Postoperative Pain, Cholecystectomy, Laparoscopic, External Oblique Intercostal Plane Block, Modified Thoracoabdominal Nerve Block (M-TAPA)
Conditions
Keywords
Cholecystectomy, Postoperative Pain, External Oblique Intercostal Plane Block, Modified Thoracoabdominal Nerve Block Through Perichondrial Approach
Brief summary
This retrospective observational study aimed to compare three pain management techniques used after laparoscopic gallbladder removal (cholecystectomy): modified thoracoabdominal nerve block through the perichondrial approach (M-TAPA), external oblique intercostal plane (EOIP) block, and local anesthetic infiltration. The study included 90 adult patients who underwent elective laparoscopic cholecystectomy between January and April 2025. Patients were divided into three groups according to the pain management technique they received during routine clinical care, with 30 patients in each group. The primary outcome was pain intensity measured 2 hours after surgery using a visual analog scale (VAS). Additional outcomes included pain scores at 15 minutes and 4, 8, 16, and 24 hours after surgery, the need for additional opioid pain medication, and opioid-related adverse events. The study aimed to evaluate differences in postoperative pain control and the need for additional pain medication among these three techniques using previously collected medical records.
Detailed description
This single-center retrospective observational study was conducted at Pamukkale University Hospital, Turkey, using routinely collected clinical data from patients who underwent elective laparoscopic cholecystectomy between January and April 2025. Adult patients aged 18 years or older with American Society of Anesthesiologists (ASA) physical status I-II were eligible for inclusion. During routine clinical care, postoperative analgesic techniques had been assigned using a sequentially numbered, opaque, sealed-envelope procedure. The investigators conducting the subsequent retrospective analysis were not involved in treatment allocation. Three analgesic techniques were evaluated: M-TAPA Group: Patients received an ultrasound-guided bilateral modified thoracoabdominal nerve block through the perichondrial approach, with 20 mL of 0.25% bupivacaine administered on each side. EOIP Group: Patients received an ultrasound-guided bilateral external oblique intercostal plane block, with 20 mL of 0.25% bupivacaine administered on each side. Local Infiltration Group: Patients received local anesthetic infiltration around the four laparoscopic port sites using a total of 20 mL of 0.50% bupivacaine. All patients underwent standardized general anesthesia and received routine perioperative analgesic treatment. A total of 135 patients had been allocated during routine clinical care. Following retrospective application of the predefined eligibility criteria, 45 patients were excluded, leaving 90 patients for analysis (30 in each group). Postoperative pain intensity during movement was evaluated using the visual analog scale (VAS) at 15 minutes and 2, 4, 8, 16, and 24 hours after surgery. The primary outcome was the VAS pain score at 2 hours. Secondary outcomes included pain scores at the remaining assessment times, the proportion of patients requiring rescue opioid analgesia, and the incidence of opioid-related adverse events. The study compared postoperative analgesic outcomes associated with the three techniques under routine clinical practice conditions. Because the analysis was retrospective and the total local anesthetic dose differed between groups, the findings were interpreted as observational associations rather than definitive causal effects.
Interventions
PROCEDUREModified Thoracoabdominal Nerve Block Through the Perichondrial Approach
Bilateral ultrasound-guided modified thoracoabdominal nerve block through the perichondrial approach (M-TAPA) was performed after completion of laparoscopic cholecystectomy. Under sterile conditions, 20 mL of 0.25% bupivacaine was injected on each side into the fascial plane between the transversus abdominis muscle and the costochondral structure, for a total volume of 40 mL. The procedure was performed as part of routine clinical care.
PROCEDUREExternal Oblique Intercostal Plane Block
Bilateral ultrasound-guided external oblique intercostal plane (EOIP) block was performed after completion of laparoscopic cholecystectomy. Under sterile conditions, 20 mL of 0.25% bupivacaine was injected on each side into the fascial plane between the external oblique and intercostal muscles at the level of the sixth and seventh ribs, for a total volume of 40 mL. The procedure was performed as part of routine clinical care.
