Laparoscopic-guided transversus abdominis plane block with low-pressure versus standard-pressure pneumoperitoneum versus port site infiltration with standard-pressure pneumoperitoneum for postoperative pain management in laparoscopic cholecystectomy: randomized controlled trial

Background: Postoperative pain remains a significant challenge following laparoscopic cholecystectomy, influencing recovery, opioid consumption, and hospital stay. Laparoscopic-guided transversus abdominis plane (TAP) block and low-pressure pneumoperitoneum have independently demonstrated analgesic benefits. This study compared three predefined perioperative analgesic strategies: low-pressure pneumoperitoneum with laparoscopic-guided TAP block (L-TAP), standard-pressure pneumoperitoneum with TAP block (S-TAP), and standard-pressure pneumoperitoneum with port-site infiltration (S-PS). Methods: A prospective, open-label, three-arm randomized controlled trial was conducted at a tertiary care center (October 2022–June 2024). One hundred and eighty patients undergoing elective laparoscopic cholecystectomy for cholelithiasis were randomized equally (n = 60 each). The principal outcome was postoperative pain assessed using the Visual Analogue Scale (VAS) at 1 h, 6 h, 24 h, 7 days, and 30 days in four positions: lying, turning, coughing, and standing; standing was not assessed at 1 h. No single timepoint–position combination was designated as a standalone primary endpoint, and comparisons were interpreted as multiple outcomes. Standard analgesia comprised intravenous paracetamol 1 g QID. Rescue analgesia with intravenous tramadol 50 mg was administered when VAS ≥ 4. Secondary outcomes included shoulder-tip pain, PONV, early mobility, morphine consumption, surgical difficulty, conversion rate, and hospital stay. Results: Both TAP groups demonstrated lower VAS pain scores than S-PS at several early time points. L-TAP showed significantly lower pain scores than S-TAP during coughing and lying at 6 h (p = 0.009 for both). Shoulder-tip pain was lower in L-TAP than S-PS (3.3% vs 20.0%; p = 0.008). Rescue tramadol requirement was lower in L-TAP and S-TAP than S-PS (8.3% and 13.3% vs 41.7%; p < 0.001). Day-1 discharge rates were 96.7%, 95.0%, and 86.7%, respectively. Conclusion: TAP-based strategies were associated with lower early postoperative pain and reduced rescue analgesic requirements than S-PS. L-TAP suggested additional analgesic benefit over S-TAP, although differences in local anesthetic dose, volume, and timing limit attribution to individual components.