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Regional anaesthesia for video –assisted thoracoscopic surgery

Introduction

Perioperative pain control is one of the major concerns in the patients undergoing video-assisted thoracoscopic surgery (VATS) .

Key words: VATS, regional anaesthesia

VATS

In the past few years VATS has been used increasingly. VATS involves intentionally creating a pneumothorax and then introducing an instrument through the chest wall to visualize the intrathoracic structures. The potential advantages of  VATS compared to thoracotomy include less postoperativ pain, fewer operative complications, shortened hospital stay,improvement of pulmonary function  and reduced costs.   There are many indications for VATS procedures: biopsy of pulmonal, mediastinal, oesophageal  tumors and diseases, resections of tumors and metastasis, lobectomy, drainage of empyema, thymectomy, sympathectomy etc. However, the fact is, that pain following VATS can be severe and long lasting.  VATS procedures can induce persistent pain two months after surgery in 38% of patients as a result of acute nerve damage.

Intraoperative anaesthetic management

VATS can be performed using either local, regional or general anaesthesia.To facilitate the thoracic procedures under optimal visualisation, a well collapsed lung on the operative side (non-dependent lung) must be achieved in most circumstances. In most cases, general anaesthesia is  required for separation of lungs using a double-lumen endobronchial tube or bronchial blocker. Awake VATS under regional anaesthesia has been increasingly employed in a variety of procedures involving pleura, lungs and mediastinum. Patients who undergo awake VATS may benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction. On the contrary potential hazard includes paradoxical respiration and mediastinal shift, which may cause progressive hypoxia, hypercapnia, hypotension and cardiorespiratory arrest. As a general rule, the procedures should not be too long and the patients should be carefully selected.

Regional anaesthesia

Regional anaesthesia for VATS procedures consists of local peripheral field block, intercostal nerve block, paravertebral block, and thoracic epidural block. To block coughing reflex ipsilateral stellate ganglion block can be used. Patients tolerate VATS utilizing local anaesthesia, sedation and spontaneous ventilation.

Thoracic epidural anaesthesia

Thoracic epidural anaesthesia (TEA) is considered by many to be the gold standard for thoracic surgery, TEA significantly reduced incidence of supraventricular tachyarrhytmias after pulmonary resections . Cardiac sympathetic blockade by TEA dilates stenotic coronary arteries, so postoperative myocardial infarction were reduced and left ventricular function can be improved. Respiratory and renal failure, stroke and mortality were reduced by TEA.

Thoracic paravertebral block

Thoracic paravertebral block (TPB) is particularly advocated for unilateral thoracic surgical procedures such as thoracotomy, VATS,breast surgery, minimal invasive cardiac surgery. Single injection thoracic paravertebral block performed preoperatively reduced pain score after VATS in clinically significant fashion. TPB through catheter inserted under direct vision during VATS is a safe and effective procedure for excellent pain control

Systematic reviews found no difference in analgesia with TPB techniques when compared with TEA regimens. Important side effects such as hypotension, urinary retention, nausea and vomiting, were less frequent with TPB than with TEA.

Compared to the other available regional techniques such as intercostals and intrapleurals TPB offers better quality, longer duration of analgesia and less side effects.

Conclusions

Well controlled and well monitored anaesthetic combinations of regional anaesthesia and general anaesthesia or sedation  are safe and valuable techniques for VATS .

Vesna Novak –Jankovic
Clinical department of anaesthesiology and intensive therapy
University Medical Centre Ljubljana
Slovenia
Corresponding author's e-mail: vnovakjankovic@gmail.com

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