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Ann Thorac Surg 2000;70:1872-1875
© 2000 The Society of Thoracic Surgeons

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Original article: general thoracic

The efficacy of intraoperative internal intercostal nerve block during video-assisted thoracic surgery on postoperative pain

^a Department of Cardiothoracic Surgery, Carmel Medical Center, The Technion, Israel Institute of Technology, Haifa, Israel
^b Departments of Anesthesiology and Community Medicine, Carmel Medical Center, The Technion, Israel Institute of Technology, Haifa, Israel
^c Department of Epidimiology, Carmel Medical Center, The Technion, Israel Institute of Technology, Haifa, Israel

Address reprint requests to Dr Bolotin, Department of Cardiothoracic Surgery, Carmel Medical Center, 7 Michal St, Haifa, Israel
e-mail: bolotin{at}netvision.net.il

Presented at the Thirty-Sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.

	Abstract

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Background. Video-assisted thoracic surgery (VATS) is widely used for many thoracic surgical procedures. Postoperative pain is less after VATS than after conventional thoracic surgery, but is still significant. The objective of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.

Methods. Thirty-two patients underwent VATS bilateral sympathectomy for the treatment of hyperhidrosis. The patients were randomly divided into two groups with similar demographic and preoperative physiologic parameters. Group A (n = 16) was submitted to thoracoscopic, internal intercostal nerve blocks performed at T2, T3, and T4 intercostal levels using 3 cc of 0.5% bupivacain in each intercostal space. The injections were performed bilaterally, immediately after the sympathectomy, through the same port. Group B (n = 16) underwent bilateral thoracic sympathectomy without the block. During the immediate postoperative period, heart rate, blood pressure, respiratory rate, pain score, and analgesic requirements were monitored every 30 minutes.

Results. No morbidity was recorded in association with the thoracoscopic, internal intercostal nerve block. The mean heart rates (77 ± 6 vs 89 ± 12 beats per minute, p < 0.001), respiratory rates (15 ± 2 vs 18 ± 3 respirations per minute, p < 0.01), pain score (1.9 ± 0.6 vs 2.7 ± 0.5, p < 0.01), and postoperative analgesic requirements (20 ± 18 vs 50 ± 21 mg pethidine HCL, p < 0.001) were significantly lower in group A. There was no significant difference in blood pressures.

Conclusions. Thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements.

	Introduction

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Palmar hyperhidrosis is a functional disorder that induces professional, psychological, and social handicaps [1]. Several medical and surgical treatments have been described for the treatment of palmar hyperhidrosis, but over the last decade, video-assisted thoracic surgery (VATS) bilateral sympathectomy has been suggested as the safer and most effective treatment [2]. The following advantages have been described for VATS as compared with thoracotomy or mini-thoracotomy: better exposure, shorter operation and hospital stay, less bleeding, less postoperative pain, and reduction in pulmonary function impairment [3–7]. Nonetheless, postoperative pain after VATS is still significant. Intercostal nerve block has been used extensively for analgesia after thoracic surgery [8]. The purpose of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.

	Material and methods

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Patients
Between March 1997 and September 1999, 32 consecutive patients underwent VATS to treat hyperhidrosis. The patients were randomly divided into two groups. In group A (16 patients), the VATS sympathectomy was immediately followed with internal, intercostal blocking of nerves 2, 3, and 4, while group B (16 patients) underwent VATS bilateral sympathectomy without any intercostal blocking. Gender distribution was identical in both groups (7 male and 9 female patients in both groups) and patients’ mean age (21.6 ± 5 vs 25.0 ± 10 years, in groups A and B, respectively) was similar. In addition, all patients had similar preoperative characteristics of primary palmar hyperhidrosis without any other major medical problem.

