Overview
Video-assisted thoracoscopic surgery (VATS) has become the dominant approach for many pulmonary resections and pleural procedures, offering faster recovery and reduced postoperative pain compared with open thoracotomy. However, VATS is still associated with significant acute and chronic postoperative pain — port-site incisions, intercostal nerve irritation from instrumentation and chest drains, and pleural inflammation all contribute meaningfully to the pain experience, even though the overall insult is less than open surgery.
PROSPECT 2022 summary (Feray et al., Anaesthesia; 69 RCTs + 2 reviews reviewed, Jan 2010–Jan 2021): Basic analgesia (paracetamol + NSAID/COX-2) is recommended pre- or intraoperatively, continued postoperatively. A regional analgesic technique is strongly recommended as VATS still causes significant pain. Paravertebral block (PVB) and erector spinae plane (ESP) block should be strongly considered; serratus anterior plane (SAP) block is also effective. Thoracic epidural analgesia is explicitly not recommended — a deliberate and clinically significant departure from open thoracotomy guidance.
VATS vs Open Thoracotomy — Why the Approach Differs
It is essential to recognise that VATS analgesia is not simply a scaled-down thoracotomy protocol. PROSPECT explicitly diverges from the open thoracotomy guideline on the single most consequential point: the role of thoracic epidural analgesia.
| Open Thoracotomy (PROSPECT 2025) | VATS (PROSPECT 2022) | |
|---|---|---|
| Pain severity | Very severe | Moderate–severe (less than open) |
| Thoracic epidural | First-line (equal to PVB) | Not recommended |
| Paravertebral block | First-line | Strongly recommended |
| ESP block | Second-line | Strongly recommended |
| Serratus anterior block | Adjunct/second-line | Recommended — effective |
| Rationale for epidural difference | Benefit/risk favours epidural given extent of trauma | Invasiveness of epidural outweighs benefit for a less painful, faster-recovery procedure |
Analgesic Pathway
- Paracetamol 1g PO
- COX-2 inhibitor or NSAID PO
- Pre-emptive regional block (surgeon or anaesthetist) before incision
- Paravertebral block or ESP block — single-shot or catheter
- Serratus anterior plane block — alternative/adjunct
- Dexamethasone 8 mg IV
- Paracetamol 1g IV (if not given pre-op)
- Thoracic epidural — not recommended for VATS
- Paracetamol 1g QDS regular
- NSAID/COX-2 regular (≤5 days)
- Opioid PRN rescue
- Early mobilisation — key advantage of VATS approach
- Chest physiotherapy, incentive spirometry
✓ Recommended | ◎ Optional/conditional | ✗ Not recommended. Based on PROSPECT 2022 (Feray et al.).
Systemic Analgesia
Basic multimodal analgesia — paracetamol + NSAID or COX-2 inhibitor — administered pre- or intraoperatively and continued postoperatively, alongside the regional technique. Opioids remain available as rescue analgesia for patients with significant postoperative pain.
| Agent | Dose | Route | Frequency | Notes |
|---|---|---|---|---|
| Paracetamol | 1 g | IV/PO | QDS | Regular throughout |
| Celecoxib | 200 mg | PO | BD | COX-2 preferred; ≤5 days |
| Ibuprofen | 400 mg | PO | TDS | Non-selective; renal function permitting |
| Dexamethasone | 8 mg | IV | Single intraop | Analgesia + PONV prophylaxis |
| Oxycodone/Morphine | Titrated | PO/IV PRN | PRN | Rescue analgesia |
Regional Analgesic Techniques
A regional analgesic technique is strongly recommended for VATS — without it, significant postoperative pain is expected despite VATS being "minimally invasive." Three techniques have good supporting evidence and broadly similar efficacy; selection depends on operator experience and patient factors.
Paravertebral Block (PVB)
PROSPECT ✓ Strongly recommendedCan be placed by the surgeon under direct thoracoscopic vision before chest closure, or percutaneously by the anaesthetist. Provides multi-dermatomal unilateral coverage.
Erector Spinae Plane Block (ESP)
PROSPECT ✓ Strongly recommendedTechnically simpler than PVB, good safety margin (distant from pleura/neuraxis). Comparable analgesic efficacy to PVB in head-to-head studies (Zhao et al.: no significant difference in pain scores, recovery quality, or opioid use at 48h).
