics of shoulder pain were
obtained using a structured interview at discharge
from hospital, and at 1 and 5 weeks after placement.
Results: 66% and 21% of patients at 1 and 5 weeks
respectively following surgery reported pain predom-
inantly in the left shoulder. At 5 weeks, only 7% found
the pain of concern and 5% required analgesics.
There were no factors found that predicted the pres-
ence and severity of pain at 1 week. Injury to the crus
of the diaphragm (OR 4.2, 1.4-12.6, P=0.01) and a past
history of any upper abdominal surgery (OR 4.2, 1.5-
11.7, P=0.007) independently predicted an increased
risk of pain at 5 weeks.
Conclusion: Shoulder pain following LAGB surgery
is common, usually affects the left shoulder, and can
in some cases last 5 weeks or more. Avoiding injury
to the crura during the procedure may prevent more
laparoscopy, gastric band, shoulder, diaphragm, bleeding,
Pain, postoperative, morbid obesity,
Shoulder pain is a common complaint following
laparoscopic surgery, initially being recognized by
gynecologists during early experience with laparo-
scopic sterilization.1The incidence varies, but is
common, being experienced in approximately one-
third of patients following laparoscopic cholecys-
tectomy,2,3while it is more frequent following
Nissen fundoplication.4The pain usually lasts 2-3
days and is relieved by simple analgesics such as
paracetamol and codeine.5Several causes of shoul-
der pain following laparoscopic surgery have been
suggested: the effect of CO2gas,6peritoneal stretch-
ing, diaphragmatic irritation, diaphragmatic injury,
and even shoulder abduction during surgery.7
A number of studies have looked at methods to
reduce the incidence and severity of shoulder pain
following laparoscopic surgery. Methods investigat-
ed include: low-pressure insufflation,3slow rate of
gas,11,12pre-emptive anti-inflammatory medica-
tion,13pre-emptive diaphragmatic local anesthetic
suction,17and regional anesthesia to peritoneal sur-
faces in the operative area.14,18,19Unfortunately,
studies have often found quite varied and sometimes
conflicting results regarding the effectiveness of
these interventions. This may be related to the vari-
ety of procedures performed and a wide variety of
study methodologies used.
Laparoscopic bariatric surgery is being performed
frequently as a response to the obesity epidemic and
Shoulder Pain is a Common Problem Following
Laparoscopic Adjustable Gastric Band Surgery
John B. Dixon, MBBS, PhD;Yigal Reuben, MBBS; Christine Halket, RN;
Paul E. O’Brien, MD
Australian Centre for Obesity Research and Education, Monash Medical School, The Alfred
Hospital, Melbourne, Australia
Presented at the 10th World Congress of the International
Federation for the Surgery of Obesity, Maastricht, The
Netherlands, September 1, 2005.
Reprint requests to: Dr. John Dixon, Australian Centre for
Obesity Research and Education, Monash Medical School, The
Alfred Hospital, Melbourne, Victoria, Australia 3004. Fax: 61 3
9510 3365; e-mail: firstname.lastname@example.org
Property of FD-Communications Inc. Not for posting, reproduction or distribution.
improved safety and efficacy of surgery,20,21and is
now the commonest laparoscopic procedure per-
formed by the luminal upper GI surgeon.
Laparoscopic adjustable gastric banding (LAGB)
surgery has rapidly become one of the most utilized
forms of bariatric surgery and has proven to be effec-
tive and very safe.22This surgery has been shown to
achieve between 50 and 60% excess weight loss at 3
years and thereafter following surgery, a result com-
parable with Roux-en-Y gastric bypass, but with
approximately one-tenth the peri-operative mortali-
ty.23We have noted that while peri-operative prob-
lems are uncommon,22shoulder pain following sur-
gery is common and at times presented a significant
problem in the weeks following surgery. The prob-
lem of shoulder pain following LAGB surgery has
not to our knowledge been explored. Indeed, we
have been unable to find any report directly address-
ing the problem of shoulder pain after any form of
laparoscopic bariatric surgery.
The aim of this prospective study was to examine
incidence, nature, severity and impact of shoulder pain
following LAGB surgery. In addition, we have under-
taken an extensive prospective collection of anesthetic
and operative data to look for factors that may predis-
pose to more severe or prolonged shoulder pain.
