Effective perioperative pain management remains a cornerstone in enhancing recovery and improving patient outcomes in laparoscopic cholecystectomy. This minimally invasive procedure, although less traumatic compared to open surgery, can still lead to significant postoperative pain, particularly in the early hours following the operation. Insufficient pain control may result in delayed mobilization, prolonged hospital stays, and increased opioid consumption, which are associated with adverse side effects and a heightened risk of complications . Regional anesthesia techniques have garnered significant attention for their ability to provide localized, opioid-sparing analgesia, thereby improving postoperative recovery profiles.External Oblique Intercostal Plane Block (EOIP) is a relatively new regional anesthesia technique targeting the intercostal nerves (T7-T11) as they traverse the plane between the external and internal oblique muscles. This block has demonstrated efficacy in controlling postoperative pain for upper abdominal surgeries, including laparoscopic cholecystectomy. By selectively anesthetizing the sensory branches of the thoracoabdominal nerves, the EOIP block provides localized analgesia with minimal motor blockade, making it an ideal choice for early mobilization (Ouchi et al., 2020).Recent advancements in ultrasound-guided techniques have improved the precision and safety of the EOIP block, allowing for consistent blockade of the targeted nerves. Clinical trials have highlighted its ability to reduce the pain significantly in the first 24 hours postoperatively, along with a marked decrease in the need for rescue analgesics. Tranrversus abdominis plane block (TAP) , first described in the early 2000s, has undergone several modifications to improve its efficacy in abdominal surgeries. The subcostal TAP block targets the anterior branches of the lower thoracic nerves (T6-T9) to provide analgesia to the upper abdominal wall. This technique is particularly suited for laparoscopic cholecystectomy, where the pain originates predominantly from the pari0etal peritoneum and abdominal wall incisions.The single puncture technique of Rectus sheath block (RSB) combined with transversus abdominis plane block (TAPB) represents a more streamlined approach to abdominal wall analgesia. ultrasonography (US) guidance for peripheral nerve blocks has become more and more popular. Transversus abdominis plane block (TAPB) and US-guided rectus sheath block (RSB) have been utilized in abdominal surgeries and have shown strong analgesic effects. Prior researches has demonstrated that in abdominal surgery, US-guided (TAPB) in conjunction with (RSB) had superior analgesic effects than either (TAPB) or (RSB) alone. Currently, multipoint nerve block procedures are generally applied in clinical practice, but they are difficult and can increase the patient's suffering. A novel method is proposed based on the neuromuscular anatomy and the location of the incisiopn in laparoscopic upper abdominal surgery: US-guided transverse abdominis plane and rectus sheath block one-puncture .
Patients undergoing elective laparoscopic cholecystectomy
American Society of Anesthesiologists (ASA) 1-II
aged 18-70 years
both genders will be included.
coagulation disorders
liver/kidney disease
History of abdominal surgery
infection in the block application area
Parallel
External intercostal plane puncture
Procedure/SurgeryPatients in this group will receive external intercostal plane block bilaterally, the block will be performed under ultrasound guidance after induction of general anesthesia using 20 ml of 0.25% bupivacaine injected into the external oblique intercostal plane on each side.
control group (nalbuphine)
DrugPatients in this group will not receive any intervention or nerve block.
the single-puncture technique of (rectus sheath block) combined with (Transversus abdominis plane block)
Procedure/SurgeryPatients in this group will receive rectus sheath block (RSB) combined with transversus abdominis plane block (TAPB) bilaterally via single puncture, the block will be performed under ultrasound guidance after induction of general anesthesia using 20 ml of 0.25% bupivacaine divided into 10 ml of 0.25% bupivacaine will be injected when the needle reaches the posterior rectus abdominis sheath and pierces the anterior layer of the posterior sheath, Then, the needle will break through the posterior layer of the tendon to the transversus abdominis plane and another 10 ml of 0.25% bupivacaine will be injected into transversus abdominis plane .
Decrase the consumption of opioids
The primary outcome of the study will be the amount of opoid (nalbuphine) consumption in the first 24 hours postoperatively.
The analgesic efficacy (sensory assessment)
Sensory assessment by defined dermal zones at 1, 2, 6, 12, and 24 hours postoperatively. The specific dermal zones will be described by vertical lines at the midline (A), mid-clavicular line (B), anterior axillary line (C), mid-axillary line (D), posterior axillary line (E), infrascapular line (F), and back midline (J). Four horizontal lines at the xiphoid level (a),12th costal level (b), the umbilical level (c), the anterior superior iliac spine to the pubic symphysis line (d), and extension to the back to the anterior superior iliac spine level (e). An additional zone will be defined as the upper 1/3 of the front thigh . Sensory assessment will be achieved using 70% ethyl alcohol swab and pinprick at 1,2, 6, 12, and 24 hours postoperatively after extubation at specific dermal zones divided by anatomic landmark lines on the abdomen, the back, and the thigh. Effective analgesic efficacy was defined as loss of cold temperature sensation to alcohol swab or loss of pinprick pain sensat
Pain intensity
pain intensity will be assessed at rest and during coughing using verbal rating scale (Jensen \& Karoly 1992) every hour till 6 hour, then every 2 hours till 12 hours, then every 4 hours till 24 hours. postoperatively as: No pain (=1) , Mild pain(=2) , Moderate pain(=3) , Sever pain(=4).
Off bed activity
time of the first off-bed activity after surgery in minutes , comparison between all arms and intervention
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