Laparoscopic cholecystectomy has recognized as the gold standard for gallbladder surgery. It offers various benefits, including less post-operative pain and quicker ambulation with return to routine activities. However, this surgery has several negative side effects, among which shoulder tip pain is a bothersome symptom.1-2 Hypercarbia activation of the sympathetic nervous system, persistent pneumoperitoneum following surgery, and fast dilation of the abdomen by carbon dioxide have all been hypothesized as causes of shoulder pain .3 Shoulder tip pain was nearly unheard of after open cholecystectomy and was initially documented following laparoscopic gynecological operations Early pain  following laparoscopic cholecystectomy is multifactorial.4-5 The pain pattern following laparoscopic cholecystectomy is consequently multimodal. It consists of three distinct parts which are shoulder pain (also known as somatic pain),   visceral pain (deep intra-abdominal pain) and incisional pain (somatic pain). Visceral pain constitutes the majority of the pain felt in the initial days following surgery and is separate from shoulder tip pain.6 As the visceral pain complication has subsided the day following surgery, shoulder discomfort usually becomes noticeable. There are also significant individual variances in pain perception following abdominal surgery.7 The prevalence of shoulder tip pain following laparoscopic cholecystectomy varies widely, with some studies reporting rates as high as 30-50% [8]. The kind, severity, & duration of pain varied amongst people and are often unpredictable. As a result, preventing and treating such pain is   controversy. A number of research have investigated ways for reducing the occurrence & severity of shoulder pain after laparoscopic surgery Release of pneumoperitoneum following laparoscopic cholecystectomy in Trendelenburg posture can alleviate shoulder pain.8 Still, not much advancement is made in this area. This study aimed to determine the optimal posture for decreasing shoulder pain following laparoscopic surgery.

The present cross sectional comparative study was carried out at the Department of general surgery Mekkran medical college Turbat from August 2025 to January 2026 following permission from the ethical board of the hospital. Sample size was determined using the WHO calculator.9 A non-probability sequential sampling method was applied. The required sample size determined for the study was 80 cases. Individuals aged 25-75 years who had laparoscopic cholecystectomy were included. Patients with morbid obesity (BMI>40 kg/m2), neuropsychiatric issues, or requiring abdominal insufflation pressure of more than 15 mmHg during surgery were excluded. On the day of surgery, patients were randomly allocated into two groups and each group had 40 participants: Group A (supine position) & Group B (Trendelenburg position) after the procedure. In Group A, the residual gas was released while the patient was in a supine posture; in Group B, the anesthetist was instructed to place the operating table in a Trendelenburg position before the residual gas was released. Patients were monitored in the post-anesthesia care unit (PACU) before moving to the post-surgical ward for 24-hour supervision. All patients received routine post-operative treatment. The VAS scale was used to assess shoulder tip pain. Demographics (age, gender, and BMI) were recorded on a pre-designed form. The operating time was determined from skin incision to wound closure. Shoulder tip discomfort was assessed using a visual analog scale at 4, 8, 12, & 24-hours following surgery. The patient's position at the completion of operation was termed "effective" if their VAS score was < 3 after 24 hours. Data was analyzed using SPSS version 16. Variables such as age, BMI, operation length, and postoperative shoulder discomfort were expressed as mean ± SD. Variables such as sex and efficacy were examined using frequency and percentages. Data was stratified by sex, age, BMI, & length of operation. After stratification, the efficacy of both groups was compared using a Chi-square test. Value of P less than 0.05 was deemed significant.

A total of 80 individuals were included in this study these were randomly divided in to group A and group B. Male were 18(45%) in group A and 15(37.5%) in group B. Similarly female were 23(57.5%) in group A and 24(60%) were in group B. The mean age of the study population was 48.10±14.12 years. In term of surgery duration, BMI, sex and mean age participants were similar as presented in table 1. Participants had mean score at PACU was 5.51±1.25, at 24th hour at was 1.84±1.46, at 12th hour was 3.31±1.04, at 8th hour 4.30±1.12 was and at 4th was 5.38±1.24. Pain comparison of both groups is presented in table 2. Both groups were categorized according to age and BMI. Individuals under the age of 50 in the Trendelenburg position group obtained 64% desired results, compared to individuals in the supine position group (36%). There was a statistical difference (0.008). Participants over the age of 50 had 53.3% more beneficial outcomes in the Trendelenburg position group than in the supine position group (47.6%) (p = 0.007).  With BMI greater than 25 kg/m2 the difference between Trendelenburg position group and supine position group were not statistically different in term of effectiveness (45.4% Vs 54.5%) (P value=0.566).Individuals with BMI 25 effectiveness was most common in the Trendelenburg position group as compared to (76.9% vs 23.0%) and was statistically significant.as presented in table 3.

