Comparison of deep and combined serratus anterior plane block after video-assisted thoracoscopic surgery; a prospective randomized trial

Abstract

Aim: Ultrasound-guided plane blocks have been employed frequently in Video-assisted thoracoscopic surgery (VATS). The aim of this study was to evaluate the effect of deep and combined serratus anterior plane block (SAPB) after VATS.
Material and Method: The patients, in the age range of 18 to 65 years, with the American Society of Anesthesiologists (ASA) physical status of I-III, and body mass index (BMI) of 18-30 kg/m2, and undergoing lung resection with VATS were included in the study. Patients were informed about the study, and their written consent was obtained. Patients were divided into Deep SAPB (DSAPB) (Group 1) and combined SAPB (CSAPB) (Group 2) groups according to the analgesia protocol.
Results: There was no statistically significant difference between the groups in terms of demographic characteristics and surgical features (p>0.05). When the groups were evaluated in terms of the block performance time, it was found to be statistically significantly longer in the CSAPB group than in the DSAPB group (p<0.001). When the groups were evaluated in terms of VAS resting scores, the 1st, 2nd, 4th, 8th, 16th, 24th, and 48th-hour VAS resting results were found to be statistically significantly higher in the DSAPB group than the CSAPB group (p<0.05). VAS cough scores were statistically significantly higher in the DSAPB group at the 1st, 2nd, 4th, 8th, 16th, 24th, and 48th-hour (p<0.05). When the groups were evaluated in terms of the side effects, additional analgesic use, and morphine consumption, they were found to be statistically significantly higher in the DSAPB group than in the CSAPB group (p: 0.026, p: 0.020, p<0.001, respectively).
Conclusion: CSAPB provided effective analgesia after VATS for 48 hours. In addition, morphine consumption and the need for additional analgesics were low in CSAPB. However, the duration of the block procedure was longer in the CSAPB application. 

Keywords

• Acute pain
• deep serratus anterior plane block
• superficial serratus anterior plane block
• combined serratus anterior plane block
• video-assisted thoracoscopic surgery
• VATS

References

1. Wang L, Wang Y, Zhang X, et al. Serratus anterior plane block or thoracic paravertebral block for postoperative pain treatment after uniportal video-assisted thoracoscopic surgery: a retrospective propensity-matched study. J Pain Res 2019; 12: 2231-8.
2. Soto RG, Fu ES. Acute pain management for patients undergoing thoracotomy. Ann Thorac Surg 2003; 75: 1349-57.
3. Wenk M, Schug SA. Perioperative pain management after thoracotomy. Curr Opin Anaesthesiol 2011; 24: 8-12.
4. Park MH, Kim JA, Ahn HJ, et al. A randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery. Anaesthesia 2018; 73: 1260-4.
5. Zengin M, Alagoz A. comparison of thoracic epidural analgesia and thoracic paravertebral block applications in the treatment of acute pain after thoracotomy in geriatric patients. Cureus 2021; 13: e18982.
6. Yayik AM, Ahiskalioglu A, Sulak MM, et al. The effect of ultrasound guided superficial serratus plane block for acute post mastectomy pain after modified radical mastectomy and axillary lymph node dissection: a randomized controlled study. JARSS 2019; 27: 121-7
7. Zengin M, Sazak H, Baldemir R, Ulger G, Alagoz A. The effect of erector spinae plane block and combined deep and superficial serratus anterior plane block on acute pain after video-assisted thoracoscopic surgery: a randomized controlled study. J Cardiothorac Vasc Anesth 2022; 36: 2991-9.
8. Coşarcan SK, Manici M, Yörükoğlu HU, et al. Toraks duvarı fasyal plan bloklar [Ultrasound guided thoracic wall blocks]. Agri 2021; 33: 205-14.

