Published online Jul 27, 2026. doi: 10.4240/wjgs.120890
Revised: June 25, 2026
Accepted: July 6, 2026
Published online: July 27, 2026
Processing time: 95 Days and 23.7 Hours
Laparoscopic appendectomy is the gold standard for treatment of acute ap
To compare the analgesic efficacy of ESPB vs TAPB for visceral pain and somatic pain following laparoscopic appendectomy.
A retrospective analysis was conducted on 183 patients who underwent laparoscopic appendectomy with ultrasound-guided nerve blocks between January 2021 and December 2024, including 91 patients in the ESPB group and 92 patients in the TAPB group. Both groups received bilateral blocks with 0.375% ropivacaine at a total volume of 30 mL. Visual Analog Scale (VAS) was used to assess visceral pain and somatic pain scores at rest and during activity at 2, 6, 12, 24, and 48 hours postoperatively. Rescue analgesia within 48 hours postoperatively, post
The ESPB group had significantly lower visceral pain VAS scores at rest and during activity at 2 hours, 6 hours, and 12 hours postoperatively compared with the TAPB group (P < 0.05), while no significant differences were observed at 24 hours and 48 hours postoperatively (P > 0.05). There were no significant differences in somatic pain VAS scores between the two groups at any time point (P > 0.05). The ESPB group had a lower rescue analgesia rate than the TAPB group (13.2% vs 26.1%, P = 0.029), less tramadol consumption (P = 0.012), and higher satisfaction scores with analgesia (P = 0.013). There were no significant differences between the two groups in time to first ambulation, time to first flatus, postoperative hospital stay, or incidence of nausea and vomiting (P > 0.05). No nerve block-related complications occurred in either group.
Compared with TAPB, ESPB provides better analgesia for visceral pain in the early postoperative period following laparoscopic appendectomy, while both techniques demonstrate equivalent analgesic effects for somatic pain. For patients with visceral pain as the predominant component postoperatively, ESPB may be a more appropriate choice.
Core Tip: This retrospective study compared the analgesic efficacy of erector spinae plane block (ESPB) and transversus abdominis plane block in patients undergoing laparoscopic appendectomy, with a specific focus on differentiating visceral and somatic pain. The results showed that ESPB provided significantly better control of early postoperative visceral pain within the first 12 hours compared with transversus abdominis plane block, while both techniques demonstrated similar effectiveness for somatic pain. Patients receiving ESPB also required less rescue analgesia and reported higher satisfaction with postoperative pain management. These findings suggest that ESPB may be a preferable regional analgesic technique for laparoscopic appendectomy when visceral pain is the predominant postoperative component.
- Citation: Cheng H, Liu C, Li MY. Erector spinae plane block vs transversus abdominis plane block for visceral and somatic pain after laparoscopic appendectomy. World J Gastrointest Surg 2026; 18(7): 120890
- URL: https://www.wjgnet.com/1948-9366/full/v18/i7/120890.htm
- DOI: https://dx.doi.org/10.4240/wjgs.120890
Laparoscopic appendectomy has become the standard surgical procedure for acute appendicitis due to its advantages of minimal trauma, rapid recovery, and fewer complications[1]. However, postoperative pain remains one of the main factors affecting early patient recovery and satisfaction[2]. Pain following laparoscopic surgery is multidimensional, primarily comprising visceral and somatic pain components[3]. Visceral pain originates from traction and inflammatory stimulation of intra-abdominal organs, peritoneal irritation caused by CO2 pneumoperitoneum, and other laparoscopic surgical insults[4], transmitted through visceral afferent nerves and manifesting as diffuse, poorly localized deep dull intra-abdominal pain; somatic pain results from surgical incision injury to somatic sensory nerves of the abdominal wall, with precise localization and exacerbation during movement. These two types of pain have different neural conduction pathways and respond differently to analgesic measures; therefore, targeted selection of analgesic strategies holds significant clinical importance.
Ultrasound-guided nerve blocks, as an important component of multimodal analgesia, can effectively reduce opioid consumption and decrease the risk of postoperative nausea and vomiting (PONV)[5]. Transversus abdominis plane block (TAPB) is currently the most widely used truncal nerve block technique in abdominal surgery, providing effective analgesia for somatic pain by blocking somatic sensory nerves of the T6-L1 segments in the abdominal wall[6,7]. Erector spinae plane block (ESPB) is an emerging fascial plane block technique that has attracted attention due to its simple operation and high safety profile[8]. Studies have demonstrated that local anesthetic injected deep to the erector spinae muscle can spread to the paravertebral space, blocking not only the dorsal and ventral branches of spinal nerves but potentially also affecting the sympathetic chain through communicating branches, thereby exerting inhibitory effects on visceral pain[9,10].
Current comparative studies on the analgesic effects of ESPB and TAPB in laparoscopic appendectomy mostly use overall pain scores or opioid consumption as observation endpoints, with few studies differentiating between visceral and somatic pain assessment[11]. This study aimed to compare the analgesic efficacy of ESPB vs TAPB for visceral and somatic pain following laparoscopic appendectomy through retrospective analysis, to provide a reference for clinical selection of nerve block techniques.