Data regarding demographics, anthropometry, past
abdominal surgery and co-morbidity were obtained
during a preoperative assessment period. Extensive
information was collected for the purposes of this study
at the time of LAGB placement,to look for associations
with postoperative shoulder pain. There was no specif-
ic intervention or change in usual practice during the
duration of the study. Informed written consent was
obtained from all patients, and the study was conduct-
ed in conformance with the Helsinki Declaration.
One surgeon placed all LAGBs (PEO) using the pars
flaccida dissection pathway. Data regarding putative
operative factors that may influence pain were col-
lected using standard data collection sheets. These
factors included: primary or revisional procedure,
associated procedure, length of procedure, duration
of insufflation, CO2volume insufflated, the extent
and site of any bleeding, type of Lap-Band®(Inamed
Health, Santa Barabara, CA, USA) placed, tightness
of the band when closed, dissection to reduce fat
along the band pathway, injury to the left crus during
greater curve dissection in the area of the angle of
His, injury to the right crus during lesser curve pars
flaccida dissection, difficulty in passage of the Lap-
Band®placer behind the stomach, and whether a
liver biopsy was taken. Insufflation rate, temperature
and pressures were not altered throughout the study.
Standard data collected included ASA classifica-
tion, premedication, all agents used during the pro-
cedure including nature and dose of intra-operative
analgesics. Non-steroidal anti-inflammatory or
cyclooxygenase II inhibitor medications were given
to all subjects for pre-emptive analgesia unless there
was a contraindication.
Data regarding shoulder pain was collected on 3
occasions: first, on discharge from hospital when
data regarding pain during the hospital stay and use
of postoperative analgesic usage was obtained from
the patient and the patient's chart. In addition, infor-
mation on current pain status at the time of dis-
charge was obtained. A nurse facilitator (CH) col-
lected this information from the patient in a standard
way during a structured interview.
Second, all patients were phoned and interviewed
by a physician (YR) at 1 and 5 weeks following
band placement. Details of the pain site(s), frequen-
cy, severity, aggravating factors, relieving factors
and analgesic usage were obtained using a standard-
ized structured interview technique.
Pain of interest was in the region of the shoulders
– right, left or both. Pain frequency was occasional,
intermittent (<50% of time), often (>50% of time)
or constant (0-4). Severity was mild when no anal-
gesics were required, mild with occasional use of
analgesics, moderate requiring regular analgesics,
severe but relieved by analgesics, and severe not
adequately relieved by analgesics (0-5).
Aggravating factors specifically questioned included:
Dixon et al
2 Obesity Surgery, 15, 2005
deep breathing, eating, drinking, generalized move-
ment, and specific shoulder movement. Relieving fac-
tors specifically questioned included: simple anal-
gesics, lying down, standing, movement, local applica-
tion of heat and peppermint. Additional factors aggra-
vating or relieving the pain were also sought.
Patient characteristics were described as mean ±
standard deviation. The prevalence, type and dura-
tion of pain were expressed in percentages of the
total patient group. The study was planned to
include at least 80 subjects, because this allowed us
to detect clinically relevant associations explaining
up to 4% of variance, r =0.2 at 0.05 level and 10%
variance, r =0.32 at 0.001.
Spearman correlation coefficients were used to
assess correlation between patient, anesthetic, and
operative factors, and the duration and severity of
pain at 1 week and the presence of pain at 5 weeks.
Ordinal and binary logistic regression was used to
assess the effect and independance of multiple vari-
ables on pain at 1 and 5 weeks. Odds ratios (OR) and
95% confidence limits (CI) are provided for factors
found to be associated with shoulder pain. A P-value
of <0.05 is considered significant, and no correction
has been made for multiple factors assessed simulta-
neously because we may lower the opportunity to
find potentially clinically relevant associations.
Eighty-seven consecutive patients (24M, 63F) hav-
ing primary (n=75) or revisional LAGB (n=12) sur-
gery were followed for 5 weeks after band place-
ment. The mean age, weight and BMI of this group
were 43.6 ± 10 years, 123.1 ± 21 kg and 44.3 ± 8
Incidence and Nature of Shoulder Pain
The majority of patients experienced pain in one or
both shoulders during the week following LAGB
surgery. Pain was most commonly experienced in
the left shoulder alone, less frequently in both, and
rarely in the right only (Table 1).
Factors that aggravated or relieved the pain are
shown in Table 2. Pain was sometimes aggravated by
eating, drinking or was associated with breathing, and
most commonly relieved by simple analgesics, lying
down or placing a hot pack on the affected shoulder.