Surgical technique: VATS sympathectomy
All patients were anesthetized using the same general anesthesia technique with fentanyl citrate 0.05% (fentanyl; Janssen, Beerse, Belgium), isoflurane (Medeva Pharmaceuticals, Bethlehem, PA), and atracurium (Tracrium; Wellcome, London, UK), and were intubated with a bronchial, left double lumen tube (Ruschelit; Willy Rusch AG, Kernen, Germany). The patients were draped in the supine position with arms abducted. A pulse oximeter probe was connected to one of the fingers on the side to be operated first. Collapse of the lung was performed by the anesthetist, and a single 12-mm valveless Thoracoport (Ethicon, Somerville, NJ) was introduced over the third rib, at the middle axillary line. A zero-degree operating videothoracoscope (Karl Storz, Tutlingen, Germany) was introduced into the pleural cavity, inspection of the anatomy was performed, and the sympathetic chain was identified. Adhesions, if present, were dissected by diathermy. An electric hook was passed through the single operating port of the scope, and cauterization of the sympathetic chain over the second and third ribs was performed. The immediate result of the procedure could be seen as a change in the shape of the wave at the pulse oximeter. Inspection of hemostasis was performed, the lung was expanded by the anesthetist and maintained at a positive pressure of 40 cm H₂O while the thoracoport was removed, and the incision rapidly sutured. The probe was moved to the other side, and the procedure was repeated.

Surgical technique: thoracoscopic internal intercostal nerve block (TINB)
Immediately after completion of the sympathectomy, an endoscopic needle (Karl Stortz, Tuttlingen, Germany) was introduced through the thoracoscope at the same port. After carefully performing negative aspiration, 3 cc of 0.5% bupivacain HCl 0.5% (Marcaine, Astra, Sweden) was injected under the parietal pleura (Fig 1). The location of the injection was the back wall, 2 cm laterally to the sympathetic chain, in intercostal spaces 2, 3, and 4. The total dose was 90 mg bupivacain HCl, less than the maximal safe dose (3 mg/kg). The procedure was visible on the monitor and a bulge of the parietal pleura was visualized.

View larger version (92K): [in this window] [in a new window]   Fig 1. The endoscopic needle shown at the injection sight (back wall, 2 cm laterally to the sympathetic chain in intercostal spaces 2, 3, and 4).

Patients whose pain score reached 3 or more ( moderate pain) were treated with pethidine (meperidine) HCl (Dolestin; Teva, Tel-Aviv, Israel) 0.5 mg/kg IV. All parameters were recorded at the following periods: at admission to the recovery unit (time 0), 30, 60, and 90 minutes after admission, and at discharge from the recovery room to the cardiothoracic department (usually 2 to 3 hours postoperative).

Chest radiograph was performed at the recovery room. Discharge occurred the following morning, after obtaining another chest radiograph.

Statistical analysis
Data were analyzed using SPSS 9.0 (SPSS, Chicago, IL). Comparisons between group A and group B were done using the Mann-Whitney U test. The comparison was conducted for each variable at each point of time, as well as for the summation of all measurement periods for each patient while in the recovery room. Results are expressed as mean ± SD. Differences were accepted to be significant at p less than 0.05.

	Results

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VATS bilateral sympathectomy was successfully performed, through a single port for each side, in all 32 patients. No death or major complications were recorded. Generally, no drain was left at the end of the procedure; however, 3 patients (2 in group A, 1 in group B) had unilateral pneumothorax, and 2 (1 in each group) had bilateral pneumothorax, requiring a chest tube for a mean of 24 hours. The pneumothorax cases were detected by radiographs taken at the recovery room (n = 3) and before discharge, 24 hours postoperative (n = 2). These patients were discharged on the second or third postoperative days. All other 27 patients were discharged on the first postoperative day. There was no difference between groups A and B in mean discharge day. All patients reported dry palms immediately after the operation and at discharge.

No morbidity was recorded in association with the VATS internal intercostal nerve block. The results of all measurements are presented in Table 1. There were significant differences in heart rate between groups A and B at all measurement periods (on admission to the recovery room, 30, 60, and 90 minutes later, and at discharge from the recovery room; Fig 2). Both the mean respiratory rate and the mean pain score were significantly lower in group A in all measurements except that at 60 minutes (Figs 3, 4). However, there were no differences in systolic blood pressure and arterial saturation between the two groups.

View larger version (17K): [in this window] [in a new window]   Fig 2. Mean ± SD of heart rate on admission to the recovery room, 30, 60, 90 minutes later, and at discharge from the recovery room. *p < 0.05.

View larger version (18K): [in this window] [in a new window]   Fig 3. Mean ± SD of pain score on admission to the recovery room, 30, 60, 90 minutes later, and at discharge from the recovery room. *p < 0.05.

View larger version (17K): [in this window] [in a new window]   Fig 4. Mean ± SD of respiratory rate on admission to the recovery room, 30, 60, 90 minutes later, and at discharge from the recovery room. *p < 0.05.

