Strategies for prevention and management of post-operative shoulder tip pain following laparoscopic cholecystectomy: a narrative review of intraperitoneal and local interventions

Post-operative shoulder tip pain remains a frequent and distressing complication following laparoscopic cholecystectomy, despite the minimally invasive nature of the procedure. This pain, distinct from incisional or visceral discomfort, is primarily attributed to diaphragmatic irritation and phrenic nerve stimulation caused by carbon dioxide pneumoperitoneum and residual intraperitoneal gas. A wide range of preventive and therapeutic strategies have been investigated to address this problem. This narrative review synthesizes evidence from randomized controlled trials, meta-analyses, and clinical studies evaluating mechanical, non-pharmacological, and pharmacological interventions aimed at reducing shoulder tip pain. These include low-pressure pneumoperitoneum, active gas evacuation techniques, intraperitoneal instillation of local anesthetics, alkalinizing agents such as sodium bicarbonate, and various adjuvant analgesics. The reviewed evidence suggests that no single intervention is universally effective; rather, a multimodal approach combining mechanical optimization and intraperitoneal pharmacologic strategies offers the greatest benefit. Further standardized, comparative trials are needed to establish optimal protocols for routine clinical practice.