Pain was still experienced by 21% of patients at 5
weeks, but only 7% found it a concern and only 4
patients (5%) required occasional oral analgesics.
Pain at 1 Week Following Surgery
Two-thirds of all patients experienced pain at 1
week after surgery. Each patient's score for frequen-
cy (0-4) and severity of pain (0-5) were added to
give a combined pain score (0-9). The median score
was 1 (interquartile range =3). The subjects were
LAGB and Shoulder Pain
Obesity Surgery, 15, 2005 3
Table 1. Prevalence, frequency and site of pain following LAGB surgery
In hospital On DischargeAt 1 week At 5 weeks
Of concern to patient
Often >50% of the time; Intermittent <50% of the time.
divided into 3 groups; no pain (n=35), a score of 1-
3 (n=34) and a score >3 (n=18). Using ordinal logis-
tic regression, there were no predictors of the pain
score at 1 week following surgery. There were no
features directly related to the surgery that were
associated with pain at 1 week. In a similar way, the
subjects were divided into two groups: those with a
score of 0 and 1, which is at or below the median
score (n=47), and those scoring >1 (n=40). Binary
logistic regression was used and again no predictors
could be found. Those with pain at 1 week were
more likely to continue to have pain at 5 weeks.
Shoulder pain score at 1 week was not associated
with an increased length of hospital stay.
The complaint of right-sided pain was unusual.
Only 8 patients (9%) reported right-sided shoulder
pain at 1 week following surgery: 2 reported pain in
the right shoulder alone and in 6 in both shoulders.
There were 2 factors found to increase the risk of R-
sided or bilateral pain. First, these 8 patients were
more likely to have had more than trivial bleeding
during the procedure although the site of bleeding
was not a significant influence; 23% of those who
had some blood removed during the procedure (24%
of all patients) either by simple swabbing or suction,
had R-shoulder pain, while only 4.5% of the remain-
der had R-shoulder pain (P=0.008, OR 6.6, 95%CI
1.4-30). In this series, there were no cases of bleed-
ing that were a significant surgical problem.
Second, a history of previous upper abdominal
surgery, cholecystectomy (n=17) and Nissen fundo-
plication (n=1), also appeared to increase the risk of
right shoulder pain (P=0.032, OR 4.6 95%CI 1.04-
20). However, it was not seen more often in those
having revisional Lap-Band®surgery.
These had combined effects with an R2of 0.114
(Cox and Snell), P=0.005. Two percent of those
with no risk factor, 16% of those with one risk fac-
tor, and 50% of those with both risk factors experi-
enced right shoulder pain at 1 week.
Factors Associated with Persistent Pain
at 5 Weeks
Of the extensive preoperative and peri-operative
data collected, there were few factors that were
associated with the persistence of pain at 5 weeks
after surgery (n=18 of 87). There was no significant
Dixon et al
4 Obesity Surgery, 15, 2005
Table 2. Number of patients reporting factors that aggravate and relieve pain, and simple analgesic usage at
1 and 5 weeks following surgery
Pain at 1 week (n=57)
Pain at 5 weeks (n=18)
Aggravated by Nothing noted
Others Raise arms
Not controlled by analgesics
association between persistent pain and the patient's
age, sex, weight and BMI. Using binary logistic
regression, two factors were found:
1) A history of previous upper abdominal surgery:
14 patients had a history of previous surgery in the
area of the gastroesophageal junction – 13 LAGB
revisions for slippage and one Nissen fundoplica-
tion. Six (36%) had pain at 5 weeks (OR 4.0,
95%CI 1.1-14.3, P=0.03) when compared with
those who had never had previous abdominal sur-
gery. However, 14 patients having primary LAGB
surgery had a history of open or laparoscopic
cholecystectomy, and 7 (50%) experienced pain at
5 weeks (OR 5.7, 95%CI 1.6-20.0, P=0.007).
Those with any history of previous upper abdom-
inal surgery have an increased likelihood of pain
at 5 weeks (OR 4.2, 95%CI 1.5-11.7, P=0.007).
2) Injury to the crus of the diaphragm during dis-
section near the angle of His: 7 of 42 (16.2%) with
no observed injury, 5 of 26 (19.7%) with a minor
pull, tug or bleeding, and 9 of 19 (47.4%) with a
significant injury as a result of bleeding, muscle
tear or concurrent crural repair for hiatal hernia
experienced pain at 5weeks. The odds ratio for
pain with significant crural injury on the left hand
side is OR 4.2, 95%CI 1.4-12.6, P=0.01.