This was a retrospective single-center study, collecting clinical data from patients at our hospital who received laparoscopic appendectomy with ultrasound-guided nerve blocks during the period from January 2021 to December 2024. The hospital ethics committee approved this study, and informed consent was waived. As this was a retrospective observational study, no formal blinding of patients, outcome assessors, or care providers was implemented. Patients and nursing staff were aware of the assigned block technique, and pain assessments were performed by ward nurses without masking to group allocation. This absence of blinding may have introduced performance and detection bias, particularly for subjective endpoints such as Visual Analog Scale (VAS) and patient satisfaction, and should be considered a methodological limitation when interpreting the results.
Inclusion criteria: (1) Age between 18 and 65 years; (2) American Society of Anesthesiologists (ASA) classification I-III; (3) Preoperative diagnosis of acute appendicitis (including simple, suppurative, and gangrenous types) or chronic appendicitis who undergoing elective or emergency laparoscopic appendectomy; (4) Preoperative ultrasound-guided ESPB and TAPB; and (5) Complete clinical data.
Exclusion criteria: (1) Underwent conversion to open surgery; (2) Suffered from severe cardiac, pulmonary, hepatic, or renal dysfunction; (3) Had coagulation disorders or infection at puncture site; (4) Allergic to local anesthetics; (5) Long-term use of opioids or history of substance abuse; (6) Existence of psychiatric disorders or cognitive impairment affecting ability to cooperate in the evaluation of pain sensations; (7) Pregnancy or lactation; and (8) Concurrent diffuse peritonitis, appendiceal perforation combined with intra-abdominal abscesses that required placement of an active abdominal drainage tube. These patients were excluded primarily because of their fundamentally different postoperative pain phenotype: The ongoing intra-abdominal inflammatory process substantially amplifies visceral afferent signaling and produces a pain burden that is not representative of uncomplicated laparoscopic appendectomy. Including such patients would have introduced significant heterogeneity into the between-group visceral pain comparison and obscured the analgesic differences attributable to the block technique alone.
A total of 289 patients received either of the two nerve block techniques after preliminary screening. Based on the inclusion and exclusion criteria, a total of 183 patients were included in the study (91 patients for ESPB group vs 92 patients for TAPB group). The selection of block technique was determined by the attending anesthesiologist’s clinical preference. ESPB was introduced into routine practice at our institution from early 2021, initially coexisting with and gradually supplementing the pre-established TAPB standard, with the choice at each case left to the discretion of the operating anesthesiologist. No formal allocation protocol, randomization, or predefined clinical criteria governed this selection. This non-systematic assignment represents a potential source of selection bias and should be considered when interpreting the results.
The inclusion criteria were patients aged between 18 to 70 years, ASA physical status I-III and all nerve blocks were performed by anesthesiologist staff with more than 5 years experience in regional anesthesia before induction of general anesthesia using a portable ultrasound machine with a high-frequency linear array probe (frequency: 6-13 MHz) as guidance. Patients were monitored for 15-20 minutes after block completion until block onset, then general anesthesia induction was performed.
ESPB. Patients were placed in a lateral decubitus position with the affected side facing upwards. The ultrasound probe was used in the sagittal plane approximately 3 cm lateral to the T12 spinous process for visualization of the transverse process and overlying erector spinae muscle. The T12 level was specifically chosen because the visceral afferent innervation of the appendix and periappendicular structures enters the thoracolumbar sympathetic chain primarily at the T10-L2 levels, converging around T12-L1. Injection at this level enables local anesthetic to spread cranially within the deep erector spinae fascial plane to the lower thoracic paravertebral space (T10-T12) and caudally toward the upper lumbar levels, thereby covering the relevant visceral afferent pathways as well as the somatic cutaneous branches of the lower thoracic and upper lumbar spinal segments. By in-plane technique, 22G needle was advanced from cephalad to caudad until its tip reaches the fascial plane between deep surface of erector spinae muscle and transverse process’ surface. After negative aspiration, 15 mL of 0.375% ropivacaine was injected. The local anesthetic spread in a spindle-shaped distribution beneath the erector spinae muscle under ultrasound visualization. Following this, the patient was turned over and both contralateral block performed similarly under total bilateral injection of 30 mL of 0.375% ropivacaine.
Lateral TAPB patients were placed in the supine position. The ultrasound probe rotates transversely between the ileac crest and costal margin at the mid-axillary line visualizing three muscles layer which from superficial to deeper is external oblique, internal oblique, and transversus abdominis muscles. An in-plane technique to identify the fascial plane between the internal oblique and transversus abdominis using a 22G needle was advanced. After negative aspiration, 15 mL of 0.375% ropivacaine was injected on both sides, for a total of 30 mL bilaterally. The local anesthetic was advanced through the cannula with ultrasound visualization; it was noted to spread in a lenticular fashion along the fascial plane.
All patients received a standardized protocol for general anesthesia. On entering the operating theatre, standard monitoring was initiated which consisted of electrocardiography, non-invasive blood pressure, pulse oximetry and end-tidal carbon dioxide partial pressure. Peripheral venous access was established. The anesthesia induction was achieved by: Midazolam 0.03 mg/kg, sufentanil 0.3-0.4 μg/kg, propofol 1.5-2.0 mg/kg and rocuronium 0.6 mg/kg After tracheal intubation, mechanical ventilation was provided with a tidal volume of 6-8 mL/kg, respiratory rate of 10-14 breaths/minute and end-tidal carbon dioxide partial pressure in the range of 35-45 mmHg. Anesthesia was maintained using sevoflurane (end-tidal concentration 1.0%-2.0%) in combination with continuous intravenous infusion of remifentanil (0.1-0.2 μg/kg/minute). Depth of anesthesia was titrated based on changes in hemodynamics, maintaining bispectral index 40-60. Sevoflurane administration was stopped 10 minutes prior to the end of surgery, remifentanil was discontinued at the finish of surgical procedure and parecoxib sodium 40 mg intravenously were applied for background analgesia.
