Erector Spinae Plane Block Versus Modified Thoracoabdominal Nerve Block For Pain Control After Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) has largely replaced open cholecystectomy as the standard surgical treatment for symptomatic gallbladder disease. The minimally invasive approach is associated with significantly less postoperative pain, shorter hospital stay, faster return to normal activity, lower risk of wound infection, and better cosmetic results. (1,2) Despite these advantages, many patients still experience moderate to severe pain in the early postoperative period. This pain results from a combination of somatic pain at trocar insertion sites, visceral pain due to gallbladder bed irritation, and referred shoulder pain from diaphragmatic stretching caused by pneumoperitoneum. (3) Effective postoperative pain control is crucial not only to improve patient comfort but also to reduce opioid consumption, facilitate early ambulation, and decrease postoperative pulmonary complications. (4) Traditionally, postoperative analgesia following LC has relied on multimodal regimens including systemic non-steroidal anti-inflammatory drugs (NSAIDs), opioids, port-site local infiltration, and intraperitoneal local anaesthetic instillation. (5) While opioids remain an important analgesic option, their side effects-such as nausea, vomiting, respiratory depression, pruritus, and delayed recovery-can adversely affect the quality of postoperative recovery. (6) Consequently, there has been increasing interest in the use of ultrasound-guided regional anaesthetic techniques as part of multimodal analgesia to improve pain control and reduce opioid requirements after LC.

Among these regional approaches, the erector spinae plane block (ESPB) has gained significant attention in recent years. The ESPB involves injecting local anaesthetic into the fascial plane deep to the erector spinae muscle, typically at a thoracic vertebral level. This allows cranio-caudal spread and potential diffusion into the paravertebral and epidural spaces, resulting in both visceral and somatic analgesia across multiple dermatomes. (7) 4. It was found that bilateral Erector Spinae Plane Block has shown promising benefits for postoperative analgesia after laparoscopic cholecystectomy which includes, reduction in postoperative pain scores, reduced opioid requirements, improved recovery and improved postoperative respiratory function and these findings highlight ESPB as an effective, safe and easy to perform block for postoperative analgesia after laparoscopic cholecystectomy. (8) A newer alternative regional technique is the Modified Thoracoabdominal Nerve Block through the Perichondrial Approach (M-TAPA). First described by Tulgar et al., this block targets the anterior and lateral cutaneous branches of the thoracoabdominal nerves (T5-T12) by depositing local anaesthetic in the perichondral plane beneath the costal cartilage. (9) Its theoretical advantage lies in providing both anterior and lateral abdominal wall analgesia, which corresponds well to the sites of trocar insertion in LC. Early evidence has been promising and demonstrated that bilateral M-TAPA significantly reduced postoperative pain scores. M-TAPA significantly reduced 24-hour opioid consumption and decreased the incidence of postoperative nausea and vomiting and also shortened hospital stay and improved patient satisfaction following LC.

AIM OF THE WORK To compare the analgesic efficacy of the Erector Spinae Plane Block (ESPB) versus the Modified Thoracoabdominal Nerve Block through the Perichondrial Approach (M-TAPA) for postoperative pain control in patients undergoing laparoscopic cholecystectomy under general anaesthesia.

Primary outcome:

Time to First Analgesic request.