title: Multiple nerve blocks after video-assisted thoracic surgery (VATS).
abstract: BACKGROUND
  Epidural analgesia and/or systemic narcotics are used for pain control after video-assisted thoracic surgery (VATS) lobectomy despite side effects. We report a video of a technique to safely place subpleural catheters in order to provide multiple nerve blocks and the results from our series comparing this technique to a standard post-operative analgesia protocol after VATS.
  
  
  METHODS
  At the end of the VATS wedge resection, two small incisions were made below and parallel to the position of the trocars, at the level of the anterior and posterior axillary line and an introducer was used to place a catheter subcutaneously. At this point, the introducer was curved, in a way to follow the anatomic shape of the costal margin of the patient, inserted into posterior incision and advanced in between the thoracic pleura and the ribs. Under direct vision from the thoracoscope and paying careful attention not to perforate the pleura, the guide was pushed toward the first rib by using a combination of blunt and hydro dissection. Once the guide reached the first rib, the introducer was removed and the catheter was left in place.
  
  
  RESULTS
  We evaluated 64 patients (29 patient-controlled analgesia (PCA), 35 SC). Propensity weighting produced two matched groups for further analysis. Mean total morphine dose and mean total morphine dose/body mass index (BMI) were both significantly decreased in the SC group for the 0-24 h period only (mean total morphine 38.1 vs. 27.8; P = 0.024 and mean total morphine/BMI 1.15 vs 0.79; P = 0.024). Complication rates did not differ between groups.
  
  
  CONCLUSIONS
  PCA narcotic analgesia with subpleural local anesthetic infusion provided similar pain control with less narcotic use in patients during the first 24 h after VATS lobectomy compared with PCA narcotic analgesia alone.
authors.affiliation: Department of Surgery, Division of Thoracic Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA.
authors.forename: Luca
authors.initials: L
authors.lastname: Milone
authors.forename: Donna
authors.initials: D
authors.lastname: Edmondson
authors.forename: Abraham
authors.initials: A
authors.lastname: Lebenthal
authors.forename: Walter
authors.initials: W
authors.lastname: Scott
mesh_terms: D016058:Analgesia, Patient-Controlled; D006801:Humans; D008175:Lung Neoplasms / Q000601:surgery; D009407:Nerve Block / Q000379:methods; D020775:Thoracic Surgery, Video-Assisted