Users Online : 559 About us |  Subscribe |  e-Alerts  | Feedback | Login   |   
Journal of Minimal Access Surgery Current Issue | Archives | Ahead Of Print Journal of Minimal Access Surgery
           Print this page Email this page   Small font sizeDefault font sizeIncrease font size 
  Search
 
  
     Search Pubmed for
 
    -  Kang DK
    -  Kang MK
    -  Woon H
    -  Hwang YH
    Article in PDF
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


   Abstract
  Introduction
  Methods
  Results
  Discussion
  Conclusion
   References
   Article Tables

 Article Access Statistics
    Viewed169    
    PDF Downloaded7    

Recommend this journal

 

Previous Article  Table of Contents   Next Article  
ORIGINAL ARTICLE
Year :   |  Volume :   |  Issue :   |  Page :
 

The feasibility of thoracoscopic-guided intercostal nerve block during uniportal video-assisted thoracoscopic lobectomy of the lung


 Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Korea

Date of Submission11-Aug-2021
Date of Acceptance29-Dec-2021
Date of Web Publication01-Mar-2022

Correspondence Address:
Min Kyun Kang,
Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Haeundae-ro 875, Haeundae-gu, 48108, Busan
Korea
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_261_21

  Abstract 

Background: Uniportal thoracoscopic surgery has become widely accepted for its favourable outcomes with regard to pain. However, post-operative pain is still a concern associated with thoracic surgery. The objective of this study was to evaluate the post-operative pain of patients undergoing uniportal video-assisted thoracoscopic surgery (VATS) lobectomies using an intra-operative intercostal nerve block.
Methods: All consecutive patients undergoing uniportal VATS lobectomies between October 2018 and October 2019 were reviewed retrospectively. Twenty consecutive patients in Group A underwent uniportal VATS lobectomies without intra-operative intercostal nerve blocks. The other 20 consecutive patients in Group B underwent uniportal VATS lobectomies with intra-operative intercostal nerve blocks. Numeric Pain Rating Scale (NRS) scores were recorded at 1, 12 and 24 h postoperatively. The number of anti-inflammatory drugs (non-steroidal anti-inflammatory drug [NSAIDs]) consumed until the time of chest tube removal was also recorded.
Results: There was no difference between the groups with regard to sex, age, chest tube duration, length of stay, operative time or laterality. There was a significant difference in post-operative NRS scores at 1 h (P < 0.001) and 12 h (P = 0.014) between the groups. The NSAID consumption was significantly lower in Group B than in Group A (P = 0.038).
Conclusion: Intra-operative intercostal nerve blocks with bupivacaine provided immediate post-operative pain relief and reduced post-operative opioid consumption in patients who underwent uniportal VATS lobectomies.


Keywords: Intercostal nerve block, lobectomy, uniport video-assisted thoracoscopic surgery



How to cite this URL:
Kang DK, Kang MK, Woon H, Hwang YH. The feasibility of thoracoscopic-guided intercostal nerve block during uniportal video-assisted thoracoscopic lobectomy of the lung. J Min Access Surg [Epub ahead of print] [cited 2022 May 28]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=338930





  Introduction Top


In the field of thoracic surgery, video-assisted thoracoscopic surgery (VATS) has become the favoured approach since VATS has an advantage in alleviating post-operative pain compared to thoracotomy.[1] The VATS approach is recommended as the standard treatment method for clinical Stage I non-small-cell lung cancer by the American College of Chest Physicians[2] and the National Comprehensive Cancer Network.[3] Recently, a number of surgeons have demonstrated the feasibility of performing VATS through a single incision. In comparison with multiport VATS, uniportal VATS has demonstrated favourable outcomes.[4],[5] Although uniportal VATS has become more widely accepted, post-operative pain remains the main concern.[6] Various methods, such as oral analgesic agents, intramuscular morphine injection, intercostal nerve blockade and epidural analgesia, have been used for the treatment of VATS post-operative pain. The advantage of using a thoracoscopic internal intercostal block was reported.[7] We hypothesise that the use of an intra-operative intercostal block would enhance pain control in patients undergoing uniportal VATS lobectomies.


