Surgery · Medical Literature
Modified Thoracoabdominal Nerves Block Through the Perichondrial Approach vs Subcostal Transversus Abdominis Plane Block for Postoperative Recovery After Laparoscopic Cholecystectomy: A Prospective, Randomized Clinical Trial.
Abstract
BACKGROUND This study compared the effects of ultrasound-guided modified thoracoabdominal nerves block through the perichondrial approach (M-TAPA) and subcostal transversus abdominis plane (TAP) block on postoperative recovery after laparoscopic cholecystectomy. MATERIAL AND METHODS Sixty patients aged 18-65 years with American Society of Anesthesiologists physical status I-II undergoing elective laparoscopic cholecystectomy under general anesthesia were included. At the end of surgery, patients were randomly assigned to receive either ultrasound-guided subcostal TAP block (group T, n=30) or M-TAPA block (group M, n=30), with 20 mL of 0.25% bupivacaine administered on each side. Primary outcome was postoperative recovery at 24 hours (Quality of Recovery-15 [QoR-15] questionnaire). Secondary outcomes included postoperative pain scores (numerical rating scale [NRS]) at 0, 2, 4, 8, 16, and 24 hours, rescue analgesic requirements, and postoperative adverse effects. RESULTS The groups were comparable in age, height, weight, duration of surgery, and anesthesia-related variables (all P>0.05). Twenty-four-hour QoR-15 scores were similar between groups (P>0.05). Likewise, NRS pain scores did not differ significantly between groups (P>0.05). Significantly fewer patients required rescue analgesia in group M than in group T (30.0% vs 60.0%, P=0.020). Total rescue analgesic dose did not differ between groups (P=0.943). Postoperative adverse effects were comparable (P>0.05). CONCLUSIONS In patients undergoing laparoscopic cholecystectomy, ultrasound-guided M-TAPA block did not provide superior postoperative recovery, as assessed by QoR-15, compared with subcostal TAP block. Nevertheless, significantly fewer patients in the M-TAPA group required rescue analgesia (30.0% vs 60.0%, P=0.020), although total rescue analgesic consumption was similar between the groups.
Clinical relevance
Laparoscopic cholecystectomy is one of the most commonly performed surgical procedures worldwide, and optimizing multimodal analgesia remains a clinical priority to enhance postoperative recovery and reduce opioid consumption. This prospective RCT addresses an evidence gap by directly comparing two ultrasound-guided regional anesthetic techniques — M-TAPA and subcostal TAP block — in an ASA I–II population, for whom enhanced recovery is both feasible and expected. The findings are timely given increasing interest in fascial plane blocks as opioid-sparing strategies in ambulatory and short-stay surgical settings.
Key findings
1. Primary outcome — 24-hour QoR-15 scores were statistically similar between the M-TAPA group (Group M, n=30) and subcostal TAP block group (Group T, n=30), with no significant between-group difference (P>0.05), indicating non-superiority of M-TAPA for overall postoperative recovery quality. 2. Postoperative pain scores (NRS) assessed at 0, 2, 4, 8, 16, and 24 hours postoperatively did not differ significantly between groups at any time point (all P>0.05). 3. Rescue analgesia requirement was significantly lower in Group M vs Group T (30.0% vs 60.0%, P=0.020), representing a clinically meaningful reduction in the proportion of patients needing additional analgesic intervention. 4. Total rescue analgesic dose consumed was not significantly different between groups (P=0.943), suggesting that when rescue analgesia was needed, the amount required was comparable regardless of block technique. 5. Postoperative adverse effects were comparable between both groups (P>0.05), supporting a similar safety profile for M-TAPA and subcostal TAP block. 6. Both groups received standardized bilateral blocks with 20 mL of 0.25% bupivacaine per side, and baseline demographic and operative variables (age, height, weight, surgical duration, anesthesia parameters) were well-matched (all P>0.05), supporting internal validity.
Practice implications
For anesthesiologists performing regional analgesia in elective laparoscopic cholecystectomy in ASA I–II patients, M-TAPA block may be preferred over subcostal TAP block when the clinical goal is to minimize the proportion of patients requiring rescue analgesia, as it reduced rescue analgesia need by 50% in relative terms (30% vs 60%, P=0.020), though it does not confer superior overall recovery quality as measured by QoR-15. Clinicians should note that both techniques, using bilateral 0.25% bupivacaine 20 mL per side, produced equivalent pain scores and adverse effect profiles, and the choice between them may ultimately depend on operator experience, anatomical considerations, and institutional familiarity with each technique. Given that the total rescue analgesic dose was equivalent when needed, future trials with larger sample sizes and active opioid-consumption endpoints are warranted to determine whether the rescue analgesia difference translates into clinically meaningful reductions in opioid-related outcomes or hospital length of stay.