These two factors provided independent effect when
modeled together (Cox and Snell R2=0.15, P=0.001).
Moreover, 11% of those with no risk factor, 33% of
those with one risk factor,and 71% of those with both
risk factors experienced pain at 5 weeks.
This prospective study shows that shoulder pain pre-
dominantly on the left side occurs in the majority of
patients following the laparoscopic placement of an
adjustable gastric band. Importantly, most patients
still experienced pain 1 week following placement,
which contrasts with most reports indicating that the
pain usually resolved within 2-3 days. Most studies,
however, have only examined the immediate post-
operative period and it is possible that a description
of more prolonged discomfort has not been sought.
Indeed, most studies of interventions designed to
reduce shoulder pain have examined the first 24-48
hours only.2-4,15,16,23A recent study by Bisgaard et
al24did examine a longer period and found that 38%
and 25% of patients having a Nissen fundoplication
had shoulder pain at 7 and 30 days following sur-
gery respectively. These findings are consistent with
ours; we found 66% and 21% experienced some
shoulder pain at 1 and 5 weeks respectively. It
would seem that surgery in the region of the gastro-
esophageal junction may be not only associated
with a higher incidence of shoulder pain, but also in
some cases a more prolonged period of pain.
It is interesting that the predominant shoulder
where pain is experienced following LAGB surgery
is the left; in contrast, following laparoscopic chole-
cystectomy it is the right. This difference suggests
that the region of surgery has an important influence
on the site of pain and that the development of the
pneumoperitoneum is not the only factor producing
shoulder pain immediately following surgery.14,25
This study has found two factors associated with
more prolonged pain (5 weeks) following LAGB
placement. These are a history of previous upper
abdominal surgery and injury to the crura during the
procedure. While the first of these is unavoidable,
the second can be potentially addressed by careful
dissection techniques to reduce the risk of crural
damage during LAGB placement. During dissection
on the greater curvature side, care should be taken to
avoid crural injury during exposure of the angle of
His, while on the lesser curvature side using the pars
flaccida technique the initial dissection should com-
mence 2-3 mm to the left of the right crus to avoid
crural damage. Placement of an instrument behind
the stomach should be performed gently to avoid
injury to both the esophagus and the crura.
Previous upper abdominal surgery including
laparoscopic cholecystectomy appears to increase the
risk of more prolonged pain and right shoulder pain
following surgery. A weakness of the present study is
the possibility that an error of association has been
made because no adjustment was made for the multi-
ple factors assessed. On the other hand, it would be
important to find any factors that may provide an
opportunity for intervention. Injury to the cura and its
association with more prolonged pain, and bleeding
during the procedure leading to a higher risk of right
shoulder pain or bilateral pain, provide associations
that may have both plausible explanations and pro-
vide useful information to the surgeon.
LAGB surgery has the potential to revolutionize
LAGB and Shoulder Pain
Obesity Surgery, 15, 2005 5
bariatric surgery. The operation is safe and effective,
with a surgical technique that is standardized, repro-
ducible and widely available. The procedure can be
performed by well-trained upper GI surgeons and is
not as technically demanding as Roux-en-Y gastric
bypass. This procedure also provides the opportunity
for day stay bariatric surgery.26Given these consider-
ations, there is a real need to study ways to minimize
the discomfort experienced by the patient following
LAGB placement. We find that the shoulder pain is
often more a concern than either visceral or wound
pain following LAGB placement. There is a need to
study ways of preventing this common problem: CO2
insufflation rates,8temperature11,12and pressures,27
pre-emptive anti-inflammatory or analgesic medica-
tions,13and pre-emptive long-acting local anaesthesia
to the operative area and diaphragm should all be
assessed.4,15,16,28-30These interventions should ideally
be assessed using randomized controlled trials, and
not be limited to an assessment of the 2-3 days fol-
lowing surgery,but should include the full duration of
pain experienced. It would be important to see if suc-
cessful pre-emptive measures influence pain follow-
ing the first postoperative week.
In conclusion, shoulder pain following LAGB
surgery is common, usually affects the left shoulder,
and can in some cases last for 5 weeks or more.
Avoiding injury to the crura during the procedure
may prevent more prolonged pain. A series of stud-
ies is required to explore measures to prevent or
minimize shoulder pain resulting from this now
well-standardized bariatric surgical procedure.
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LAGB and Shoulder Pain
Obesity Surgery, 15, 2005 7