Comparing analgesic efficacy of different local blocks after laparoscopic cholecystectomy: author's reply.

Abstract

We express our gratitude to the authors for their valuable comments on our recent study comparing the analgesic effects of modified thoracoabdominal nerve block through the perichondral approach (M-TAPA) and subcostal transversus abdominis plane block (TAPB) [1]. They have raised several questions concerning the study design and results. First, they addressed concerns regarding our analgesic protocol, which did not involve the routine use of nonopioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) after surgery. As the authors rightfully mentioned, non-opioid analgesics like acetaminophen and NSAIDs are widely used for postoperative pain management. We administered these non-opioid analgesics intraoperatively, and, considering the short surgery duration, we believe that their effects sufficiently covered postoperative pain during the fasting period (approximately 6 hours). Additionally, for laparoscopic cholecystectomy, we followed our institution's standard analgesic protocol by administering 40 mg of intravenous nefopam during the first 8 hours postoperatively. Notably, we recently reported on the opioid-sparing and analgesic effects of intravenous nefopam during thoracic surgery [2]. Moreover, 6 hours post-surgery, when patients' pain had significantly decreased and they resumed oral intake, we administered an oral tramadol/ acetaminophen combination tablet as a rescue analgesic. Second, the authors expressed concerns that our study participants may have received insufficient postoperative pain control based on the pain intensity results. Although we administered non-opioid analgesics and performed nerve blockade in both groups, we observed high pain scores immediately after surgery. It is plausible that the participants' responses to the pain assessment might have influenced these results. According to a recent prospective study on the cutoff pain scores for mild, moderate, and severe pain in adult Korean patients, the cutoff score between mild and moderate pain was 5.5 on the numeric rating scale [3]. Our previous prospective study conducted in a post-anesthesia care unit yielded similar results [4]. Since we did not provide specific guidance beyond the numeric rating scale (with 0 indicating no pain and 10 indicating the worst pain imaginable), the participants tended to respond with scores closer to the midpoint of 5 when their consciousness was not entirely clear immediately after surgery. Third, the authors highlighted the high occurrence rate of postoperative nausea and vomiting (PONV) among