VATS guided intercostal nerve block

Following insertion of the camera and under video vision a needle is placed percutaneously through the skin at the back into the intercostal spaces over the distribution of the incisions required for the thoracoscopic procedures.  The tip of the needle is used to feel each rib and the needle is passed just below the rib till it is seen to tent the pleural in the intercostal space.  The needle is aspirated to ensure that it is not in a major vessel.  Approximately 2mls of 0.5% Chirocaine is injected into each intercostal space.

Successful injection is confirmed by seeing a sausage shaped elevation of the pleura in each intercostal space.  This bolus of Chirocaine lasts for approximately 24 hours which gets the patient over the initial postoperative period.  I would favour moving to a longer infusion time, though we are currently having difficulties obtaining suitable cannulae and tunnelling devices.  We continue our efforts to research the available devices.  Unfortunately standard epidural cannulae tend not to be satisfactory as they are too fine, too flexible and do not have enough holes along the length of the catheter to anaesthetise multiple intercostal spaces.