Comparison Between Paravertebral and Erector Spinal Block Efficacy in Robotic Thoracic Surgeries

A Prospective Comparison of Continues Catheter Paravertebral Block vs Continues Catheter Erector Spinal Block in Patients Undergoing Robotic Assistant Thoracic Surgery

The overall goal of this work is to find the preferred continues catheter- based thoracic block for patients who undergoing major ROBOTIC assisted thoracic surgery (Lobectomy, multiple segmental resection and thoracotomy). Specifically, this project aims to complete the following:

1. To compare analgesic efficiency of continuous TPVB vs ESP block in patients undergoing major robotic thoracoscopic operation
2. To assess failure rate, time to catheter placement and patient satisfaction of each block group
3. To compare complication rate of each block

All adult patients undergoing major robotic thoracic procedures, such as Lobectomy, multiple segmental resection and thoracotomy. The recruitment period is planned for approximately 1 year. The follow-up period will be from admission until hospital discharge.

Video-assisted thoracic surgery (VATS) is a type of minimally invasive thoracic surgery that can remove parts of the diseased lung and lymph nodes. In video-assisted thoracoscopic surgery (VATS), a small tube called a thoracoscope is inserted through a small cut (incision) between the ribs. At the end of the tube is a small camera. This lets the surgeon see the entire chest cavity without having to open up the chest or spread the ribs. The surgeon then removes lung tissue with specially designed instruments inserted through one or two additional small incisions. The VATS technique can be used for other types of chest procedures involving the lungs, esophagus, thymus, pleural or pericardium besides lung cancer surgery.

Thoracic paravertebral block (TPVB) is the technique of injecting local anesthetic adjacent to the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramina. This results in ipsilateral somatic and sympathetic nerve blockade in multiple contiguous thoracic dermatomes above and below the site of injection

In recent years a new conceptual type of regional anesthesia has emerged: the Erector Spinae Plane Block (ESP block). Originally it was described in 2016 in a case report regarding analgesia intervention for thoracic neuropathic pain. Since then, there has been growing interest and research adding experience about the ESP block for pain control after thoracic and abdominal surgery and also traumatic injury of chest and abdomen. Current literature is limited to approximately 60 publications, the majority of which is case reports and case series.

Comparison of both techniques:

In thoracic surgery, both the Erector Spinae Plane (ESP) block and the Thoracic Paravertebral Block (TPVB) are utilized for analgesia.

Erector Spinae Plane (ESP) Block:

Advantages:

• Technical Simplicity: The ESP block is generally easier to perform due to its superficial anatomical location, making it more accessible, especially for practitioners less experienced with deeper blocks.
• Safety Profile: There's a reduced risk of complications such as pneumothorax because the injection site is farther from the pleura and major vascular structures.
• Analgesic Efficacy: Studies suggest that ESP blocks provide effective analgesia for thoracic surgeries, with benefits comparable to TPVB when a similar number of injections are administered.

Disadvantages:

• Potentially Limited Analgesic Coverage: While effective, the ESP block may not provide as extensive analgesic coverage as TPVB in some cases, potentially necessitating additional analgesic measures.
• Limited Long-Term Data: As a relatively newer technique, long-term efficacy and safety data are less comprehensive compared to TPVB.

Thoracic Paravertebral Block (TPVB):

Advantages:

• Established Efficacy: TPVB has a long-standing history of providing reliable analgesia for thoracic surgeries, with well-documented outcomes.
• Comprehensive Analgesia: It offers effective unilateral analgesia, which can be advantageous for procedures involving one side of the thorax.

Disadvantages:

• Technical Complexity: TPVB requires a higher degree of technical skill due to the proximity to the pleura and neurovascular structures, increasing the risk of complications.
• Risk of Complications: There's a higher potential for adverse events such as pneumothorax, vascular puncture, and hypotension.

In summary, both ESP and TPVB are effective for analgesia in thoracic surgery. The choice between them should be guided by patient-specific factors, surgical requirements, and the clinician's expertise with each technique.

Inclusion Criteria:

• Age ≥18 years
• All patients undergo major robotic thoracic surgery

Exclusion Criteria:

• Patients who refuse to participate in the study.
• Patients who are unable to give an informed consent.
• Patients with local inflammation at the puncture site
• Patients with known allergy to local anesthetisc
• Pregnancy