Laparoscopic cholecystectomy has become the gold standard for treating gallbladder diseases, including symptomatic gallstones and cholecystitis. Introduced by Dr. Erich Mühe in 1985, this minimally invasive procedure revolutionized surgical practice by providing an effective alternative to open cholecystectomy [1]. The technique offers significant advantages including faster recovery, shorter hospital stays, and reduced postoperative complications [2]. Despite these benefits, patients undergoing laparoscopic cholecystectomy may still experience moderate to severe postoperative pain, comprising both somatic pain from trocar site incisions and visceral pain from deep abdominal structures [3]. This pain is most intense during the first few hours post-surgery, particularly during coughing, respiratory movements, and mobilization [4]. Effective pain management is crucial as uncontrolled pain can prolong hospital stays, delay recovery, and increase opioid requirements. Recent studies have highlighted the efficacy of the Erector Spinae Plane (ESP) block as a regional anesthesia technique for managing postoperative pain. Forero et al. (2016) first described this ultrasound-guided technique, which involves injection of local anesthetic into the fascial plane deep to the erector spinae muscles [5]. This provides both visceral and somatic analgesia by affecting the ventral and dorsal rami of spinal nerves. Studies by Tulgar et al. (2019) demonstrated that ESP blocks significantly reduce postoperative pain scores and opioid consumption in the first 24 hours following laparoscopic cholecystectomy [6]. Port Site Infiltration (PSI) represents another approach to enhance postoperative pain control. This technique involves administering local anesthetics directly at trocar insertion sites to reduce pain originating from these areas. Bisgaard et al. (1999) reported that multiregional local anesthetic infiltration significantly reduced postoperative pain and analgesic use [7]. Similarly, Nazir et al. (2014) demonstrated that port site infiltration effectively reduced pain for up to 24 hours post-surgery [8]. While both techniques show promise for postoperative analgesia, limited comparative data exists regarding their relative efficacy. This study aims to compare the analgesic efficacy of ESP block versus PSI for postoperative pain management in patients undergoing laparoscopic cholecystectomy.

Study Design This prospective, randomized, double-blinded comparative study was conducted at the National Institute of Medical Sciences and Research, Jaipur, after institutional ethical committee approval. The study was performed over 18 months with allocation by envelope method using purposive sampling. Participants A total of 86 patients were enrolled and randomly assigned to two groups of 43 patients each. Inclusion criteria comprised patients aged 18-60 years with American Society of Anesthesiologists (ASA) Grade I-II scheduled for elective laparoscopic cholecystectomy. Exclusion criteria included patient refusal, ASA Grade III-IV, cardiac and renal disorders, history of allergy to local anesthetic agents, and conversion to open cholecystectomy. Interventions Group I (ESP Block): Patients received a right-sided ESP block at T10 vertebral level using 20 ml of 0.375% ropivacaine under ultrasound guidance in the left lateral decubitus position pre-induction. Group II (PSI): Patients received port site infiltration with 20 ml of 0.375% ropivacaine (5 ml per port site) after trocar removal before wound closure. Anesthesia Protocol All patients received standardized general anesthesia with fentanyl 2 μg/kg, propofol 2 mg/kg, and vecuronium 0.1 mg/kg for induction. Mechanical ventilation was maintained throughout surgery. Intraoperative fentanyl 1 μg/kg was administered if heart rate and blood pressure increased 20% above baseline. Outcome Measures Primary outcomes included time to first rescue analgesia and total opioid consumption in 24 hours. Secondary outcomes comprised Visual Analogue Scale (VAS) pain scores at rest, 30 minutes, one, three, six, 12, and 24 hours postoperatively, and incidence of postoperative complications including nausea, vomiting, and hypotension. Statistical Analysis Data were analyzed using SPSS software. Continuous variables were expressed as mean ± standard deviation. Statistical significance was determined using a p-value threshold of ≤ 0.05.

