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Gharagozloo. Mini-invasive Surg 2020;4:8 I http://dx.doi.org/10.20517/2574-1225.2019.62 Page 5 of 13
[11]
a role in preemptive analgesia . Consequently, NMDA antagonists such as ketamine or dextromethorphan
are possible agents which may result in preemptive analgesia. However, mostly due to study design and
variance in the definition of preemptive analgesia, studies comparing pre-incisional and post-incisional
pain control have shown inconsistent results.

The timing of preemptive analgesia has been controversial. In its purest sense, preemptive analgesia is that
which is applied prior to any stimulation of the nociceptors by any noxious stimulus. However, studies
[12]
have defined it as pre-surgical vs. post-surgical administration . Obviously, anesthesia and its attendant
procedures represent noxious stimuli to the patient. Newer concepts of preemptive analgesia are based on
the realization that the surgical incision alone does not trigger central sensitization, and that other noxious
stimuli such as the inflammatory mediators, ectopic neural activity, and preoperative noxious stimuli
[12]
may play a significant role in the overall pain experience . Further studies are required to clarify the
appropriate time for preemptive analgesic intervention, which is designed to prevent central sensitization.
It is currently unknown what severity or duration of pain is required for sensitization to occur, thus the
timing of analgesia is also unknown. Prevention of central sensitization remains the key to a successful
strategy for the control of acute and chronic pain.

Options for postoperative pain management
There are several options for pain management in the postoperative robotic thoracic surgical patient.
However, the focus of any regimen should be timing and accurate measurement of pain. Early initiation of
therapy is paramount to a successful strategy. In addition, since the goal of robotic, or minimally invasive,
surgery is early discharge and a quicker recovery, pain management should be compatible with shorter
hospitalization and treatment in the outpatient setting.

Under-treatment of pain remains a problem in both hospital and outpatient settings. A multi-center survey
showed that, although patients’ satisfaction with pain management had improved from 14% to 19%, as
[13]
many as eight out of ten patients reported inadequate pain management . This study showed that mobility
improved with better pain control .
[13]

Assessment of pain needs to be accurate and consistent. Although there are many proven approaches, there
remains a shortage of knowledge and a lack in consistency and follow-through. Use of a pain scale has been
shown to provide a clear method for evaluating and tracking postoperative pain. The visual analog scale
has been shown to be an effective tool for measuring surgical pain. Furthermore, it has been shown to be
an excellent tool for comparing pain levels between groups at a point in time or to track a single patient’s
pain and response to interventions [14,15] . The intensity of pain should be recorded and reviewed at regular
intervals as well as after each intervention, and the same measurement scale for pain should be used across
all disciplines, from anesthesia to the bedside nurse.

Systemic pain control
Opioid administration
Until recently, opioids have been the mainstay of analgesia in the postoperative robotic surgery patient.
They have proven value in managing severe pain. Opioid administration begins intravenously in the
perioperative period. It usually continues via intravenous methods until the patient is awake and able to
take a diet without difficulty. This can take up to a day depending on the patient’s reaction to anesthesia,
timing of the surgery, and individual pain perception. Patient controlled analgesia (PCA) is an accepted
route of intravenous (IV) opioid administration. It has a high acceptance level among patients and
allows for quick and easy administration. However, this technique is not always necessary in the patient
undergoing minimally invasive surgery and should be considered on an individual basis. Intravenous
opioids should be converted to the oral route as soon as possible. While intravenous opioids have rapid