	Comment

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Despite the clear advantages over the traditional thoracotomy, VATS is a procedure that induces significant morbidity, including postoperative pain and temporary impairment of lung function [10–12].

Several methods were suggested for the treatment of VATS postoperative pain: local analgesia, general intramuscular or intravenous analgesia, epidural block, and intercostal block [13]. Danby and coworkers raised the possibility of performing VATS pleurodesis without general anesthesia, using local and intercostal block with IV sedation [14]. On the other hand, Leger and coworkers failed to demonstrate any significant advantage of intercostal block for pain management after thoracoscopic surgery [8]. The advantage of the thoracoscopic internal intercostal block presented in our study over the traditional intercostal block is the accuracy of the block. The block is performed under direct vision, and a bulge of the visceral pleura is seen over the intercostal space. Temes and coworkers described a thoracoscopic intercostal nerve block using a 22-gauge spinal needle bent 180 degrees [15]. At the end of the VATS procedure, they injected bupivacaine and epinephrine to the nerves supplying the intercostal spaces entered. This procedure may be accurate in terms of the local intercostal space; however, it cannot be done under direct vision. Moreover, in several cases in our experience, immediate leak of the analgesic fluid through the damaged parietal pleura was observed. This leak was easily viewed and another injection of bupivacain was immediately performed, usually at a location 1 to 2 cm lateral to the previous injection point. In this study, the block was done into the second, third, and forth intercostal spaces, in order to block the pain caused by both the single port, performed through the second intercostal space, and the cauterization of the sympathetic chain, done over the second and third ribs.

In our randomized study, the treated group demonstrated more moderate heart and respiratory rates, as well as objective pain reduction. The reduction in the subjective estimation pain score was significant on admission, 30 and 90 minutes later, and at discharge from the recovery room. The lack of a significant difference in the pain scores and respiratory rates at 60 minutes may reflect the effect of the IV pethidine treatment, which was required and administered in much higher doses in the control group. The combination of pain reduction and limited use of IV pethidine may induce less pulmonary function impairment. The results of this study are particularly encouraging due to the use of a single port and the absence of a chest tube, which should result in less postoperative pain to both groups of patients [16].

Two important issues could not be addressed in this study: the duration of the block’s effect (whether 2 to 3 hours or more), and the relationship between pain reduction and a limited use of IV analgesia and lung function improvement. Another question to be addressed in the future is whether the pain after a VATS visceral procedure is mainly due to the thoracic port or due to the damage to the visceral pleura and the rib’s periosteum during the sympathetic chain coagulation. In this study, the internal intercostal nerve block covered both surgical areas, but this question may be important for other procedures.

In conclusion, thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements. For methodological reasons, we tested this technique on young, healthy, and preoperatively similar surgical patients with hyperhidrosis; therefore, one may assume that thoracoscopic, internal intercostal nerve block for other kind of VATS should be at least as effective as in the current study.

	Discussion

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DR NOEL NELLIS (Dublin, GA): I appreciate this review. I have a couple of concerns. I think most thoracic surgeons have used this technique intraoperatively with open thoracotomies for many years. I’m interested in a couple of aspects. You only evaluated pain relief for just the recovery room period of time, which was 2 hours. What happened after that? What were the medication dosages? How much analgesia was given? After the patients returned home, what was the difference in the pain relief? Were there any complications related to the intercostal nerve injections? Was there any difference in postoperative neuropathy, following the injections.

Thank you for your paper.

DR BOLOTIN: This study was done just in the acute phase, so I do not have the data of the later need for analgesic requirement. In this study, we assessed an operation in which the pain is not so severe, and that is why we think the results are even more important. We did not get any late neuralgia due to this intercostal nerve block.

DR GIUSEPPE CARDILLO (Rome, Italy): I enjoyed your paper. I have just a small question. Do you have any experience with injection of analgesics just around the thoracoscopic port?

DR BOLOTIN: We tried it in the past, but did not check it in an organized study. However, we believe that the currently presented block is so accurate that it really should be much more effective than treating just the area of the endoscopic port. In this case we chose intercostal spaces 2, 3, and 4, and in our case this actually covered both the thoracic port and the sympathectomy coagulation. So we covered both. And then for other indications, the right internal space for the right entrance or the right position in the chest should be chosen.

	References

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