  Methods Top


Patients

This retrospective study was approved by the Institutional Review Board of Haeundae Paik Hospital at the Inje University of Korea. The patients were divided into two groups. In Group A, 20 consecutive patients underwent elective uniportal VATS lobectomies without intra-operative intercostal nerve blocks between October 2018 and April 2019. In Group B, 20 consecutive patients underwent elective uniportal VATS lobectomies with intra-operative intercostal nerve blocks between June 2019 and October 2019. Patients with benign pulmonary disease and lung cancer requiring anatomical lung resection were included in the inclusion criteria of uniportal VATS lobectomy. The indication for uniportal VATS lobectomy for lung cancer included: (i) Clinical Stage I–II patients; (ii) clinical Stage IIIA patients with resectable N2 station metastasis. Patients who underwent surgery in the ipsilateral thorax were excluded from both groups because adhesion and prolongation of operative time could affect post-operative pain.

All patients used intravenous (IV) patient-controlled anaesthesia (PCA). The agent for PCA was made into 100 ml by mixing 2000 μg of fentanyl and normal saline. If the patient had additional analgesic requirements postoperatively, ibuprofen 800 mg was injected intravenously when the numeric pain rating scale (NRS) score (0 being no pain and 10 being the worst pain imaginable) was more than 6. During the post-operative period, the patient's pain level was assessed by NRS scores, which was the primary outcome of the study. The NRS scores were recorded at 1, 12 and 24 h postoperatively. The secondary outcomes were the number and amount of anti-inflammatory drugs (non-steroidal anti-inflammatory drug [NSAIDs]) consumed until the time to chest tube removal.

Surgical technique: Uniportal video-assisted thoracoscopic surgery

All patients were placed under double-lumen intubation anaesthesia on lateral decubitus position. In both groups, an incision measuring 4–5 cm was made in the fifth or sixth intercostal space on the anterior axillary line. The soft tissue and intercostal muscles were retracted with an X-small wound retractor (Alexis; Applied Medical, Rancho Santa Margarita, CA, USA) to secure the intercostal space. All procedures were performed with a 5-mm, 30° video thoracoscope, endoscope instruments, Ligasure (Valleylab, Covidien, Boulder, CO, USA), and an endoscopic linear stapler. At the end of the procedure, a chest tube (24 Fr.) was placed in the thoracic cavity. The chest tube was inserted through a single incision.

Intra-operative internal intercostal nerve block

At the end of VATS lobectomy, a 23G scalp needle was introduced through the uniport. According to the need, the scalp needle was bent about 30°. An injection of 5 cc of 0.5% bupivacaine HCl 0.5% was performed under the parietal pleura in the region of the intercostal bundle after careful aspiration. The location of the injection was from the third to the seventh intercostal space lateral to the sympathetic chain. Thoracoscope monitoring was conducted to detect a bulge in the parietal pleura and bleeding.

Statistical analysis

The continuous variables are presented as interquartile range or mean ± standard deviation to compare the continuous variables, the t-test for normally distributed data or the Mann–Whitney U-test for non-normally distributed data was used. The categorical variables are presented as numbers and percentages. To compare the categorical variables, the Chi-squared test or Fisher's exact test was used. The statistical analyses were conducted using SPSS (Version window 18.0; SPSS Inc., Chicago, IL, USA). For all analyses, statistical significance was set at P < 0.05.


  Results Top


A total of 40 patients undergoing lobectomy using uniportal VATS were included in this analysis. Twenty patients in Group B received intra-operative intercostal nerve blocks using 0.5% bupivacaine HCl 0.5% at the end of surgery. The 20 patients in Group A did not receive intra-operative intercostal nerve blocks. The patient demographics included sex, age, chest tube duration, length of stay, operative time, laterality time, diagnosis and pathologic stage. There were no significant differences between the groups [Table 1].
Table 1: Patient characteristics

Click here to view


The postoperative NRS scores are shown in [Table 2]. There was a significant difference in postoperative NRS scores at 1 h and 12 h between the two groups. There was not a significant difference in post-operative NRS scores at 24 h. The number of post-operative analgesics injected until the time of chest tube removal is shown in [Table 3]. The NSAID consumption until the time of chest tube removal was significantly lower in Group B than in Group A.
Table 2: Post-operative numeric pain rating scale scores

