Pain Management Approaches for Robotic-Assisted Thoracic Surgery: A Retrospective Analysis

Purpose: Robotic-assisted thoracic surgery (RATS) is increasingly used for thoracic procedures; however, there are various regional anesthesia techniques for optimal pain management. This study aimed to compare the analgesic effectiveness and perioperative outcomes of different regional anesthesia techniques with those of general anesthesia (GA) in patients undergoing RATS. Patients and Methods: We conducted a retrospective cohort study of adult patients undergoing elective RATS at Soroka University Medical Center from January 2018 to July 2024. Patients were grouped based on intraoperative pain management approach: thoracic epidural analgesia (TEA), thoracic paravertebral block (PVB), erector spinae plane (ESP) block, serratus anterior plane (SAP) block, or General anesthesia alone. Primary outcomes included postoperative pain (measured by Visual Analog Scale scores; VAS) and opioid consumption. Secondary outcomes included intraoperative hemodynamic stability, postoperative complications, and length of hospitalization. Results: A total of 158 patients were analyzed: TEA (n=5), PVB (n=65), ESP (n=40), SAP (n=14), and GA alone (n=34). Demographics and surgical characteristics were similar across groups. Significant differences were observed in Post-Anesthesia Care Unit (PACU) morphine use (p < 0.001), with the lowest consumption in the ESP (3.75 ± 5.51 mg) and SAP (3.92 ± 4.00 mg) groups and the highest in the GA group (12.42 ± 6.01 mg). PACU VAS scores at 30 minutes and 1 hour were significantly lower in the PVB, ESP, and SAP groups compared to GA (p < 0.01). Hypotension and vasopressor use were most frequent with TEA and PVB, while SAP and ESP were associated with better hemodynamic profiles. No significant differences were observed in postoperative infection rates or hospital stay duration. Conclusion: Regional pain management techniques, particularly ESP and SAP blocks, were associated with reduced pain and opioid use while maintaining hemodynamic stability compared to GA. Given the relatively small sample sizes in the TEA and SAP groups, these findings should be interpreted cautiously, and prospective studies are needed to confirm and refine these approaches.