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Gharagozloo. Mini-invasive Surg 2020;4:8 I http://dx.doi.org/10.20517/2574-1225.2019.62 Page 9 of 13

Figure 3. Tunneler for subpleural placement of local anesthetic catheters

thoracotomy and found that the use of extrapleural catheter for analgesia was superior to systemic
[30]
narcotics . In addition, the use of extrapleural catheters resulted in lower narcotic consumption and
[35]
decreased pulmonary complications. DiMaio et al. compared the use of a local infusion of an anesthetic
to an epidural catheter and found not only improved pain and decreased narcotic usage, but also improved
pulmonary function, as demonstrated by an increase in lung volumes. Choice of local anesthetic is surgeon
dependent. Moreover, the above-mentioned review did not find a difference in pain relief or postoperative
[30]
complications when comparing bupivacaine, lidocaine, and lignocaine . Complications related to the
catheter and the local anesthetic agents are low. Reported complications have been less than 0.6% and have
included: transient hypotension, transient Horner’s syndrome from placement of catheters above the third
intercostal space, transient ipsilateral femoral nerve dysfunction from placement of catheters lower than the
eighth intercostal space and infusion of the local anesthetic into the retroperitoneum, bupivacaine toxicity
[30]
in the form of confusion, transient elevation of liver enzymes, and rib osteomyelitis .

Technique for the placement of subpleural catheters after robotic surgery. https://youtu.be/2JaF3j4re40;
https://youtu.be/b49GXgEmyZM

The video of this technique can be accessed using the above links. Although several techniques have
been described, we have devised a rapid and reproducible technique for the extrapleural placement of the
catheters. With this technique, two soaker catheters are inserted through a subpleural tunnel that extends
from the second to the eighth intercostal spaces and encompasses the area of the trocars.

Following the completion of the robotic procedure and undocking of the robot, the camera trocar is
removed. An endoscopic camera (Olympus Endoeye 0 Degree) is introduced through the anterior port
and used to visualize the paravertebral pleura. In this technique, a specially designed tunneling device
is introduced through the camera port and used to begin the formation of a subpleural tunnel. After the
formation of the tunnel, the metal tunneling device is withdrawn and a peelable sheath is positioned over
the tunneler and replaced in the pleural tunnel. The metal tunneler is withdrawn and the sheath is left
in place inside the pleural tunnel. Two five-inch on-Q soaker catheters are introduced through separate
puncture sites placed anteriorly in the same intercostal space as the inferior incision [Figure 3]. The on-Q
soaker catheters are passed into the long subpleural sheath, and then the sheath is withdrawn and peeled
away, leaving the soaker catheters in the subpleural tunnel. The catheters are positioned in an overlapping
staggered manner to provide infusion of the local anesthetic for the entirety of the pleural tunnel extending
from the second to the eighth intercostal spaces. We use the on-Q Pain Buster soaker catheters (I-Flow
Corporation, Lake Forest, CA), which are small flexible catheters with multiple side holes that can deliver