Click here to view
Table 3: Post-operative analgesic use

Click here to view



  Discussion Top


In the field of thoracic surgery, effective pain control can reduce post-operative pulmonary complications and relieve patient concerns. Despite the advantages over a thoracotomy with regard to pain, VATS can still induce significant post-operative pain and temporary impairment of lung function. Various efforts have been undertaken to alleviate VATS post-operative pain, including local analgesia, general IV analgesia, epidural blocks and intercostal nerve blocks.[7] Bolotin et al. reported the significant advantage of intercostal nerve blocks for pain management after thoracoscopic surgery.[8] The advantage of an intra-operative intercostal nerve block is the accuracy of the block. The injection of local anaesthetics is performed under direct vision, and a bulge in the visceral pleura can be seen over the intercostal space. Temes et al. reported a thoracoscopic nerve block supplying the intercostal spaces entered during the procedure.[9] However, local anaesthetic leakage through the damaged parietal pleura can occur. Hsieh et al. reported a continuous intercostal nerve block after uniportal VATS anatomical resection.[10] The intercostal catheter placement is a more invasive procedure and more expensive than simple intra-operative intercostal nerve blocks. In our study, the injection was done at multiple levels, from the third to the seventh intercostal space, to alleviate the pain caused by the uniport performed through the fifth intercostal space.

In 2004, Rocco first reported experience with uniportal VATS wedge resection.[4] Since then, this technique has been adopted by several centres in Europe and Asia. Beginning in 2011, our hospital adopted uniportal VATS and it is currently used as a standard means of minimally invasive thoracic surgery. To improve on the results of uniportal VATS, we thought that appropriate post-operative pain control would be very important. In our study, a decrease in immediate post-operative pain, which was assessed at 1 and 12 h post-operatively, was achieved by using an intra-operative intercostal nerve block. Furthermore, post-operative NSAID consumption until the time of chest tube removal was also decreased in the intra-operative intercostal nerve block group.

This study has several limitations. First, this study was a retrospective study based on a relatively small cohort from a single institution. To evaluate the efficacy of intra-operative intercostal nerve blocks in uniportal VATS, a larger multi-institutional, prospective study may be necessary. Second, our study only investigated the immediate post-operative period, so we could not recognise the development of chronic pain. To minimise potential bias in a retrospective study, all procedures were performed by a single surgeon.

In conclusion, an intra-operative intercostal nerve block with bupivacaine during a uniportal VATS lobectomy could alleviate immediate post-operative pain.


  Conclusion Top


The results of our retrospective study showed that an intra-operative intercostal nerve block with bupivacaine provided immediate post-operative pain relief and reduced the post-operative opioid consumption in patients who underwent uniportal VATS lobectomies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: A comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362-5.  Back to cited text no. 1
    
2.
Scott WJ, Howington J, Feigenberg S, Movsas B, Pisters K; American College of Chest Physicians. Treatment of non-small cell lung cancer stage I and stage II: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132:234S-42S.  Back to cited text no. 2
    
3.
National Comprehensive Cancer Network (NCCN). NCCN Guidelines. Available from: https://www.nccn.org/professionals/physician_gls/default.aspx#site. [Last accessed on 2019 Aug 11].  Back to cited text no. 3
    
4.
Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726-8.  Back to cited text no. 4
    
5.
Gonzalez-Rivas D, Paradela M, Fernandez R, Delgado M, Fieira E, Mendez L, et al. Uniportal video-assisted thoracoscopic lobectomy: Two years of experience. Ann Thorac Surg 2013;95:426-32.  Back to cited text no. 5
    
6.
Young R, McElnay P, Leslie R, West D. Is uniport thoracoscopic surgery less painful than multiple port approaches? Interact Cardiovasc Thorac Surg 2015;20:409-14.  Back to cited text no. 6
    
7.
Mulder DS. Pain management principles and anesthesia techniques for thoracoscopy. Ann Thorac Surg 1993;56:630-2.  Back to cited text no. 7
    
8.
Bolotin G, Lazarovici H, Uretzky G, Zlotnick AY, Tamir A, Saute M. The efficacy of intraoperative internal intercostal nerve block during video-assisted thoracic surgery on postoperative pain. Ann Thorac Surg 2000;70:1872-5.  Back to cited text no. 8
    
9.
Temes RT, Won RS, Kessler RM, Wernly JA. Thoracoscopic intercostal nerve blocks. Ann Thorac Surg 1995;59:787-8.  Back to cited text no. 9
    
10.
Hsieh MJ, Wang KC, Liu HP, Gonzalez-Rivas D, Wu CY, Liu YH, et al. Management of acute postoperative pain with continuous intercostal nerve block after single port video-assisted thoracoscopic anatomic resection. J Thorac Dis 2016;8:3563-71.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
Print this article  Email this article
Previous Article  Next Article

    

2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04