All surgeries were performed by a single surgical team with a standardized three-port laparoscopic appendectomy technique. An umbilical 10 mm port was placed as a camera port and two operating ports with 5 mm trocars were placed in the left lower quadrant and suprapubic region. Pneumoperitoneum was established with CO2 at a pressure of 12-14 mmHg. The mesoappendix was divided using an ultrasonic scalpel or electrocautery, and the appendiceal base was secured with double ligation or Hem-o-lok clips prior to transection. The specimen was removed via the umbilical incision. After the inspection of hemostasis, pneumoperitoneum was released and incisions were closed.
Both groups received postoperative multimodal analgesia. Intravenous parecoxib sodium 40 mg was given as a routine every 12 hours. In case the VAS score at rest for any patient was ≥ 4 points in the postoperative period, tramadol 100 mg was given intramuscularly as a breakthrough analgesic.
General data: Baseline data was collected for the two groups: (1) Demographic characteristics (age, gender, body mass index); (2) ASA classification; (3) Type of appendicitis (acute/chronic appendicitis), pathological classification; (4) Nature of surgery (elective/emergency); and (5) Intraoperative variables (operating time, pneumoperitoneum time, intraoperative blood loss, total amount of remifentanil used during the operation).
Primary outcome measures: VAS scoring was used to assess the severity of visceral and somatic pain at various postoperative time points (baseline: 2, 6, 12, 24, and 48 hours post-operatively after tracheal extubation). The VAS was a 10 cm ruler with the “0” end at no pain and the “10” end as intolerable intense severity of pain. Patients marked the line at whatever point they felt corresponded to their experience of the pain, with higher scores indicating greater intensity.
Further tests were conducted to differentiate the two types of pain: (1) Visceral pain VAS score: Patients were asked to point to their lower abdomen and rate, e.g., deep dull, distending or cramping abdominal pain which may be described by its diffuse vague localization with accompanying autonomic symptoms such as nausea in relation nerve root activation; and (2) Somatic pain VAS score: They were also instructed to identify the incision sites on the layers of ab
Secondary outcome measures: (1) Rescue analgesia after surgery: We recorded the number of patients using rescue analgesic medications (tramadol) as well as their total consumption for 48 hours post-surgery, calculating the rate of rescue analgesia; (2) Quality indicators for recovery post-operation: Including time to first ambulation after surgery, time to first flatus in postoperative phase, length of stay after perioperative hospitalization; (3) PONV: Nausea and vomiting status was evaluated by a 4-level scoring system during 24 hours period following operation, grade-0 represented none nausea or vomit; grade-1 represented mild nausea without vomit; grade-2 moderate nausea or who experienced 1-2 episodes vomits; grade-3 approached severe nausea or ≥ 3 times from vomiting requiring medicinal intervention higher score indicated more severe with more incidences: Also noted were PONV-known incidence ≥ grade 1 score and use of antiemetics drugs.
Statistical analyses were executed via SPSS 26.0 software. Continuous variables were initially assessed for normality (Shapiro-Wilk test) and their homogeneity of variance using Levene’s test. Normally distributed continuous variables were presented as mean ± SD, with intragroup comparisons conducted using independent samples t-test; non-normally distributed continuous variables were described as median (interquartile range), and the intergroup comparison was performed by the Mann-Whitney U test. Categorical data were reported as n (%), and comparisons between groups were using χ2 test; for ordinal data comparison between two groups Mann-Whitney U test was implemented. Repeated measures analysis of variance (ANOVA) between VAS scores at different postoperative time points was undertaken; when data did not meet the sphericity assumption (Mauchly’s test of sphericity P < 0.05), degrees of freedom were adjusted using the Greenhouse Geisser correction. P < 0.05 was considered statistically significant.
No statistically significant differences were observed between the two groups with respect to age, sex, body mass index, ASA classification, appendicitis type, pathological type, surgical nature, operation time, pneumoperitoneum time, intraoperative blood loss and remifentanil consumption (P > 0.05; Table 1), representing comparability.
