Introduction Thoracic epidural analgesia remains the gold standard for postoperative pain management after major open surgery, but is potentially associated with hypotension, urinary retention, and delayed recovery. Rectus sheath catheters offer a simple regional alternative that avoids sympathetic blockade while maintaining somatic analgesia. This review aims to compare analgesic efficacy, complications, recovery, patient satisfaction, and costs between rectus sheath catheters and thoracic epidural anaesthesia in open surgical procedures. Methods This systematic review was registered with PROSPERO (CRD420251234467). A systematic PubMed search was conducted to identify studies comparing continuous wound infusion via rectus sheath catheters with thoracic epidural anaesthesia in adult patients undergoing open abdominal, pelvic, thoracic, or vascular surgery. Randomized clinical trials, as well as prospective and retrospective comparative studies, were included. A meta-analysis was performed for randomized trials. Results 31 studies (21 prospective, 10 retrospective) involving 2162 patients were included. Rectus sheath catheters and thoracic epidural anaesthesia did not differ significantly with respect to postoperative pain (SMD: -0. 35; 95%CI: -2. 01-1. 32) or opioid consumption (SMD: -0. 32; 95%CI: -1. 71-1. 07). No differences were observed in recovery of bowel function, urinary retention, time to mobilisation, or length of hospital stay. Rectus sheath catheters significantly reduced the risk of hypotension compared with thoracic epidural anaesthesia (RR: 0. 40; 95%CI: 0. 26-0. 60) and were associated with lower costs ranging from 500 to 6632 per case. Subgroup analyses suggested less urinary retention and earlier mobilisation with rectus sheath catheters in non-visceral surgery and non-laparotomy incisions. Conclusions Rectus sheath catheters provide analgesia comparable to thoracic epidural anaesthesia with fewer complications, facilitating earlier recovery and potential cost savings. Considering the growing shift toward fast-track surgery, rectus sheath catheters represent a pragmatic and resource-efficient alternative for postoperative pain management in open surgical procedures.
Fankhauser et al. (2026) studied this question.