RIPB Versus EOIPB for Pain Control After Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is one of the most commonly performed minimally invasive abdominal surgical procedures. Although it is associated with less postoperative pain and faster recovery compared with open surgery, postoperative pain may still occur due to trocar insertion, abdominal wall trauma, pneumoperitoneum-related peritoneal irritation, and visceral manipulation. Inadequate analgesia may delay mobilization, increase analgesic consumption, contribute to postoperative nausea and vomiting, and negatively affect postoperative recovery.

Ultrasound-guided fascial plane blocks are increasingly used as part of multimodal analgesia strategies for abdominal surgery. These techniques may reduce postoperative analgesic requirements by targeting the thoracoabdominal nerve branches that supply the abdominal wall. The recto-intercostal plane block and the external oblique intercostal plane block are two ultrasound-guided fascial plane blocks that may provide analgesia for the upper abdominal wall through different anatomical planes.

This study is designed as a prospective observational study in patients scheduled for elective laparoscopic cholecystectomy under general anesthesia. Patients will be included according to the regional analgesia technique performed as part of routine clinical practice. Patients receiving bilateral recto-intercostal plane block will form the RIPB group, while patients receiving bilateral external oblique intercostal plane block will form the EOIPB group. Both blocks will be performed after anesthesia induction as part of a preemptive analgesia approach.

All patients will receive standardized general anesthesia and routine postoperative multimodal analgesia. Intravenous tramadol will be administered postoperatively using a patient-controlled analgesia device. Postoperative pain intensity will be evaluated using the Numeric Rating Scale at predetermined time points during the first 24 hours. Total tramadol consumption, rescue analgesic requirement, postoperative nausea and vomiting, quality of recovery, mobilization time, length of hospital stay, and possible block-related complications will be recorded.

The study aims to determine whether recto-intercostal plane block provides superior postoperative analgesia compared with external oblique intercostal plane block in patients undergoing elective laparoscopic cholecystectomy.

• Bilateral Ultrasound-Guided Recto-Intercostal Plane Block (Procedure): Bilateral recto-intercostal plane block was performed under ultrasound guidance after anesthesia induction. Local anesthetic was injected into the fascial plane between the rectus abdominis muscle and the intercostal structures as part of routine preemptive analgesia.
• Bilateral Ultrasound-Guided External Oblique Intercostal Plane Block (Procedure): Bilateral external oblique intercostal plane block was performed under ultrasound guidance after anesthesia induction. Local anesthetic was injected into the fascial plane between the external oblique muscle and the intercostal muscles as part of routine preemptive analgesia.

Primary outcomes

• Cumulative Postoperative Tramadol Consumption [Postoperative 24 hours]: Total intravenous tramadol consumption delivered via patient-controlled analgesia during the first 24 hours after surgery.

Secondary outcomes

• Postoperative Pain Scores at Rest [Postoperative 1, 3, 6, 9,12, 18, and 24 hours]: Pain intensity at rest assessed using the Numeric Rating Scale, ranging from 0 indicating no pain to 10 indicating the worst imaginable pain.
• Postoperative Pain Scores During Activity [Postoperative 1, 3, 6, 9, 12, 18, and 24 hours]: Pain intensity during activity assessed using the Numeric Rating Scale, ranging from 0 indicating no pain to 10 indicating the worst imaginable pain.
• Quality of Recovery [Postoperative 24 hours]: Quality of recovery assessed using the Quality of Recovery-15 questionnaire.Quality of recovery will be assessed using the Quality of Recovery-15 questionnaire. The Quality of Recovery-15 is a 15-item patient-reported outcome measure with a total score ranging from 0 to 150, where higher scores indicate better postoperative recovery.
• Rescue Analgesic Requirement [Postoperative 24 hours]: Number of patients requiring additional rescue analgesia due to Numeric Rating Scale score of 4 or higher.
• Postoperative Nausea and Vomiting [Postoperative 24 hours]: Incidence of postoperative nausea and vomiting during the first 24 hours after surgery.
• Length of Hospital Stay [From the date of surgery through the date of hospital discharge, assessed up to 30 days postoperatively.]: Duration of postoperative hospital stay until discharge.
• Block-Related Complications [Postoperative 24 hours]: Incidence of complications related to the regional block procedure, including pneumothorax and local anesthetic systemic toxicity.
• Intraoperative remifentanil consumption [From induction of anesthesia to the end of surgery]: Total dose of remifentanil administered during the intraoperative period for each participant, recorded from the anesthesia record and expressed in micrograms (µg).

Sex: All, ages: 18 Years to 75 Years

Inclusion Criteria:

* Age between 18 and 75 years
* American Society of Anesthesiologists (ASA) physical status I-III
* Scheduled for elective laparoscopic cholecystectomy under general anesthesia
* Written informed consent obtained

Exclusion Criteria:

* Refusal to participate
* Inability to understand the study protocol or provide informed consent
* Known allergy to local anesthetics, tramadol, paracetamol, dexketoprofen, or other study drugs
* Chronic opioid or steroid use
* Psychiatric or cognitive disorder preventing reliable pain assessment
* Inability to use patient-controlled analgesia
* Pregnancy or breastfeeding
* Coagulopathy
* Infection at the block site
* Difficult or prolonged intubation requiring three or more attempts
* Conversion to open surgery
* Surgery lasting longer than 120 minutes
* Intraoperative or postoperative complications requiring deviation from the standard analgesia protocol

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