Serratus Anterior Plane Block (SAP)
PROSPECT ✓ EffectiveTargets intercostal nerves between serratus anterior and intercostal muscles in the mid-axillary line — well-suited to VATS port placement, which is typically in this region.
Dosing Reference — All Three Techniques
| Technique | Agent | Concentration | Volume | ± Adjuvant |
|---|---|---|---|---|
| PVB | Ropivacaine | 0.5% | 15–20 mL | Dexamethasone 4 mg or dexmedetomidine — may improve quality/duration |
| ESP | Ropivacaine | 0.3–0.4% | 20 mL | Dexmedetomidine reduced pain scores, rescue need, and LOS in comparative study (Gao et al.) |
| SAP | Ropivacaine | 0.375% | 20 mL | Deep + superficial combined approach described for enhanced coverage |
Which to choose? No technique has demonstrated clear superiority. ESP is technically the simplest and safest to learn (furthest from pleura and major vessels), making it a reasonable default for less experienced operators. PVB may offer marginally denser coverage. SAP is a good option when port placement is lateral/mid-axillary. Choice should reflect operator experience and patient-specific factors.
Why Is Epidural Not Recommended for VATS?
This is the most clinically significant and most debated recommendation in the VATS guideline. PROSPECT's position: several regional techniques (PVB, ESP, SAP) provide similar pain relief to epidural analgesia, without the adverse effects that can delay ambulation — and early ambulation is a defining goal of the VATS/minimally-invasive approach.
The PROSPECT methodology explicitly weighs the invasiveness of an intervention against the severity of pain it is meant to treat. Epidural analgesia carries risks — hypotension, urinary retention, motor block, epidural haematoma, technical placement difficulty — that are easier to justify against the very severe pain of open thoracotomy than against the comparatively lesser pain of VATS. When unilateral fascial plane or paravertebral blocks achieve comparable analgesia with a more favourable risk profile and without delaying mobilisation, the PROSPECT framework favours them.
Note — this was contested: Following publication, a correspondence (Chow, 2022) questioned whether epidural should still be considered, particularly for converted or borderline cases. The PROSPECT authors (Joshi et al., reply 2022) reaffirmed their position, stating they "stand by" the recommendation against epidural — even as a second-line option for true VATS procedures — citing the comparable efficacy of fascial plane/paravertebral blocks with a better side-effect profile. This reflects genuine, ongoing discussion in the field rather than uncontested consensus, and individual practice should be guided by the clinical context (e.g. a VATS converted to open mid-procedure may warrant reconsideration).
Not Recommended
See discussion above. Comparable analgesia achievable with PVB/ESP/SAP without epidural-associated risks or delayed mobilisation.
Insufficient evidence specific to VATS to support routine use; invasiveness not justified given availability of effective fascial plane techniques.
Practical Analgesic Protocol
Suggested protocol for VATS lobectomy or wedge resection:
Key VATS priority: The whole point of the minimally invasive approach is early mobilisation and faster recovery. Any analgesic technique chosen should support, not undermine, this goal — which is precisely why epidural (associated with motor block and delayed ambulation) is avoided in favour of motor-sparing fascial plane and paravertebral techniques.
References
- Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M; PROSPECT Working Group. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2022;77(3):311–325. DOI 10.1111/anae.15609 ↗
- Chow TKF. PROSPECT guidelines no longer recommend thoracic epidural analgesia for video-assisted thoracoscopic surgery. Anaesthesia. 2022;77:937.
- Joshi GP, Bonnet F, Van de Velde M. PROSPECT guidelines for pain management after video-assisted thoracoscopic surgery: a reply. Anaesthesia. 2022;77:934–946. DOI 10.1111/anae.15737 ↗
- Shelley BG, Anderson KJ, Macfarlane AJR. Regional anaesthesia for thoracic surgery: what is the PROSPECT that fascial plane blocks are the answer? Anaesthesia. 2022;77:252–256.
- Zhao H, et al. Erector spinae plane block versus paravertebral block for VATS: comparative study. (cited in Feray et al. 2022).
- Gao Z, et al. Dexmedetomidine as adjuvant in ESP block for VATS: comparative study of adjuvants. (cited in Feray et al. 2022).
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: ERAS Society recommendations. Eur J Cardiothorac Surg. 2019;55(1):91–115.