Description: This video demonstrates a novel surgeon-administered intraoperative brachial plexus block performed during open shoulder surgery through the standard deltopectoral approach. The aim is to provide predictable, prolonged pain control while improving operative efficiency and avoiding the complications of traditional interscalene blocks.

Patient preparation: Patients are placed under general anesthesia in the beach chair position at approximately 45°. While exposure is developed, the scrub technician prepares Gelfoam pledgets soaked in 0.5% bupivacaine and a 5 mL syringe attached to a pediatric size 8 Foley catheter. Preparation is performed in parallel with exposure so no additional operative time is required.

Step 1: Site definition.

During early deltopectoral exposure, the interval between the conjoined tendon and pectoralis minor is identified. This fat-filled window provides direct access to the brachial plexus without additional incisions. A small fascial slit is developed, with gentle palpatory dissection to confirm the plexus while avoiding injury.

Step 2: Channel creation.

A controlled channel is created superficial to the brachial plexus trunks, extending toward the suprascapular nerve, which defines its superior limit. This ensures the anesthetic will lie directly over the plexus rather than dispersing unpredictably.

Step 3: Placement of catheter and anesthetic.

The catheter tip is guided into the prepared channel. Bupivacaine-soaked Gelfoam pledgets (approximately 5–6 pieces) are loosely packed into the space to act as both a dam and a reservoir. This design retains the anesthetic adjacent to the plexus and permits sustained release. After placement, 5 mL of bupivacaine is injected proximal to the dam. The fascial slit naturally narrows once retractors are released, securing the pledgets in position. Care is taken not to overpack the space, preventing compression of neural structures.

Clinical outcomes: This technique has been performed in more than 200 patients. Ninety-six percent reported satisfactory pain control, with most requiring only minimal oral opioids. No cases of rebound pain, respiratory compromise, or brachial plexus neuropathy were observed. Three patients with chronic opioid use presented for additional pain support within 48 hours, and one unrelated pulmonary embolus was reported. No conversions to inpatient care for uncontrolled pain occurred.

Conclusion: The surgeon-administered intraoperative brachial plexus block is safe, efficient, and reproducible. It integrates seamlessly into standard surgical workflow, requires approximately two minutes to perform, and avoids the cost, complexity, and complications of interscalene nerve blocks. By combining direct visualization with a Gelfoam reservoir system, this technique delivers consistent and prolonged pain relief and represents a practical alternative to the current gold standard of ultrasound-guided interscalene block.