. Baseline Characteristics No significant differences were observed between groups for age, sex distribution, diagnosis or duration of surgery (p > 0.05). Variable Port Site Infiltration (n = 43) Erector Spinae Block (n = 43) p-value Age (years, mean SD) 33.40 8.58 41.79 11.35 0.053 Male : Female 20 : 23 32 : 11 0.007 Duration of surgery (min, mean SD) 96.76 13.32 110.81 10.98 0.359 2. Analgesic Efficacy Outcome Port Site Infiltration Erector Spinae Block p-value Time to first rescue analgesia (min, mean ± SD) 53.35 ± 5.80 57.67 ± 9.69 0.004 Total fentanyl 0–24 h (µg, mean ± SD) 210.46 ± 22.87 128.62 ± 18.65 0.034 3. Post-operative Pain Scores (VAS) Time point Port Site Infiltration (mean ± SD) Erector Spinae Block (mean ± SD) p-value At rest (PACU) 8.81 ± 0.39 8.49 ± 0.85 0.026 30 min 7.67 ± 0.64 7.40 ± 0.97 0.122 1 h 6.35 ± 0.65 5.84 ± 2.18 0.144 3 h 6.28 ± 0.59 5.72 ± 2.09 0.097 6 h 5.19 ± 2.24 6.00 ± 7.51 0.498 12 h 5.67 ± 2.00 2.40 ± 0.58 0.049 24 h 5.19 ± 2.15 2.00 ± 0.00 0.047 4. Post-operative Complications Complication Port Site Infiltration n (%) Erector Spinae Block n (%) p-value Nausea 5 (11.6) 4 (9.3) 0.488 Vomiting 3 (7.0) 2 (4.7) 0.441 Hypotension 2 (4.7) 1 (2.3) 0.252 Table legends Table 1: Baseline characteristics of study participants. Table 2: Primary analgesic outcomes at 24 h. Table 3: Post-operative pain intensity measured by Visual Analogue Scale. Table 4: Frequency of post-operative complications within 24 h.

This study demonstrates the superior efficacy of ESP block compared to PSI for postoperative analgesia following laparoscopic cholecystectomy. The ESP block provided significantly longer time to first rescue analgesia and reduced total opioid consumption, which aligns with findings from previous studies. The extended analgesic duration observed with ESP block can be attributed to its mechanism of action. As described by Adhikary et al. (2018), the ESP block affects both somatic and visceral pain pathways by spreading to paravertebral, epidural, and intercostal spaces [9]. This comprehensive coverage explains the superior pain control compared to PSI, which primarily addresses incisional pain at port sites. The significant reduction in opioid consumption with ESP block has important clinical implications. Krishna et al. (2020) similarly reported substantial decreases in opioid requirements with ESP blocks, highlighting their role in multimodal analgesia protocols [10]. This reduction is particularly relevant given current efforts to minimize opioid-related complications and address the ongoing opioid crisis. The lower VAS scores at 12 and 24 hours postoperatively in the ESP group suggest sustained analgesic benefits beyond the immediate postoperative period. This finding is consistent with research by Chin et al. (2017), who demonstrated prolonged analgesia with ESP blocks in thoracic surgery [11]. The sustained pain relief may contribute to faster recovery and improved patient satisfaction. Both techniques demonstrated comparable safety profiles, which is crucial for clinical implementation. The similar incidence of postoperative complications between groups indicates that ESP block does not introduce additional risks compared to PSI. This safety profile, combined with superior efficacy, supports the routine use of ESP blocks for laparoscopic cholecystectomy. Limitations This single-center study may limit generalizability of findings. The relatively short follow-up period of 24 hours does not capture long-term outcomes. Future multi-center studies with extended follow-up periods would strengthen the evidence base for ESP block utilization.

The Erector Spinae Plane block demonstrates superior postoperative analgesia compared to Port Site Infiltration in patients undergoing laparoscopic cholecystectomy. The ESP block provides significantly longer time to rescue analgesia, reduced opioid consumption, and lower pain scores at 12 and 24 hours postoperatively while maintaining a comparable safety profile. These findings support the implementation of ESP blocks as an effective component of multimodal analgesia protocols for laparoscopic cholecystectomy. Future research should explore the broader applications of ESP blocks in various surgical procedures and investigate long-term patient outcomes.

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