Efficacy of fascial plane blocks in enhanced recovery after surgery protocols for abdominal surgery

Editor, Enhanced recovery after surgery (ERAS) protocols aim to optimise peri-operative care, reduce complications, and accelerate patient recovery. A key factor contributing to improved postoperative outcomes is the optimisation of multimodal analgesia strategies, particularly through the use of regional anaesthesia techniques.1 Among these techniques, fascial plane blocks have emerged as valuable analgesia options, although they represent a heterogeneous and often technically demanding group of procedures with contradictory efficacy data, variable ultrasound presentation (sono-anatomy), steep learning curves, and potential for increased local anaesthetic systemic toxicity when cumulative doses rise. Together with ERAS protocols, these techniques are constantly evolving to enhance patient outcomes while promoting multimodal analgesia at the same time. What do randomised controlled trials say about the role and potential benefits of integrating fascial plane blocks into ERAS pathways? A well established role for these blocks in existing guidelines for abdominal surgery is lacking. We conducted a systematic review of the literature with a meta-analysis whose main outcome was to analyse postoperative pain during the first 24 h after abdominal surgery. We searched PubMed, Scopus and Embase (up to 16 March 2025) to identify studies according to the following PICOS question: patients undergoing surgery (abdominal laparoscopic approach in the majority of cases) within established ERAS protocol (Population) that received a fascial plane block (Intervention) versus placebo, no block or sham block (Comparator) evaluated for pain severity 24 h after surgery (Outcome) in randomised controlled trials (Study design). No restrictions were applied based on date or language, and we followed the PRISMA guidelines and Cochrane methodology for our systematic review and meta-analysis. Our protocol was registered on PROSPERO (CRD420251084020) and a detailed PRISMA flowchart is available as Supplementary Digital Content (SDC), https://links.lww.com/EJAIC/A138. We retrieved 9 randomised controlled trials (RCTs) for eligibility; however, 6 fully met our inclusion criteria and reported the outcome of interest. All included trials implemented specific ERAS protocol. They assessed pain 24 h after surgery using the visual analog scale (VAS) or the Numeric Rating Scale (NRS), involving a total of 619 patients from Spain, Italy, China, and Denmark. Table 1 summarises the main characteristics of the included trials.2–7 The surgical procedures examined included hepatic,2,3 colorectal,4,5 gastric bypass6 and minor gynaecological7 surgeries. The fascial blocks used were the transversus abdominis plane (TAP) block,2–4 the anterior quadratus lumborum (QL) block,5 the laparoscopic-guided TAP6 and a combination of TAP and rectus sheath (RS).7 All analyses were conducted in RStudio (Posit Team, 2025; RStudio: Integrated Development Environment for R; Posit Software, PBC, Boston, MA; R version 4.4.1), using the “meta” package. The I2 for heterogeneity was categorised as follows: <25% low, 26–50% moderate, >50% high. All analyses followed the intention to treat (ITT) principles. Figure 1 presents the forest plot of the postoperative pain 24 h after surgery based on the 6 included trials. The mean NRS/VAS score for the patients who received a fascial block in addition to the ERAS protocol was lower (regional anaesthesia group) compared to the control group (no regional anaesthesia), indicating a beneficial effect (mean difference: –1.38 NRS/VAS score; 95% CI [–2.58 to –0.17]; P = 0.02; I2 = 96.1%). Table 1 - Details of the included RCTs RCT Type of surgery No. patients (intervention group) No. patients (control group) Fascial plane blocks in the intervention group Control Country Ruiz-Tovar et al. 2020 Gastric bypass surgery. ERAS program 70 70 Postoperative laparoscopic-guided TAP (TAP-lap) Patients not receiving TAP-lap (control) Spain Huang et al. 2020 Liver cancer scheduled for open hepatectomy. ERAS program 48 48 Pre-operative TAP with anaesthetic and local wound infiltration with normal saline at the conclusion of surgery and subcostal TAP performed bilaterally at the parasternal line and at the anterior axillary line. Pre-operative TAP with saline and local wound infiltration with anaesthetic at the conclusion of surgery China Zhang et al. 2020 Laparoscopic hepatectomy. ERAS program 25 25 Bilateral dual TAP block in addition Standardised general anaesthesia China Ren et al. 2021 Colorectal surgery. ERAS program 80 80 TAP block treatment (TAP group) Local wound infiltration (LWI group) China Tanggaard et al. 2023 Laparoscopic hemicolectomy due to colon cancer. ERAS program 34 35 Anterior QL block on each side with ropivacaine Isotonic saline (placebo) Denmark Terranova et al. 2024 Laparoscopic minor gynaecological surgery. ERAS program 53 51 Transversus abdominis plane (TAP) + rectus sheath (RS) block No TAP/RS Italy ERAS, enhanced recovery after surgery; QL, quadratus lumborum; RS, rectus sheath; TAP, transverse abdominal plane. Fig. 1: Forest plot of the postoperative pain 24 h after surgery (NRS/VAS score).Interest in utilising the fascial plane blocks has grown over the last decade, with numerous studies supporting their usefulness in various clinical settings.8 In light of the PROSPECT guidelines and other recommendations, which highlight limited or inconsistent evidence for the use of fascial plane blocks across various surgeries, as for laparoscopic colorectal surgery,9,10 our results, although limited by potential sources of bias, indicate that fascial plane blocks (particularly the TAP block) are effective in enhancing analgesia during the first 24 h. This suggests fascial plane blocks as a valuable alternative to other techniques (e.g., epidural, intrathecal morphine) which may give relevant adverse effects. Fascial plane blocks may have a particular place in certain clinical settings, such as hip fracture repair, where neuraxial techniques may occasionally be contraindicated or impractical due to patient comorbidities and are increasingly utilised as part of individualised peri-operative plans. The rationale for a less procedure-specific approach is to reflect this clinical reality and to explore whether certain fascial plane blocks may offer generalisable benefits also across abdominal ERAS pathways. The main strength of this analysis lies in the inclusion of trials with a focus only on elective surgeries in which a clear ERAS protocol was followed. 4 RCTs were rated at a low risk while 2 were at some concerns for bias (Figure 2, Supplemental Digital Content, https://links.lww.com/EJAIC/A138). Indeed, heterogeneity is high and potential sources of bias which may justify the elevated heterogeneity in our analysis may include: different approaches to TAP block (subcostal and low TAP, ultrasound and laparoscopic guidance), different abdominal surgeries (gastrointestinal and gynaecological), and different surgical approaches (laparoscopic and laparotomic). Other limitations are the timing of pain assessment limited to only 24 h postoperatively, and the limitation in number of available trials. This necessitates further studies to confirm or expand on these results. Additionally, variability in outcome measurement must be considered, as we included studies that assessed pain using both the Visual Analog Scale (VAS) and Numeric Rating Scale (NRS) scores. The generalisability of our findings to broader populations is also a concern, as the included studies focused only on TAP, QL, and a combination of TAP/RS blocks within the context of abdominal and minor gynaecological surgery. ERAS protocols and fascial plane blocks are continuously evolving across many surgical contexts. We believe that multimodal analgesia strategies including regional anaesthesia are key interventions that contribute to improved postoperative outcomes. Our study highlights the potential role of the fascial plane blocks in this clinical scenario, amidst the lack of robust evidence across different guidelines. This study deepens the existing literature results and supports recommendations from societies like ERAS. To resolve current ambiguities and advance clinical practice, head-to-head comparisons of different fascial blocks versus neuraxial techniques within ERAS pathways, dose-finding studies to mitigate toxicity, and the incorporation of inflammatory biomarkers into predictive models may represent future research directions.