9. Zengin M, Baldemir R, Ulger G, et al. Postoperative analgesic efficacy of thoracic paravertebral block and erector spinae plane block combination in video-assisted thoracic surgery. Cureus 2021; 13: e15614.
10. Blanco R, Parras T, McDonnell JG, et al. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107-13.
11. Moon S, Lee J, Kim H, et al. Comparison of the intraoperative analgesic efficacy between ultrasound-guided deep and superficial serratus anterior plane block during video-assisted thoracoscopic lobectomy: A prospective randomized clinical trial. Medicine (Baltimore) 2020; 99: e23214.
12. Edwards JT, Langridge XT, Cheng GS, et al. Superficial vs. deep serratus anterior plane block for analgesia in patients undergoing mastectomy: a randomized prospective trial. J Clin Anesth 2021; 75: 110470.
13. Hanley C, Wall T, Bukowska I, et al. Ultrasound-guided continuous deep serratus anterior plane block versus continuous thoracic paravertebral block for perioperative analgesia in videoscopic-assisted thoracic surgery. Eur J Pain 2020; 24: 828-38.
14. Diéguez P, Casas P, López S, et al. Ultrasound guided nerve block for breast surgery. Revista Española de Anestesiología y Reanimación (English Edition) 2016; 63: 159-67.
15. Khalil AE, Abdallah NM, Bashandy GM, et al. Ultrasound-guided serratus anterior plane block versus thoracic epidural analgesia for thoracotomy pain. J Cardiothorac Vasc Anesth 2017; 31: 152-8.
16. Finnerty DT, McMahon A, McNamara JR, et al. Comparing erector spinae plane block with serratus anterior plane block for minimally invasive thoracic surgery: a randomised clinical trial. Br J Anaesth 2020; 125: 802-10.
17. Hong B, Bang S, Chung W, et al. Multimodal analgesia with multiple intermittent doses of erector spinae plane block through a catheter after total mastectomy: a retrospective observational study. Korean J Pain 2019; 32 :206-14.
18. Chin KJ, Dinsmore MJ, Lewis S, Opioid-sparing multimodal analgesia with bilateral bi-level erector spinae plane blocks in scoliosis surgery: a case report of two patients. Eur Spine J 2020; 29: 138-44.
19. Zengin M, Baldemir R, Ülger G, et al. Comparison of thoracic epidural analgesia and thoracic paravertebral block in pain management after thoracotomy. Anatolian Curr Med J 2022; 4; 70-5.
20. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the enhanced recovery after surgery (ERAS®) society and the european society of thoracic surgeons (ESTS). Eur J Cardiothorac Surg 2019; 55: 91-115.
21. Pirsaharkhiz N, Comolli K, Fujiwara W, et al. Utility of erector spinae plane block in thoracic surgery. J Cardiothorac Surg 2020; 15: 91.
22. Güven BB, Ertürk T, Ersoy A. Postoperative analgesic effectiveness of bilateral erector spinae plane block for adult cardiac surgery: a randomized controlled trial. J Health Sci Med 2022; 5: 150-5.
23. Vig S, Bhan S, Ahuja D, et al. Serratus anterior plane block for post-thoracotomy analgesia: a novel technique for the surgeon and anaesthetist. Indian J Surg Oncol 2019; 10: 535-9.
24. Baytar MS, Yılmaz C, Karasu D, et al. Comparison of ultrasonography guided serratus anterior plane block and thoracic paravertebral block in video-assisted thoracoscopic surgery: a prospective randomized double-blind study. Korean J Pain 2021; 34: 234-40.
25. Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2014; 18: 626-35.
26. Richardson J, Sabanathan S, Mearns AJ, et al. Efficacy of pre-emptive analgesia and continuous extrapleural intercostal nerve block on post-thoracotomy pain and pulmonary mechanics. J Cardiovasc Surg (Torino) 1994; 35: 219-28
27. Krediet AC, Moayeri N, van Geffen GJ, et al. Different approaches to ultrasound-guided thoracic paravertebral block: an ıllustrated review. Anesthesiology 2015; 123: 459-74.