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Purpose This study investigated whether the divided method of multi-level intercostal nerve block (ML-ICB) could reduce the ropivacaine dose required during thoracoscopic pulmonary resection, while maintaining the resting postoperative pain scores. Methods This retrospective, single-cohort study enrolled 241 patients who underwent thoracoscopic pulmonary resection for malignant tumors between October 2020 and March 2022 at a cancer hospital in Japan. ML-ICB was performed by surgeons under direct vision. The differences in intraoperative anesthetic use and postoperative pain-related variables at the beginning and end of surgery between group A (single-shot ML-ICB; 0.75% ropivacaine, 20 mL at the end of the surgery) and group B (divided ML-ICB, performed at the beginning and end of surgery; 0.25% ropivacaine, 30 mL total) were assessed. The numerical rating scale (NRS) was used to evaluate pain 1 h and 24 h postoperatively. Results Intraoperative remifentanil use was significantly lower in group B (14.4 ± 6.4 [mu]g/kg/h) than in group A (16.7 ± 8.4 [mu]g/kg/h) (P = 0.02). The proportion of patients with NRS scores of 0 to 3 at 24 h was significantly higher in group B (85.4%, 106/124) than in group A (73.5%, 86/117) (P = 0.02). The proportion of patients not requiring postoperative intravenous rescue drugs was significantly higher in group B (78.2%, 97/124) than in group A (61.5%, 72/117) (P < 0.01). Conclusion The divided method of ML-ICB could reduce the intraoperative remifentanil dose, decrease the postoperative pain score at 24 h, and curtail postoperative intravenous rescue drug use, despite using half the total ropivacaine dose intraoperatively., Author(s): Aiko Nakai [sup.1], Jyunya Nakada [sup.1], Yusuke Takahashi [sup.2], Noriaki Sakakura [sup.2], Katuhiro Masago [sup.3], Sakura Okamoto [sup.1], Hiroaki Kuroda [sup.2] Author Affiliations: (1) https://ror.org/03kfmm080, grid.410800.d, 0000 0001 0722 [...]