Continuous Subpleural Infusion of Local Anesthetic for Pain Control After Robotic Thoracic Surgery—Background and Technique

Although robotic thoracic surgery is associated with lower pain-related morbidity, it is important to address pain in a patient undergoing robotic thoracic surgery as diligently as a patient undergoing any other thoracic surgical procedure. Unlike in the abdomen, even the most minimally invasive procedures in the chest can be painful.

Therefore, regardless of the number and type of incisions or ports, pain associated with robotic thoracic surgical procedures should be recognized and treated aggressively. For robotic thoracic surgical patients, minimizing pulmonary complications is the key to decreasing morbidity. The ultimate goal is to clear secretions, maintain expansion of the lung, and decrease the complications associated with pulmonary collapse. Control of pain is the core requirement for all postoperative measures in robotic thoracic surgical patients. Once the pain is controlled, the morbidity associated with thoracic surgery is decreased.
 

Pain Control Strategy
Optimal pain control is achieved through a multifaceted strategy that addresses both systemic and local pain pathways. Strategies for local pain control have included epidural analgesia, cryoanalgesia, paravertebral blocks, and reversible chemical neurolysis with prolonged subpleural infusion of anesthetic agents.

Presently, robotic surgeons begin or end the procedure with infiltration of the intercostal nerve with local anesthetic. One shortcoming of this approach is that the local pain control is short-lived, and the effect of the local anesthetic quickly wears off.

On the other hand, multiple studies have shown the continuous infusion of local anesthetic through a catheter placed in an extrapleural tunnel overlaying the intercostal nerves to be safe and efficacious (1–3). One advantage of this technique is prolonged local pain control. Randomized studies have also demonstrated better pain relief, better pulmonary function, lower pulmonary complications, and lower use of narcotics with the use of extrapleural infusion catheters (4–6). A study by Taylor et al. examined the use of this technique in minimally invasive surgery and found it to be an effective form of analgesia and successful in decreasing narcotic requirements postoperatively (6). In addition, a study by Concha et al. compared the use of intercostal nerve blocks combined with IV PCA to epidural analgesia and found no statistically significant difference between the two groups (7). In a review on extrapleural catheter use in patients undergoing thoracotomy, the author found that the use of extrapleural catheter for analgesia was superior to systemic narcotics (1). The use of extrapleural catheters also resulted in lower narcotic consumption and decreased pulmonary complications. Studies have compared prolonged local infusion of an anesthetic to an epidural catheter and have found not only improved pain and decreased narcotic usage, but also improved pulmonary function, as demonstrated by an increase in lung volumes (8). 

Complications related to the catheter and the local anesthetic agents are low. Reported complications have been less than 0.6% and have included transient hypotension, transient Horner’s syndrome from placement of catheters above the third intercostal space, transient ipsilateral femoral nerve dysfunction from placement of catheters lower than the eighth intercostal space with infusion of the local anesthetic into the retroperitoneum, bupivacaine toxicity in the form of confusion, transient elevation of liver enzymes, and rib osteomyelitis (1, 8–10).

Procedure
Following the completion of the robotic procedure and undocking of the robot, the camera trocar is removed (8). A zero degree endoscopic camera is introduced through the anterior port and used to visualize the paravertebral pleura. In this technique, a specially designed tunneling device is introduced through the camera port and used to begin the formation of a subpleural tunnel. 

After the formation of the tunnel, the metal tunneling device is withdrawn and a peelable sheath is positioned over the tunneler and replaced in the subpleural tunnel. The metal tunneler is withdrawn and the sheath is left in place inside the subpleural tunnel. 

Next, two five-inch ON-Q soaker catheters are introduced through separate puncture sites placed anteriorly in the same intercostal space as the inferior incision. The ON-Q soaker catheters are passed into the long subpleural sheath, and the sheath is withdrawn and peeled away, leaving the soaker catheters in the subpleural tunnel. The catheters are positioned in an overlapping staggered manner to provide infusion of the local anesthetic for the entirety of the pleural tunnel extending from the second to the eighth intercostal spaces. 

The catheters used are small and flexible with multiple side holes that can deliver the infusion over multiple areas. For robotic thoracic surgery applications, two catheters are used with the infusion rate of approximately 4 mL/hr (2 mL per catheter/hr), a 400 mL reservoir, and 0.125 bupivacaine. A second 400 mL reservoir is placed on postoperative day five. 

This system is used after the patient is discharged from the hospital, giving the patient ten days of local pain control. It provides excellent prolonged pain control after robotic thoracic surgery while decreasing the need for narcotics.

References

1. Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy. Ann Thorac Surg 2005:80:1550-9.
2. Tempesta BJ, Gharagozloo F, Margolis M, Strother E. Prolonged subpleural infusion of local anesthetic for pain relief after thoracic surgery. Chest 2007;13:661A
3. Gharagozloo F. Pain management following robotic thoracic surgery. Mini-invasive Surg 2020;4:8. http://dx.doi.org/10.20517/2574-1225.2019.62
4. Wheatley GH, Rosenbaum DH, Paul MC, Dine AP, Wait MA, et al. Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg 2005;130:464-8.
5. Duarte AM, Pospisilova E, Reilly E, Mujenda F, Hamaya Y, et al. Reduction of postincisional allodynia by subcutaneous bupivicaine. Anesthesiology 2005;103:113-25.
6. Taylor R, Massey S, Stuart-Smith K. Postoperative analgesia in video-assisted thoracoscopy: the role of intercostal blockade. J Cardiothorac Vasc Anesth 2004;18:317-21.
7. Concha M, Dagnino J, Cariaga M, Aquilera J, Aparicio R, et al. Analgesia after thoracotomy: epidural fentanyl/bupivacaine compared with intercostal nerve block plus intravenous morphine. J Cadriothorac Vasc Anesth 2004;18:322-6.
8. Gharagozloo F. et.al. Pain Control after Robotic Thoracic Surgery. Chapter in Gharagozloo F, Patel V, Giulianotti P, Poston R, Gruessner R, Meyers M: (eds.) Robotic Surgery. Second Edition, Springer, 2021
9. Bousema J, Dias EM, Hagen SM, Govaert B, Meijer P, van der Broek FJC. Subpleural multilevel intercostal continuous analgesia after thoracoscopic pulmonary resection: a pilot study. J. cardiothorac Surg 2019; 14: 79.
10. Jung J, Park SY, Haam S. Efficacy of subpleural continuous infusion of local anesthetics after thoracoscopic pulmonary resection for primary lung cancer compared to intravenous patient-controlled analgesia.

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