“Will it hurt?” is the question almost every patient asks before lung surgery. The honest answer is that pain after lung surgery is managed by layering several techniques together, not by relying on one strong painkiller. During the operation, the surgeon places long-acting local anaesthetic blocks across 5 to 6 ribs under direct vision, soothing the nerves that supply the chest wall. A patient-controlled pain pump (PCA) covers the first 24 to 48 hours. Paracetamol and an anti-inflammatory tablet are given alongside where suitable. The goal is that you are awake, comfortable, coughing, taking a deep breath and walking on the day after surgery — because being able to move is what protects you from the complications of lying in bed. Private appointments within 2–3 working days. Self-referrals welcome.
Last reviewed: May 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Several techniques work together — surgeon-placed nerve blocks, a patient-controlled pain pump, simple painkillers layered to keep you comfortable.
Long-acting local anaesthetic spread along the intercostal nerves across multiple levels by the surgeon during the operation.
Adequate pain relief protects you from clots in the legs, chest infections and a sluggish bowel — risks that come from being stuck in bed.
Pain after lung surgery is not one experience — it is four distinct phases, each managed differently. The hours in theatre. The first 24 to 48 hours in recovery. The few days on the ward. The weeks at home. The technique that works for each phase is different, and the plan is decided before you go to sleep, not improvised once you wake up.
Each phase has a clear goal: not the absence of all sensation, but enough pain control that you can cough, take a deep breath, and walk. That is what protects the lungs after surgery and lets recovery move forward. Discuss your pain plan with Dr Okiror before surgery →
Pain control is not a single decision made at the end of the operation. It is a planned sequence designed to keep you comfortable through four distinct phases of recovery, each of which calls for different techniques. Knowing what to expect in each phase is one of the most useful things you can do before surgery.
You are under general anaesthetic. The anaesthetist gives strong painkillers through the drip. The surgeon places long-acting local anaesthetic blocks across 5 to 6 ribs at the end of the operation, while still looking inside the chest. The anaesthetist may also have placed a block before the operation started, under ultrasound guidance.
You wake up alert. The intercostal blocks are still working. The patient-controlled pain pump (PCA) is by the bedside — you press the button if you need top-up. Paracetamol and an anti-inflammatory tablet are given regularly. The goal of day one is sitting up, coughing, taking a deep breath, and walking.
The PCA is weaned and replaced with oral painkillers. Most patients having keyhole or robotic surgery go home within 2 to 4 days; thoracotomy takes longer. By discharge, you should be walking comfortably and managing on regular paracetamol with an anti-inflammatory and a small amount of mild opioid for breakthrough.
Pain settles steadily. Patients commonly notice zinging sensations, occasional sharp twinges along the incision, and a numb patch around the scars — these are the small nerves healing and are not pain in any harmful sense. Most patients are off all painkillers within 2 to 4 weeks.
The main form of local pain relief for keyhole (VATS) and robotic lung surgery is a series of injections of long-acting local anaesthetic, placed by the surgeon at the end of the operation. The anaesthetic is levobupivacaine 0.25% — a refined version of the kind of local anaesthetic you would have at the dentist, but designed to last 12 to 18 hours rather than a couple of hours.
What makes the block effective is that it is multi-level — spanning 5 to 6 intercostal spaces, not just one. The nerves that supply sensation to the chest wall run along the under-surface of each rib, and they need to be blocked not only at the level of the operation but at the ribs above and below as well. Spreading the local anaesthetic along the nerves of multiple ribs in a single operation is what gives reliable pain relief across the whole area.
The blocks are placed under direct vision. Through the camera, the surgeon is looking at the nerve being injected. The local anaesthetic is delivered precisely where it needs to go and the spread along the nerve can be confirmed visually. This is a different proposition from blocks placed blindly from the outside.
Blocks placed from the outside by feel or by ultrasound work, but rely on the operator interpreting indirect signals. When the surgeon is looking at the nerve through the camera and watches the local anaesthetic spread along it, placement is precise and confirmed in real time. That visual confirmation is what intrathoracic, surgeon-placed blocks add over external techniques.
For an open operation (thoracotomy), a paravertebral catheter is used instead of a single set of intercostal blocks. The same approach is used for patients who already have chronic pain or who take long-term strong painkillers — situations where a one-off block is unlikely to provide enough cover.
A paravertebral catheter is a small, soft tube placed by the surgeon during the operation. It sits in the space just next to the spine, where the nerves emerge from the spinal cord on their way out to the chest wall. The catheter is connected to a small pump that delivers a continuous trickle of long-acting local anaesthetic for several days after surgery. The pain relief extends for as long as the catheter is in place, which is usually until the chest drains come out and you are mobile and comfortable on oral painkillers.
The reason for using a paravertebral catheter for thoracotomy is straightforward. An open operation involves a longer wound and more extensive disturbance of the chest wall than keyhole surgery, and the pain typically takes longer to settle. Continuous local anaesthetic over several days is the most reliable way to keep that pain in check, alongside the PCA, paracetamol and anti-inflammatories.
A paravertebral catheter is not the same as an epidural. An epidural sits inside the spinal canal itself; a paravertebral catheter sits outside it, just to the side of the spine. The bleeding and infection risks are different and lower, and patients on blood thinners can usually still have a paravertebral catheter when an epidural would not be safe.
Pain control in modern thoracic surgery is a collaboration between the surgeon and the anaesthetist. Before the operation begins, the anaesthetic team sometimes places blocks under ultrasound guidance — injecting local anaesthetic around the nerves at the back of the chest wall before the surgery starts. The surgeon then adds the intrathoracic blocks at the end of the operation.