The most common abdominal operation performed globally is laparoscopic cholecystectomy Pain is the most prevalent complaint following laparoscopic cholecystectomy, resulting in a longer hospital stay. Common following surgery problems include upper abdominal & shoulder tip pain.10-11Following laparoscopic surgery, pain intensity is strongly linked to residual gas volume in the abdomen. Leftover carbon dioxide in the abdomen, which causes pneumoperitoneum, irritates the phrenic nerve & diaphragm. This causes shoulder tip discomfort, which is a sort of transferred pain. Patient satisfaction is affected.12 Release of pneumoperitoneum following laparoscopic cholecystectomy in Trendelenburg posture can alleviate shoulder pain. However, little progress is made in this area. This study aimed to determine the optimal posture for decreasing shoulder discomfort following laparoscopic surgery. This evidence-based approach might enhance healthcare practices and increase patient satisfaction.13 A total of 80 individuals were included in this study these were randomly divided in to group A and group B. Male were 18(45%) in group A and 15(37.5%) in group B. Similarly female were 23(57.5%) in group A and 24(60%) were in group B. The mean age of the study population was 48.10±14.12 years. Similar the study conducted by Dey and Malik in which female were predominant gender and participants aged 20-60 years which support our study.14 This study found that Trendelenburg's posture provided much greater pain alleviation than supine position following laparoscopic cholecystectomy. After 24 hours the Trendelenburg group had a statistically significant mean VAS score of 1.41 ± 1.38, with relief serving as a proxy for efficacy. These findings are similar to the study completed by Arslan and Waqar in which the Trendelenburg's posture provided much greater pain relief than supine position following laparoscopic cholecystectomy.15 based on privous study, 35 -70 percent of laparoscopic surgeries cause shoulder tip pain. This often impacts the subject's right side. Inflammation of the phrenic nerve may lead to directed pain.16 According to Zeeni et al, using the Trendelenburg posture following gynecologic laparoscopic surgery can alleviate shoulder discomfort without the need of medication. The study found that patients remained in the Trendelenburg position had considerably reduced pain levels. According to Zeeni et al, using the Trendelenburg posture following gynecologic laparoscopic surgery can alleviate shoulder discomfort without the need of medication. The study found that patients remained in the Trendelenburg position had considerably reduced pain levels.17 Another study found that the Trendelenburg posture resulted in a substantial decrease in pain scores after 24 hours.18 The results are comparable to what we saw. In our study both groups were classified based on age and BMI. Individuals under the age of 50 in the Trendelenburg position group achieved 64% of their intended outcomes, compared to 36% in the supine position group. There was a statistical difference (0.008). Participants over the age of 50 had 53.3% better results in the Trendelenburg position group compared to the supine position group (47.6%) (p = 0.007). With a BMI greater than 25 kg/m2, the difference in efficiency between the Trendelenburg and supine positions was not statistically significant (45.4% vs 54.5%, P=0.566).Individuals with BMI 25 effectiveness was more prevalent in the Trendelenburg position group as comparison to (76.9% vs 23.0%), which was statistically significant. our study findings are similar to the study carried out by Arslan and Waqar.15 Our study found that individuals with low BMI experienced considerable postoperative pain reduction with the Trendelenburg posture. Individuals with a low BMI are more prone to experience shoulder discomfort after a laparoscopy, with earlier start and increased pain levels. One theory suggests that gas may remain in thin individuals' upper abdomens after laparoscopic surgery, while obese patients have a smaller upper abdominal region covered by the omentum.20 Our study has several limitations which include a limited sample size and a single-center study. Larger sample size in various situations may give stronger evidence on the effect of Trendelenburg posture on shoulder pain following cholecystectomy.

Our study concluded that as compared to supine position for increasing patient satisfaction and relieving shoulder-tip pain Trendelenburg position was more effective.