| Variable | ESPB group (n = 91) | TAPB group (n = 92) | t/χ2/Z value | P value |
| Age (years) | 42.3 ± 12.6 | 41.8 ± 13.1 | 0.263 | 0.793 |
| Sex | 0.132 | 0.716 | ||
| Male | 49 (53.8) | 52 (56.5) | ||
| Female | 42 (46.2) | 40 (43.5) | ||
| BMI (kg/m²) | 23.8 ± 3.2 | 24.1 ± 3.4 | -0.61 | 0.543 |
| ASA classification | -0.426 | 0.67 | ||
| Class I | 34 (37.4) | 32 (34.8) | ||
| Class II | 48 (52.7) | 52 (56.5) | ||
| Class III | 9 (9.9) | 8 (8.7) | ||
| Appendicitis type | 0.059 | 0.808 | ||
| Acute appendicitis | 78 (85.7) | 80 (87.0) | ||
| Chronic appendicitis | 13 (14.3) | 12 (13.0) | ||
| Pathological classification | 0.155 | 0.925 | ||
| Simple | 31 (34.1) | 29 (31.5) | ||
| Suppurative | 47 (51.6) | 50 (54.3) | ||
| Gangrenous | 13 (14.3) | 13 (14.2) | ||
| Nature of surgery | 0.011 | 0.916 | ||
| Elective | 26 (28.6) | 27 (29.3) | ||
| Emergency | 65 (71.4) | 65 (70.7) | ||
| Operative time (minutes) | 58.4 ± 15.2 | 56.9 ± 14.8 | 0.68 | 0.497 |
| Pneumoperitoneum duration (minutes) | 45.6 ± 12.3 | 44.2 ± 11.9 | 0.787 | 0.432 |
| Intraoperative blood loss (mL) | 15.0 (10.0, 25.0) | 15.0 (10.0, 20.0) | -0.524 | 0.6 |
| Intraoperative remifentanil consumption (μg) | 312.5 ± 68.4 | 305.8 ± 71.2 | 0.651 | 0.516 |
For VAS scores of visceral pain at rest, repeated measures ANOVA showed that the time effect (F = 254.38, P < 0.001), group effect (F = 52.16, P < 0.001) and time × group interaction effect (F = 16.82, P < 0.001) were statistically significant as well. For visceral pain VAS scores with activity, the time effect (F = 278.65, P < 0.001), group effect (F = 48.73, P < 0.001) and time × group interaction effect (F = 15.94, P < 0.001) were all significant. The visceral pain VAS score at rest and during activity of the 2 groups at postoperative 2, 6, and 12 hours were significantly reduced in ESPB as compared to TAPB (P < 0.05), however; there were no statistically significant differences between visceral pain VAS scores of both groups at postoperative time intervals of 24 hours and 48 hours (P > 0.05; Table 2, Figure 1).
| Time point | State | ESPB group (n = 91) | TAPB group (n = 92) | t value | P value |
| 2 hours postoperatively | Rest | 2.1 ± 0.8 | 3.2 ± 0.9 | -8.741 | < 0.001 |
| Activity | 2.8 ± 0.9 | 4.0 ± 1.0 | -8.648 | < 0.001 | |
| 6 hours postoperatively | Rest | 2.3 ± 0.7 | 3.1 ± 0.8 | -7.275 | < 0.001 |
| Activity | 3.0 ± 0.8 | 3.9 ± 0.9 | -7.243 | < 0.001 | |
| 12 hours postoperatively | Rest | 1.9 ± 0.6 | 2.4 ± 0.7 | -5.237 | < 0.001 |
| Activity | 2.5 ± 0.7 | 3.1 ± 0.8 | -5.479 | < 0.001 | |
| 24 hours postoperatively | Rest | 1.4 ± 0.5 | 1.5 ± 0.6 | -1.242 | 0.216 |
| Activity | 1.9 ± 0.6 | 2.0 ± 0.7 | -1.055 | 0.293 | |
| 48 hours postoperatively | Rest | 0.8 ± 0.4 | 0.9 ± 0.5 | -1.517 | 0.131 |
| Activity | 1.2 ± 0.5 | 1.3 ± 0.5 | -1.38 | 0.169 |
For somatic pain VAS scores at rest, the time effect was statistically significant (F = 298.72, P < 0.001) as indicated by repeated measures ANOVA analysis; however, group effect (F = 0.76, P = 0.384) and time × group interaction effect (F = 0.38, P = 798) were not statistically significant. The time of somatic pain VAS scores during activity was statistically significant (F = 326.41, P < 0.001), and for groups (F = 0.89, P = 0.347) and the interaction effect of time × groups (F = 0.52, P = 0.712) were not statistically significant between the two groups on activity level somatic pain VAS scores in anesthesia duration. Discriminative pain during somatic type for the two groups was not statistically different at any healing point postoperatively in respect of VAS with either a rest or activity-unconstrained approach (P > 0.05; Table 3, Figure 2).
| Time point | State | ESPB group (n = 91) | TAPB group (n = 92) | t value | P value |
| 2 hours postoperatively | Rest | 2.4 ± 0.8 | 2.3 ± 0.9 | 0.798 | 0.426 |
| Activity | 3.5 ± 1.0 | 3.4 ± 1.1 | 0.649 | 0.517 | |
| 6 hours postoperatively | Rest | 2.2 ± 0.7 | 2.1 ± 0.8 | 0.905 | 0.367 |
| Activity | 3.2 ± 0.9 | 3.1 ± 0.9 | 0.754 | 0.452 | |
| 12 hours postoperatively | Rest | 1.8 ± 0.6 | 1.7 ± 0.7 | 1.054 | 0.293 |
| Activity | 2.6 ± 0.8 | 2.5 ± 0.8 | 0.853 | 0.395 | |
| 24 hours postoperatively | Rest | 1.3 ± 0.5 | 1.2 ± 0.5 | 1.369 | 0.173 |
| Activity | 1.9 ± 0.6 | 1.8 ± 0.6 | 1.133 | 0.259 | |
| 48 hours postoperatively | Rest | 0.7 ± 0.4 | 0.7 ± 0.4 | 0 | 1 |
| Activity | 1.1 ± 0.5 | 1.0 ± 0.5 | 1.351 | 0.178 |
The postoperative analgesic effects were compared between the ESPB group (n = 91) and TAPB group (n = 92). The requirements of rescue analgesia and tramadol consumption were significantly different. The incidence of rescue analgesia was lower in patients receiving ESPB than in those undergoing TAPB (13.2% vs 26.1%, χ2 = 4.768, P = 0.029). Significantly lower median tramadol consumption was also found in the ESPB group, 0 mg (0, 0) compared to TAPB group 0 mg (0, 100), Z = -2.518, P = 0.012. In summary, ESPB was more effective than TAPB in controlling postoperative pain with significant reduction of rescue analgesia need as well as opioid consumption (Table 4).
