Association between modified same-intercostal chest tube placement and acute postoperative pain after uniportal VATS lobectomy: an overlap weighted retrospective cohort study

Background: Chest tube placement is a routine but critical component of uniportal video-assisted thoracoscopic surgery (VATS). The routine method places the chest tube directly through the working incision, which may exacerbate acute postoperative pain. Multiple modified placement strategies have been proposed, yet evidence evaluating their comparative effectiveness on pain outcomes remains limited. This study examined the association between a newly proposed modified same-intercostal chest tube placement and acute postoperative pain following uniportal VATS lobectomy. Methods: This retrospective cohort study included adult patients undergoing elective uniportal VATS lobectomy at a tertiary medical center in Beijing, China, from June 2021 to June 2023. Among 1,701 screened patients, 1,082 met inclusion criteria. The exposure was tunneled same-intercostal chest tube placement, which creates a short subcutaneous and intramuscular tunnel along the superior border of the lower rib without traversing the rib or accessing an adjacent intercostal space. The primary outcomes were moderate-to-severe pain at rest within the first 24 hours. Propensity score overlap weighting was applied to achieve baseline covariate balance. Weighted logistic regression estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Pragmatic care-adjusted sensitivity analyses incorporated both baseline covariates and postoperative covariates. Results: < 0.001). Conclusions: The modified tunneled chest tube placement technique may meaningfully improve acute postoperative pain after uniportal VATS.