Transversus abdominis plane block versus thoracic epidural analgesia for laparoscopic surgery: implication for ERAS protocols . A systematic review and meta-analysis

Postoperative analgesia is a crucial component in optimized postoperative recovery protocols, especially in laparoscopic surgery, a minimally invasive technique that reduces surgical trauma and accelerates recovery. The transversus abdominis plane block has been proposed as an alternative to thoracic epidural analgesia, which, although effective, is associated with significant side effects such as hypotension, urinary retention, and muscle weakness. However, the current literature lacks a systematic synthesis directly comparing these two analgesic techniques following laparoscopic surgery of the abdomen. This study aims to evaluate the effectiveness of transversus abdominis plane block to thoracic epidural analgesia in postoperative pain control, with a particular focus on functional outcomes and hospital length of stay. A systematic review and meta-analysis were conducted according to PRISMA guidelines and registered in the PROSPERO database (CRD42024508473). Randomized controlled trials (RCTs) comparing the transversus abdominis plane block and thoracic epidural analgesia in adult patients undergoing laparoscopic surgery were selected. The primary outcome analyzed was static pain at 24 hours, while secondary outcomes included static pain at 0-2 hours, dynamic pain at 0-2 and 24-36 hours, opioid consumption, time to first mobilization, time to first flatus, and hospital length of stay. A total of 264 articles were identified, of which five RCTs (N.=400 patients) met the inclusion criteria. The analysis showed no significant differences in pain control between the transversus abdominis plane block and thoracic epidural analgesia in the first 24 postoperative hours (Cohen's d=-0.12, 95% CI: -0.48; 0.24) or in total opioid consumption (Cohen's d=-0.09, 95% CI: -0.45; 0.26). However, the transversus abdominis plane block was associated with faster functional recovery, with a significant reduction in time to first flatus (Cohen's d=-0.61, 95% CI: -1.15; -0.07, P=0.027) and time to first mobilization (Cohen's d=-0.76, 95% CI: -1.25; -0.27, P=0.003). No significant differences were found in hospital length of stay (Cohen's d=-0.14, 95% CI: -0.50; 0.22). The transversus abdominis plane block provides effective analgesia and promotes faster functional recovery compared to thoracic epidural analgesia. Given these advantages, it may represent a valid alternative in optimized postoperative recovery protocols. However, further high-quality studies are needed to confirm its efficacy and define standardized guidelines for its use in laparoscopic surgery.