| Variable | ESPB group (n = 91) | TAPB group (n = 92) | χ2/Z value | P value |
| Rescue analgesia, n (%) | 12 (13.2) | 24 (26.1) | 4.768 | 0.029 |
| Tramadol consumption (mg) | 0 (0, 0) | 0 (0, 100) | -2.518 | 0.012 |
The results of postoperative recovery parameters, between ESPB group (n = 91) and TAPB group (n = 92), were compared. There were no significant differences in time to first ambulation (12.4 ± 3.8 hours and 13.1 ± 4.2 hours, P = 0.238), time to first flatus (19.8 ± 5.4 hours vs 20.5 ± 5.8 hours, P = 0.394), or postoperative hospital stay [20 (20, 30) days and 20 (20, 30) days, P = 0.381], respectively; similar postoperative recovery of ESPB and TAPB was found, as shown in the Table 5.
| Variable | ESPB group (n = 91) | TAPB group (n = 92) | t/Z value | P value |
| Time to first ambulation (hours) | 12.4 ± 3.8 | 13.1 ± 4.2 | -1.185 | 0.238 |
| Time to first flatus (hours) | 19.8 ± 5.4 | 20.5 ± 5.8 | -0.854 | 0.394 |
| Postoperative hospital stay (days) | 2.0 (2.0, 3.0) | 2.0 (2.0, 3.0) | -0.876 | 0.381 |
The comparison of PONV between the ESPB group (n = 91) and TAPB group (n = 92) in this study. The distribution of PONV grades in both groups was similar, with 68.1% vs 63.0%, 19.8% vs 21.7%, 8.8% vs 10.9%, and 33% vs 43% of patients having a grade 0, grade 1, grade 2 and grade 3 of PONV in the ESPB and TAPB groups respectively (Z = -0.892, P = 0.372). Statistical analyses revealed no statistically significant difference in overall incidence of PONV (31.9% vs 37.0%, P = 0.473) or use of antiemetics (12.1% vs 15.2%, P = 0.538, Table 6).
| Variable | ESPB group (n = 91) | TAPB group (n = 92) | Z/χ2 value | P value |
| PONV grade | -0.892 | 0.372 | ||
| Grade 0 | 62 (68.1) | 58 (63.0) | ||
| Grade 1 | 18 (19.8) | 20 (21.7) | ||
| Grade 2 | 8 (8.8) | 10 (10.9) | ||
| Grade 3 | 3 (3.3) | 4 (4.3) | ||
| PONV incidence | 29 (31.9) | 34 (37.0) | 0.516 | 0.473 |
| Antiemetic use | 11 (12.1) | 14 (15.2) | 0.38 | 0.538 |
All data are expressed as mean ± SD. Patient satisfaction scores were compared between the ESPB group (n = 91) and TAPB group (n = 92) using a 5-point scale. Groups scored significantly differently on satisfaction (Z = -2.486, P = 0.013). The ESPB group was more satisfied, with 29.7% of patients rating it as 5 points compared with 19.6% in the TAPB group. In contrast, the TAPB group had a higher proportion of patients with lower satisfaction scores (2-3 points: 28.3% vs 16.5%). Overall satisfaction was significantly higher in patients belonging to the ESPB group than those of the TAPB (Table 7).
| Variable | ESPB group (n = 91) | TAPB group (n = 92) | Z value | P value |
| Satisfaction score | -2.486 | 0.013 | ||
| 1 point | 1 (1.1) | 2 (2.2) | ||
| 2 points | 3 (3.3) | 8 (8.7) | ||
| 3 points | 12 (13.2) | 18 (19.6) | ||
| 4 points | 48 (52.7) | 46 (50.0) |
This analysis aimed to compare the analgesic efficacy of ESPB and TAPB for visceral and somatic pain post laparoscopic appendectomy. The findings showed that ESPB resulted in better control of visceral pain than TAPB in the early postoperative period, and both block techniques had similar analgesic effects on somatic pain. These findings are very important for the clinical selection of appropriate nerve block techniques produced by pain characteristics.
In recent years, pain research has focused on the multidimensional nature of pain after laparoscopic surgery[12]. Visceral pain and somatic pain are fundamentally different in terms of the neural conduction pathways involved, characteristics of pain, and response to analgesic measures[13]. Visceral pain is mainly induced by mechanical pulling of intraabdominal viscera, elaboration of inflammatory mediators and CO2 pneumoperitoneum irritation, which are transmitted through visceral afferent fibers to the spinal cord and carried over sympathetic chain[14]. Somatic pain results from direct injury of somatic sensory nerves of the abdominal wall by surgical incision, which are innervated by the anterior branches of spinal nerves[15]. The majority of the available studies comparing analgesic effects between ESPB and TAPB have used total pain scores as endpoints, without separating them into their two qualitatively distinct components[16]. Separate pain types were included in the study, which could better reflect two block techniques characteristics of these pain types.
