A surgeon-placed TAP block beats port-site infiltration in the first hours after cholecystectomy

Design

Systematic review, random-effects meta-analysis and trial sequential analysis, PROSPERO registered, GRADE assessed

Population

711 adults across 8 randomised trials undergoing laparoscopic cholecystectomy

Primary outcome

Postoperative pain on visual analogue scale, with opioid use and recovery outcomes

Effect

Lower pain scores at 1, 3, 6 and 24 hours (pooled differences not reported in the abstract), GRADE high at 1 and 3 hours; no difference in operative time, shoulder pain, rescue analgesia or nausea; modest reduction in hospital stay

Eight randomised trials and 711 adults undergoing laparoscopic cholecystectomy were pooled to compare a laparoscopic-guided transversus abdominis plane block - placed by the surgeon under direct vision from inside the abdomen - with the conventional port-site local anaesthetic infiltration. The block was bilateral in six trials and unilateral in two.

Pain scores were lower with the block at 1, 3, 6 and 24 hours, with GRADE certainty rated high at 1 and 3 hours, moderate for most secondary outcomes and low for pain at 6 and 12 hours. The abstract does not give the pooled mean differences, so the size of the benefit cannot be quoted here - only its direction and the certainty attached to it. Nothing else moved: operative time, shoulder pain, rescue analgesia, postoperative nausea and vomiting and discharge within 24 hours were all comparable, with a modest shortening of hospital stay favouring the block. Trial sequential analysis confirmed the early analgesia and hospital stay findings had accumulated enough information to be reliable; several other outcomes remained inconclusive.

The practical attraction is that this version of the block does not need the anaesthetist to leave the head of the table or an ultrasound machine to be free - it is placed intraperitoneally under vision at a point in the operation when nothing else is happening. In a busy Indian day-case list that is a real difference from a preoperative ultrasound-guided block, and the trade is that the analgesia advantage is confined to the first day and does not reduce the need for rescue analgesia.

• Agree the laparoscopic-guided block with the surgeon preoperatively; it is placed by them, under vision.
• Expect the benefit in the first hours only, and plan multimodal analgesia for the rest of the day regardless.
• Do not promise less shoulder pain or less nausea; neither differed.
• Note that rescue analgesia requirement was unchanged, which limits how much the pain score difference means.
• The strongest evidence sits at 1 and 3 hours, where GRADE certainty was high.

The statistics, in plain English

Trial sequential analysis asks whether enough patients have been randomised for a finding to be trusted rather than to be an early fluctuation, so its confirmation of the early pain benefit carries real weight, and its inconclusive verdict on other outcomes should be read as a genuine unknown. GRADE certainty falling from high at 1 hour to low at 6 and 12 hours means the later timepoints rest on fewer or more heterogeneous trials. A significant difference in pain scores with unchanged rescue analgesia usually indicates a real but modest effect.

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