Awake breast surgery combines the reduction of hospitalization, postoperative stress, and postoperative lymphopenia, furthermore local anaesthesia and peripheral nerve block provide better analgesia during glandular displacement techniques, as during oncoplastic and axillary surgery. COVID-19 outbreak determined a strong effect on clinical practice worldwide1 and novel approach as awake breast surgery could combine fast track surgery and cross-infection reduction with an optimization of resources and resource optimization in terms of spaces and economic savings with shorter hospital stays.

Fast track awake breast surgery provides a reduction of operative room time length of stay and potentially surgical treatment for a wider number of oncological patients.

Costa et al proposed, to perform regional anaesthesia for breast procedures, a combination of three techniques: Pecs II block to cover muscles, axilla and lateral cutaneous branches of intercostal nerves (reliably from T2 to T4), erector spinae block block to cover lateral cutaneous branches from T4 to T7 and parasternal block or transversus thoracic muscle plane block to cover anterior cutaneous branches.

The introduction of erector spinae block in breast surgery, represents an alternative to general anaesthesia and locoregional conventional techniques, like epidural anaesthesia or paravertebral block in oncological breast surgery, especially in high-risk patients.

Santonastaso et al, wonder if the secret to obtaining perfect anaesthesia/analgesia for radical mastectomy procedures associated with sentinel lymph node biopsy, when we need to avoid general anaesthesia, could be the association of multiple techniques between Pecs, Serratus Anterior Block and Erector Spinae Block. More randomized trials are required to provide a certain answer to this question.

References

1. Vanni G, Pellicciaro M, Materazzo M, et al. Awake breast cancer surgery: strategy in the beginning of COVID-19 emergency. Breast Cancer 2021;28:137–144.

2. Costa F, Strumia A, Remore LM, Pascarella G, Del Buono R, Tedesco M, et al. Breast surgery analgesia: another perspective for PROSPECT guidelines. Anaesthesia 2020;75:1404–5.

3. Santonastaso D, Dechiara A, Bagaphou CT, Cittadini A, Marsigli F, Russo E, Agnoletti V. Erector spinae plane block associated to serratus anterior plane block for awake radical mastectomy in a patient with extreme obesity. Minerva Anestesiologica 2021 June;87(6):734–6.