The additional analgesic effect of ESPB on visceral pain can be attributed to its different pattern of drug diffusion. Anatomical investigations have demonstrated that local anesthetic deposited in a deep manner, beneath the erector spinae muscle, can migrate along this fascial plane and extend towards anteriorly to the intercostal muscles into the paravertebral space[17]. The paravertebral space houses not just spinal nerve roots but also the sympathetic chain and communicating branches[18]. Cadaveric studies demonstrate that dye can spread to the ipsilateral paravertebral space after ESPB at the T12 level and also reach even the lateral portion of epidural space[19]. This pattern of spread allows ESPB to potentially block visceral afferent nerves and therefore have inhibitory effects on visceral pain. In the specific context of lower abdominal surgery, the visceral afferent innervation of the appendix and periappendicular peritoneal structures is conveyed through the lesser and least splanchnic nerves, entering the thoracolumbar sympathetic chain at the T10-L1 spinal levels. By facilitating local anesthetic spread to the paravertebral space at these levels, ESPB may modulate these visceral afferent pathways and thereby attenuate the deep, diffuse pain characteristic of peritoneal irritation and appendiceal inflammation[20]. In this study, the ESPB cohort had significantly lower early postoperative visceral pain scores compared with the TAPB group suggesting that there may be some effect of ESPB on visceral afferent nerves.
In contrast, TAPB produces a limited infiltration in the fascial plane between transversus abdominis and internal oblique muscles, mainly truncating anterior cutaneous branches of intercostal nerves, subcostal nerves as well as iliohypogastric and ilioinguinal nerves passing through this plane[21]. These nerves are somatic sensory peripheral nerves which innervate the abdominal wall skin and musculature, so TAPB has anchoring analgesic effects on somatic pain[22]. But TAPB cannot reach or innervate sympathetic nerve[23] in the paravertebral space, thus limiting its regulation on visceral pain. This anatomical characteristic agrees with the present study findings.
Notably, the differences in visceral pain scores between the two groups were most clearly observed at the earliest time point assessed (the first 12 hours postoperatively), as by both 24 hours and especially 48 hours postoperative period scores tended to converge. There are many reasons that may account for this phenomenon: First, the analgesic duration of single injection nerve blocks are not prolonged; their clinical effects can not outstrip the pharmacokinetics of local anesthetics[24]; second, postoperative visceral pain intensity declines progressively over time; both group have relatively low scores after 24 hours and intergroup differences lose their clinical significance at later time points; moreover, parecoxib sodium used routinely administered also has some inhibition viscera inflammation induced pain[25].
The groups did not differ significantly in somatic pain scores at any time point, which is congruent with previous findings[26,27]. Despite the discrepancy in the blockade mechanism between ESPB and TAPB, they can exert blocking effect on abdominal wall somatic sensory nerves via different pathways. The TAPB can directly anesthetize the terminal nerve branches in transversus abdominis plane, while ESPB might present similar actions indirectly by blocking posterior branches of spinal nerves and anterior branches after spread to paravertebral space[28]. The comparable somatic analgesia obtained by both techniques may explain also why we detected no significant differences between groups in the quality indicators of postoperative recovery in our study.
The lower rescue analgesia rate and tramadol consumption in the ESPB group might be attributed to its additional efficacy for visceral pain control. Visceral pain is the primary cause of immediate postoperative pain after laparoscopic surgery (including appendectomy)[29]; poor visceral analgesia increases the risk that patients will exceed their threshold for requesting rescue analgesia. We hypothesize that the blockade of visceral pain receptors plays an indirect role in overall experience of analgesia, as we found a higher satisfaction scale for analgesia in ESPB group.
This study has certain limitations. First, being a retrospective study, while the groups had balanced baseline characteristics there is always some potential for selection bias and confounding factors, especially as block selection was on anesthesiologist preference rather than randomization. Second, there was no formal blinding of patients, outcome assessors or care providers; patients were aware of their assigned block technique and pain assessments were completed in a non-masked fashion according to group allocation, which may have led to detection and performance bias for subjective endpoints like VAS scores and satisfaction measures. Third, the patient reports of visceral vs somatic pain were based solely on standardized verbal descriptions without any objective neurophysiological confirmation. This is a major methodological limitation, as postoperative pain following laparoscopic appendectomy oftentimes has a mixed picture and risk of misclassification cannot be ruled out; more accurate pain-type differentiation should therefore preferably rely on validated instruments or quantitative sensory testing in future studies. Fourth, a formal prospective sample size calculation was not done; post-hoc power analysis confirmed > 90% power to detect the between-group differences observed in visceral pain VAS scores; however, the study is likely underpowered to detect smaller clinically meaningful intergroup differences in certain pain subtypes or secondary outcomes. Additionally, this study did not perform a dynamic monitoring of the local anesthetics spread field; hence, there was no direct attempt to verify the ESPB spreading fields towards the paravertebral space and any possible correlation with analgesic effects. Prospective randomized controlled trials with imaging examinations and neuroelectrophysiological monitoring are required in the future to further elucidate the mechanism of action of ESPB.
