Compared with conventional sternotomy, minimally invasive cardiac surgery (MICS) is associated with significant advantages such as reduced tissue trauma, faster recovery, and shorter hospital stay. However, the management of postoperative pain caused by intercostal nerve injury, pleural irritation, and tissue retraction remains a major challenge. Despite the less invasive nature of MICS, patients often report experiencing pain similar to that experienced following conventional cardiac surgery, particularly during the acute postoperative period. Effective pain management is essential for optimizing recovery, reducing the consumption of opioids, and preventing the transition to chronic postsurgical pain. Regional anesthesia techniques play a key role in multimodal analgesia for MICS. Thoracic epidural analgesia exhibits strong analgesic efficacy
nevertheless, it remains underutilized owing to concerns regarding anticoagulation-related complications and hemodynamic instability. The thoracic paravertebral block is a safer alternative that provides comparable pain relief with fewer side effects. Similarly, ultrasound-guided fascial plane blocks, such as serratus anterior, parasternal intercostal, interpectoral + pectoserratus, and erector spinae plane blocks, have gained popularity owing to their safety and feasibility
however, the effectiveness of these blocks varies according to the surgical approach and type of incision. Systemic analgesia is an integral component of multimodal pain management in MICS. Despite the efficacy of opioids, a shift toward opioid-sparing strategies has been observed given the significant adverse effects associated with the use of opioids. Intravenous adjuncts such as dexmedetomidine, ketamine, and non-steroidal anti-inflammatory drugs can reduce opioid consumption and improve postoperative pain control. Despite advances in pain management, a single approach that can provide comprehensive analgesia for MICS remains to be established. A multimodal strategy that combines systemic and regional techniques must be developed to optimize pain management and long-term outcomes.