# Timing Matters: A Randomized Controlled Trial Comparing Preoperative and Postoperative Erector Spinae Plane Block for Analgesia in Laparoscopic Cholecystectomy

## TL;DR

This study compares preoperative and postoperative erector spinae plane blocks for pain management in cholecystectomy, finding similar pain relief but better hemodynamic stability with preoperative blocks.

## Contribution

The study provides evidence that preoperative erector spinae plane blocks offer better intraoperative hemodynamic stability without compromising analgesic outcomes.

## Key findings

- Preoperative ESPB showed more stable intraoperative blood pressure compared to postoperative ESPB.
- Both preoperative and postoperative ESPB provided similar postoperative pain relief and opioid sparing effects.
- No ESPB-related complications were observed in either group.

## Abstract

Background and Objectives: The erector spinae plane block (ESPB) is an emerging regional anesthesia technique that has demonstrated effectiveness in reducing postoperative pain and opioid consumption following laparoscopic cholecystectomy (LC). However, the optimal timing of ESPB whether administered preoperatively or postoperatively remains uncertain, particularly regarding its influence on intraoperative hemodynamic stability and procedural feasibility. This study aimed to compare the analgesic efficacy, intraoperative hemodynamic profiles, and procedural advantages of preoperative versus postoperative ESPB in patients undergoing elective LC. Materials and Methods: In this prospective, randomized, and single-blind clinical trial, 80 ASA I–II adult patients scheduled for elective LC were randomly assigned to receive bilateral ESPB either before anesthesia induction (Group 1) or immediately after surgery but prior to extubation (Group 2). All patients received standardized general anesthesia. The primary outcome was postoperative pain measured by the numeric rating scale (NRS) at 2 h postoperatively. Secondary outcomes included NRS scores at other time points (0, 4, 6, 12, and 24 h), intraoperative and postoperative hemodynamic parameters, cumulative 24 h rescue analgesic consumption, patient satisfaction scores, and adverse events. Results: Both groups experienced significant reductions in postoperative NRS scores, with no statistically significant differences between groups in pain intensity or tramadol consumption. However, the preoperative ESPB group exhibited significantly more stable intraoperative blood pressure readings, particularly at 30 and 60 min after incision and at extubation. No ESPB-related complications occurred in either group. Patient satisfaction levels were comparable across groups. Conclusions: Preoperative and postoperative ESPBs offer comparable analgesic efficacy and opioid sparing effects in LC. However, preoperative ESPB provides enhanced intraoperative hemodynamic stability and avoids the logistical challenges of performing blocks under anesthesia, including repositioning related risks. These findings suggest that preoperative ESPB may be considered for integration into enhanced recovery after surgery (ERAS) protocols for minimally invasive biliary surgery, pending further large-scale multicenter trials.