In conclusion, this retrospective study suggested that ESPB seemed to be superior to TAPB for early postoperative visceral pain control compared with TAPB within 12 hours after laparoscopic appendectomy and comparable analgesic efficacy for somatic pain. Clients required less rescue analgesia after ESPB and they reported greater satisfaction following ESPB. In patients where visceral pain is the major postoperative feature, ESPB may be a better regional anaesthetic approach. Nevertheless, these findings should be interpreted while keeping the retrospective design, absence of formal blinding and validated tools for masked pain-type classification in mind. Before robust clinical recommendations can be made, these findings need to be confirmed by prospective randomized controlled trials incorporating standardised pain classification tools.
| 1. | Schildberg C, Weber U, König V, Linnartz M, Heisler S, Hafkesbrink J, Fricke M, Mantke R. Laparoscopic appendectomy as the gold standard: What role remains for open surgery, conversion, and disease severity? : An analysis of 32,000 cases with appendicitis in Germany. World J Emerg Surg. 2025;20:53. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 7] [Reference Citation Analysis (0)] |
| 2. | Biput SJ, Slouha E, Gregory JA, Krumbach B, Clunes LA, Kollias TF. Pain Management During Adult Laparoscopic Appendectomy: A Systematic Review. Cureus. 2024;16:e52037. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 2] [Cited by in RCA: 3] [Article Influence: 1.5] [Reference Citation Analysis (0)] |
| 3. | Jiang B, Ye S. Pharmacotherapeutic pain management in patients undergoing laparoscopic cholecystectomy: A review. Adv Clin Exp Med. 2022;31:1275-1288. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 23] [Reference Citation Analysis (0)] |
| 4. | Yang GW, Cheng H, Song XY, Yang YF, Liu H, Ji FH, Peng K. Effect of Oxycodone-Based Multimodal Analgesia on Visceral Pain After Major Laparoscopic Gastrointestinal Surgery: A Randomised, Double-Blind, Controlled Trial. Drug Des Devel Ther. 2024;18:1799-1810. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 17] [Reference Citation Analysis (0)] |
| 5. | Sertcakacilar G, Yildiz GO. Analgesic efficacy of ultrasound-guided transversus abdominis plane block and lateral approach quadratus lumborum block after laparoscopic appendectomy: A randomized controlled trial. Ann Med Surg (Lond). 2022;79:104002. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 11] [Reference Citation Analysis (0)] |
| 6. | Liu X, Song T, Chen X, Zhang J, Shan C, Chang L, Xu H. Quadratus lumborum block versus transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol. 2020;20:53. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 15] [Cited by in RCA: 55] [Article Influence: 9.2] [Reference Citation Analysis (0)] |
| 7. | Zewdu D, Tantu T, Eanga S, Tilahun T. Analgesic efficacy of erector spinae plane block versus transversus abdominis plane block for laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trial. Front Med (Lausanne). 2024;11:1399253. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 5] [Reference Citation Analysis (0)] |
| 8. | Oraee S, Rajai Firouzabadi S, Mohammadi I, Alinejadfard M, Golsorkh H, Hatami S. Erector spinae plane block for laparoscopic surgeries: a systematic review and meta-analysis. BMC Anesthesiol. 2024;24:389. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 8] [Reference Citation Analysis (0)] |
| 9. | Sørenstua M, Leonardsen AL, Chin KJ. Dorsal root ganglion: a key to understanding the therapeutic effects of the erector spinae plane (ESP) and other intertransverse process blocks? Reg Anesth Pain Med. 2024;49:223-226. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 8] [Cited by in RCA: 21] [Article Influence: 10.5] [Reference Citation Analysis (0)] |
| 10. | Sia CJ, Wee S, Au-Yong AP, Lie SA, Tan WJ, Foo FJ, Kam JH, Lee DJ, Koh FH. Analgesia efficacy of erector spinae plane block in laparoscopic abdominal surgeries: a systemic review and meta-analysis. Int J Surg. 2024;110:4393-4401. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 15] [Reference Citation Analysis (0)] |
| 11. | Qian L, Hu NQ, Shen QH, Ni K. Comparison of the efficiency of ultrasound-guided ESPB and TAPB on postoperative analgesia: a system review and meta-analysis. Front Med (Lausanne). 2025;12:1595778. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 5] [Reference Citation Analysis (0)] |
| 12. | Lirk P, Badaoui J, Stuempflen M, Hedayat M, Freys SM, Joshi GP; PROSPECT group of the European Society for Regional Anaesthesia and Pain Therapy (ESRA). PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management. Eur J Anaesthesiol. 2024;41:161-173. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 28] [Cited by in RCA: 27] [Article Influence: 13.5] [Reference Citation Analysis (8)] |
| 13. | Boezaart AP, Smith CR, Chembrovich S, Zasimovich Y, Server A, Morgan G, Theron A, Booysen K, Reina MA. Visceral versus somatic pain: an educational review of anatomy and clinical implications. Reg Anesth Pain Med. 2021;46:629-636. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 10] [Cited by in RCA: 57] [Article Influence: 11.4] [Reference Citation Analysis (0)] |