The two are complementary rather than competing. A preoperative anaesthetic block, when used, gives a head start on pain control from the moment of incision. The intraoperative surgical block then extends the cover for the hours and days that follow. Whether a preoperative block is needed depends on the planned operation, the patient, and the anaesthetic team's judgement on the day — it is not required for every case.
The anaesthetist also manages the strong painkillers given through the drip during the operation itself. By the time you wake up, the local anaesthetic blocks are working, the strong drip painkillers are wearing off, and the PCA is ready to use. The handover between phases is what keeps the experience smooth.
Patient-controlled means you give yourself the dose when you need it — you do not have to ask a nurse and wait. Studies show patients who control their own analgesia use less total opioid and report better pain control than patients given fixed doses on a schedule. Putting you in charge of the pump is what makes it work.
A PCA is a small electronic pump connected to the drip in your arm. It delivers a measured dose of a strong painkiller (typically morphine or fentanyl) every time you press a button. The pump sits next to the bed and you keep the button handle.
The most common worry patients have about a PCA is that they might give themselves too much. The pump is designed so that you cannot. After each press, it locks itself out for several minutes — another press in that window does nothing. The total dose over each hour is also capped. The settings are individualised to you and reviewed by the team. If you fall asleep, you stop pressing, and that is the natural safety mechanism.
Most patients use the PCA most heavily in the first 12 hours and then less frequently as the local anaesthetic blocks settle the chest wall pain. By 24 to 48 hours, most patients are eating and drinking and ready to switch to oral painkillers. The PCA comes off then.
Pain felt at the tip of the shoulder after chest surgery is universally surprising to patients. The operation was on the chest. Why does the shoulder hurt? The answer lies in how the brain interprets nerve signals.
The diaphragm — the breathing muscle that separates the chest from the abdomen — shares its main nerve supply (the phrenic nerve) with the skin over the shoulder. When the diaphragm is gently irritated by air, fluid or instruments inside the chest during surgery, the signal travels up the phrenic nerve, and the brain interprets it as coming from the shoulder. This is called referred pain. It is not a sign of anything wrong with the shoulder itself.
Most patients find shoulder tip pain settles within a few days with simple measures: a warm compress, gentle movement, regular paracetamol and an anti-inflammatory. It does not respond well to strong opioid painkillers because the underlying problem is nerve signalling, not tissue injury. Knowing in advance what it is and that it will pass is half of dealing with it.
For some patients, a phrenic nerve block is placed at the end of the operation to reduce shoulder tip pain specifically. This involves injecting a small amount of long-acting local anaesthetic around the phrenic nerve where it runs alongside the heart.
The phrenic block is particularly useful for young women undergoing surgery for thoracic endometriosis on the diaphragm, where shoulder tip pain can otherwise be severe. It is not used routinely — the decision is made case by case depending on the operation and the diaphragmatic involvement. For most lung operations, simple measures and a warm compress are enough.
The single most important reason to take pain relief seriously after thoracic surgery is not how it feels. It is what it allows you to do. We expect you to be up and about the day after surgery — sitting in a chair, walking to the bathroom, coughing, taking deep breaths. You cannot do any of that if you are in pain.
Beyond keeping you comfortable, adequate pain relief reduces the risk of complications that come from staying in bed:
Multimodal pain control — layering several techniques together rather than relying on strong painkillers alone — is what allows day-one mobilisation to be the standard rather than the exception. It is the foundation of modern thoracic surgical recovery.
You will go home with a small supply of oral painkillers. The plan is usually regular paracetamol, an anti-inflammatory tablet (such as ibuprofen) where suitable, and a short course of a mild oral opioid for breakthrough pain only — taken when needed, not on a fixed schedule. The aim is to taper off the opioid first, then the anti-inflammatory, with paracetamol as the last to stop.
Most patients are off all painkillers within 2 to 4 weeks. Some patients, particularly after thoracotomy or after operations that have involved significant chest wall disturbance, need them for longer. The team plans for this individually.
In the weeks after surgery, almost all patients notice:
These are signs of healing, not of anything wrong. They settle over weeks to months.
Pain that is worsening rather than improving, new fever or chills, increasing breathlessness, redness or fluid coming from a wound, or a feeling that something is not right — ring the team. Pain that is gradually settling, with normal energy returning, is the expected pattern.
No two patients are the same. The exact balance of intercostal blocks, paravertebral catheter, PCA, paracetamol and anti-inflammatory tablets — and whether a phrenic block is added — depends on the operation, on your individual circumstances, and on whether you have other conditions that affect medication choice. Patients on blood thinners, patients with chronic pain conditions, patients with kidney or liver disease, patients with previous bad experiences with opioids: each situation is planned for in advance.
If you are worried about pain control before surgery, that is the time to say so. The pain plan is set out at the preoperative consultation with Dr Okiror and again with the anaesthetic team before the operation. By the time you are wheeled into theatre, the plan should already be clear to you, and you should feel that your concerns have been addressed.
Private thoracic surgery and the full multimodal pain pathway are delivered at London Bridge Hospital (HCA UK) and The Lister Hospital Chelsea. Both have full anaesthetic, theatre, recovery and inpatient capacity, and both work with experienced thoracic anaesthetic teams. Outpatient consultations are available at LBH, The Lister, and at outreach clinics in Canary Wharf and the City of London. Private appointments are typically available within 2–3 working days. Most major insurers are recognised; self-pay is straightforward to arrange.
Common questions from patients and families about pain control before, during and after lung surgery. If your question is not answered here, please contact Jo Mitchelson.
Book a Consultation →Or call Jo Mitchelson, PA:
020 7952 2882
Appointments within 2–3 working days. Self-referrals welcome. Most major insurers recognised; self-pay straightforward to arrange.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
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