Pain management principles and anesthesia techniques for thoracoscopy.

Thoracic surgeons have recently pursued innovative techniques that can help minimize postoperative pain. These have taken two basic directions. The first consists of a modification of the operative procedure itself, such that the surgical insult and hence the resulting pain are minimized. Modifications of the conventional thoracotomy technique have led to the development of the muscle-sparing thoracotomy and the linear or small transaxillary thoracotomy. The ultimate modification has been video-assisted thoracic surgery techniques, which are associated with a marked reduction in postoperative pain. The second approach centers on techniques that improve postoperative pain control. The recently published Agency Health Care Policy and Research guidelines provide a comprehensive review of the therapeutic options for postoperative pain control. These guidelines emphasize the value of nonsteroidal antiinflammatory drugs in conjunction with opioids as the preferred form of analgesia. Many authors have advocated the induction of spinal analgesia after thoracotomy, using either epidural opioids or local anesthesia, or both. Patient-controlled analgesia and multiple intercostal nerve blocks are other methods for managing postthoracotomy pain. The potential benefits conferred by aggressive pain control after thoracotomy are enormous for the patients, the surgeons, and the entire health-care system.