| 14. | Woodroffe RW, Pearson AC, Pearlman AM, Howard MA, Nauta HJW, Nagel SJ, Hori YS, Machado AG, Almeida Frizon L, Helland L, Holland MT, Gillies GT, Wilson S. Spinal Cord Stimulation for Visceral Pain: Present Approaches and Future Strategies. Pain Med. 2020;21:2298-2309. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 1] [Cited by in RCA: 11] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
| 15. | Lohmöller K, Carstensen V, Pogatzki-Zahn EM, Freys SM, Weibel S, Schnabel A. Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis. Surg Endosc. 2024;38:1844-1866. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 6] [Reference Citation Analysis (0)] |
| 16. | Liheng L, Siyuan C, Zhen C, Changxue W. Erector Spinae Plane Block versus Transversus Abdominis Plane Block for Postoperative Analgesia in Abdominal Surgery: A Systematic Review and Meta-Analysis. J Invest Surg. 2022;35:1711-1722. [RCA] [PubMed] [DOI] [Full Text] [Cited by in Crossref: 25] [Cited by in RCA: 21] [Article Influence: 5.3] [Reference Citation Analysis (0)] |
| 17. | Sørenstua M, Zantalis N, Raeder J, Vamnes JS, Leonardsen AL. Spread of local anesthetics after erector spinae plane block: an MRI study in healthy volunteers. Reg Anesth Pain Med. 2023;48:74-79. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 73] [Reference Citation Analysis (0)] |
| 18. | Kim SH. Anatomical classification and clinical application of thoracic paraspinal blocks. Korean J Anesthesiol. 2022;75:295-306. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 31] [Reference Citation Analysis (0)] |
| 19. | Diwan S, Shivamallappa S, Timane R, Pai P, Gupta A. Pathways of dye spread after injections in the paraspinal spaces-A cadaveric study. Saudi J Anaesth. 2024;18:181-186. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in Crossref: 1] [Cited by in RCA: 4] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
| 20. | Yılmaz ET, Gülmez DD, Apan A, Keles BO, Coşkun M, Döger C, Kesicioglu T, Serim VA, Uygur FA, Sengul I. A novel comparison of erector spinae plane block and paravertebral block in laparoscopic cholecystectomy. Rev Assoc Med Bras (1992). 2024;70:e20231457. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 4] [Reference Citation Analysis (0)] |
| 21. | Hou P, Liu W, Chen R, Mi H, Jia S, Lin J. Comparison of erector spinae plane block and transverse abdominis plane block in postoperative recovery after laparoscopic colorectal surgery: a randomized, double-blind, controlled trial. Perioper Med (Lond). 2024;13:116. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 3] [Reference Citation Analysis (0)] |
| 22. | Park JW, Kim EK, Park S, Han WK, Lee J, Lee JH, Nahm FS. Erector spinae plane block in laparoscopic colorectal surgery for reducing opioid requirement and facilitating early ambulation: a double-blind, randomized trial. Sci Rep. 2023;13:12056. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 12] [Reference Citation Analysis (0)] |
| 23. | Vaghela SS, Chaurasiya MK, Prakash R, Khan MP. Ultrasound-Guided Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Laparoscopic Inguinal Hernia Repair and Appendicectomy Using Ropivacaine With Dexmedetomidine. Cureus. 2023;15:e33450. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 8] [Reference Citation Analysis (0)] |
| 24. | Fallon F, Moorthy A, Skerritt C, Crowe GG, Buggy DJ. Latest Advances in Regional Anaesthesia. Medicina (Kaunas). 2024;60:735. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 10] [Reference Citation Analysis (0)] |
| 25. | Ge Z, Li M, Chen Y, Sun Y, Zhang R, Zhang J, Bai X, Zhang Y, Chen Q. The Efficacy and Safety of Parecoxib Multimodal Preemptive Analgesia in Artificial Joint Replacement: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Ther. 2023;12:1065-1078. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 9] [Reference Citation Analysis (0)] |
| 26. | Choi JJ, Chang YJ, Lee D, Kim HW, Kwak HJ. Effect of Erector Spinae Plane Block on Postoperative Pain after Laparoscopic Colorectal Surgery: A Randomized Controlled Study. J Pers Med. 2022;12:1717. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 7] [Reference Citation Analysis (0)] |
| 27. | Li Q, Li Q, Peng W, Liu Z, Mai Y, Shi C, Mo P. Ultrasound-guided bilateral erector spinae plane block in laparoscopic colon cancer surgery : A randomized controlled prospective trial. Anaesthesiologie. 2022;71:224-232. [RCA] [PubMed] [DOI] [Full Text] [Cited by in RCA: 7] [Reference Citation Analysis (0)] |
| 28. | Alsharari AF, Alshammari FF, Salihu D, Alruwaili MM. Postoperative Pain Management in Children Undergoing Laparoscopic Appendectomy: A Scoping Review. Healthcare (Basel). 2023;11:870. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 6] [Reference Citation Analysis (0)] |
| 29. | Lin J, Huang Y, Wen Y, Yang W, Zuo Y. Ultrasound-guided stellate ganglion block attenuates early postoperative visceral pain after laparoscopic hysterectomy: A prospective randomized controlled trial. PLoS One. 2025;20:e0339677. [RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)] [Cited by in RCA: 2] [Reference Citation Analysis (0)] |