VOLTAREN APPLICATION TO SHOULDERS AND ARM EXERCISES TO DECREASE PAIN AND THE NEED FOR POSTOPERATIVE OPIOIDS FOLLOWING LAPAROSCOPIC HIATAL HERNIA REPAIR
Anthony Basta1, Joshua Haag*1, Megan Mai1, Raymar Turangan1, Andre Miller2, Farzaneh Banki1,3
1The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 2Memorial Hermann Health System, Houston, TX; 3Memorial Hermann Southeast Esophageal Disease Center, Houston, TX
Introduction: Shoulder pain after laparoscopic hiatal hernia repair can result in significant discomfort. Our aim was to assess the application of Diclofenac Sodium (Voltaren) to shoulders, and arm exercises to reduce postoperative shoulder pain and need for opioids following laparoscopic hiatal hernia repair. Methods: Tylenol IV was given to all. Pain scores were documented on arrival to the PACU. Voltaren application to shoulders/Exercise of arms (VE) was started on 03/01/2022. The protocol included 4 doses of Voltaren application to both shoulders by post-operative nurses. The first 2 doses: in PACU, each followed by 5 abductions of both arms devised by our physical therapist. 2 more doses: in predischarge unit, each followed by 5 abductions of both arms. Pain scores were documented before and 30 minutes after each VE application. Pain scores on arrival to the PACU and prior to discharge from the predischarge unit, and the need for opioids were compared in patients in whom Voltaren and arm exercises were not applied (N0-VE) vs.VE group. Toradol was given in the PACU to all patients ≤70 years with normal kidney function. All had opioid-free anesthesia. Postoperative nurses were asked if VE improved postoperative shoulder pain. Results: From 06/18/2021 to 09/30/2022, there were 152 hiatal hernia repairs in 151 patients. There were 121/152 (79.6%) primary and 31/152 (20.4%) reoperative, 81/152 (53.3%) were No-VE. VE was planned in 75/152 (49.3%) and was applied in 71/152 (46.7%). There was no difference in age/sex/BMI/size/ type of hiatal hernia and operative time between the No-VE vs.VE groups. Need for opioid medication in PACU and in the discharge unit: No-VE vs.VE: 66/81 (81.5%) vs. 30/71 (42.3%), p<0.001. Median change in pain score from arrival to the PACU to discharge from the predischarge unit: No-VE vs. VE: 0 (-4-0) vs. -2.0 (-3-0), p=0.501. SDS was planned in 131/152 (86.2%) and planned and performed in 124/131 (94.7%): No-VE: 65/124 (52.4%) vs. VE: 59/124 (47.6%), p=0.327. There was no difference in age/sex/BMI/size and type of hiatal hernia and operative time between SDS no-VE and SDS VE. Need for opioid medication in the recovery room and in the discharge unit: No-VE vs. VE: 51/65 (78.5%) vs. 23/59 (39.0%), p<0.001. Median change in pain score from arrival at the PACU to discharge from the predischarge unit: No VE vs.VE: 0 (-4-0) vs. -2 (-3-0), p=0.652, 8/12 (67.7%) postoperative nurses thought VE improved postoperative shoulder pain. Conclusion: The combination of Voltaren application on shoulders and exercises of arms (VE), reduces the need for opioids in postoperative recovery period following laparoscopic primary and reoperative hiatal hernia repair. The change in the pain score from arrival to discharge showed that VE results in an improvement in shoulder pain compared to No-VE, but it did not reach statistical significance.
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