PROCEDURELocal anesthetic infiltration
Local anesthetic infiltration was performed by the surgeon at the end of laparoscopic cholecystectomy. A total of 20 mL of 0.50% bupivacaine was administered around the four laparoscopic port sites, with approximately 5 mL injected at each site. The procedure was performed as part of routine clinical care.
Sponsors
Pamukkale University
Study design
Observational model
COHORT
Time perspective
RETROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Adults aged 18 years or older. American Society of Anesthesiologists (ASA) physical status I-II. Patients who underwent elective laparoscopic cholecystectomy under general anesthesia between January and April 2025. Patients who received M-TAPA block, EOIP block, or local anesthetic infiltration as part of routine clinical care. Availability of complete medical records for postoperative pain assessment and analgesic outcomes
Exclusion criteria
Major organ failure, including renal, hepatic, or cardiac failure. Significant cardiovascular conditions, including atrioventricular block, unstable angina, myocardial infarction within the preceding 6 weeks, heart rate below 50 beats/min, or systolic blood pressure below 90 mmHg. Body mass index (BMI) ≥35 kg/m². Neurological or psychiatric disorders that could impair communication or pain assessment. Use of antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, or mirtazapine. Patients requiring additional surgical procedures. Patients undergoing anesthesia other than general anesthesia. Incomplete medical records.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Postoperative Pain Intensity at 2 Hours | 2 hours after surgery | Postoperative pain intensity during movement was assessed using the Visual Analog Scale (VAS) 2 hours after laparoscopic cholecystectomy. The VAS ranges from 0 to 10, where 0 indicates no pain and 10 indicates the worst imaginable pain. Lower scores indicate less postoperative pain. VAS scores were compared among the M-TAPA, EOIP, and local anesthetic infiltration groups. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Postoperative Pain Intensity at 15 Minutes | 15 minutes after surgery | Postoperative pain intensity during movement was assessed using the Visual Analog Scale (VAS), ranging from 0 (no pain) to 10 (worst imaginable pain). Lower scores indicate less pain. VAS scores were compared among the M-TAPA, EOIP, and local anesthetic infiltration groups. |
| Postoperative Pain Intensity at 4 Hours | 4 hours after surgery | Postoperative pain intensity during movement was assessed using the Visual Analog Scale (VAS), ranging from 0 (no pain) to 10 (worst imaginable pain). Lower scores indicate less pain. VAS scores were compared among the M-TAPA, EOIP, and local anesthetic infiltration groups. |
| Postoperative Pain Intensity at 8 Hours | 8 hours after surgery | Postoperative pain intensity during movement was assessed using the Visual Analog Scale (VAS), ranging from 0 (no pain) to 10 (worst imaginable pain). Lower scores indicate less pain. VAS scores were compared among the M-TAPA, EOIP, and local anesthetic infiltration groups. |
| Postoperative Pain Intensity at 16 Hours | 24 hours after surgery | Postoperative pain intensity during movement was assessed using the Visual Analog Scale (VAS), ranging from 0 (no pain) to 10 (worst imaginable pain). Lower scores indicate less pain. VAS scores were compared among the M-TAPA, EOIP, and local anesthetic infiltration groups. |
| Proportion of Patients Requiring Rescue Opioid Analgesia | Within 24 hours after surgery | The proportion of patients requiring additional opioid analgesia after surgery was assessed using routinely collected medical records. Rescue opioid requirement was recorded as a binary outcome (yes/no) and compared among the M-TAPA, EOIP, and local anesthetic infiltration groups. Results were expressed as the number and percentage of patients requiring rescue opioid treatment. |
| Incidence of Opioid-Related Adverse Events | Within 24 hours after surgery | The incidence of opioid-related adverse events, including nausea, vomiting, pruritus, hypotension, bradycardia, respiratory depression, and sedation, was assessed using routinely collected postoperative medical records. The occurrence of these events was compared among the three analgesic groups. |
Countries
Turkey (Türkiye)
Outcome results
None listed