Effectiveness of Combined Fascial Plane Blocks for Postoperative Pain in Gynecologic Cancer Surgery: A Prospective Observational Study

Effectiveness of Combined Fascial Plane Blocks for Postoperative Pain in Gynecologic Cancer Surgery: A Prospective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of Combined Fascial Plane Blocks for Postoperative Pain in Gynecologic Cancer Surgery: A Prospective Observational Study Ayşe Menekşe Çakır, Menşure Kaya This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9080781/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Fascial plane blocks are widely incorporated into multimodal analgesia for major gynecologic cancer surgery; however, comparative data on combined block strategies in real-world clinical practice remain limited. Methods: This prospective observational study included adult patients undergoing open gynecologic oncologic surgery through a standardized midline supra- and infraumbilical laparotomy incision. Patients were categorized into three groups according to the block strategy routinely used in clinical practice: Lateral TAP alone (n = 27), Lateral TAP + quadratus lumborum block (QLB-1) (n = 34), or Lateral TAP + rectus sheath block (RSB) (n = 33). All blocks were performed under ultrasound guidance at the end of surgery. Postoperative pain scores (visual analog scale, VAS), cumulative rescue morphine consumption, NSAID use, postoperative nausea and vomiting, recovery of bowel function, time to mobilization, time to oral intake, and length of hospital stay were recorded during the first 24 hours. Results: Total morphine consumption was significantly higher in the Lateral TAP group (3.4 ± 1.4 mg) compared with the Lateral TAP + QLB-1 (1.3 ± 1.6 mg) and Lateral TAP + RSB (1.3 ± 1.1 mg) groups (p < 0.05). VAS scores at all postoperative time points were significantly greater in the Lateral TAP group. Postoperative nausea and vomiting occurred in 70.4% of patients in the Lateral TAP group, compared with 23.5% and 18.2% in the Lateral TAP + QLB-1 and Lateral TAP + RSB groups, respectively (p < 0.05). Recovery of bowel function, mobilization, and initiation of oral intake occurred significantly earlier in both combined-block groups, and hospital stay was reduced by approximately 1 day compared with Lateral TAP block alone. Conclusions: In routine clinical practice, combined fascial plane block strategies (Lateral TAP + QLB-1 and Lateral TAP + RSB) were associated with improved postoperative analgesia and enhanced recovery compared with Lateral TAP alone after major gynecologic cancer surgery. These findings support the integration of combined fascial plane block approaches into ERAS-based multimodal analgesia pathways. Fascial plane block gynecologic oncology postoperative pain observational study Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Postoperative pain remains a major clinical challenge following gynecologic oncologic surgery, as inadequate analgesia is associated with delayed mobilization, prolonged hospitalization, and increased opioid-related adverse effects ( 1 ). Effective pain control is therefore a key component of perioperative care, and Enhanced Recovery After Surgery (ERAS) guidelines strongly recommend multimodal, opioid-sparing analgesic strategies in this patient population ( 2 ). Among regional anesthesia techniques, ultrasound-guided fascial plane blocks—including the lateral transversus abdominis plane (TAP) block, quadratus lumborum block (QLB-1), and rectus sheath block (RSB)—have gained widespread acceptance because of their favorable safety profile and their ability to provide both somatic and, in some cases, visceral analgesia ( 3 , 4 ). Although each of these blocks has demonstrated analgesic efficacy when used alone, recent studies suggest that combining different fascial plane blocks may further enhance analgesic coverage. However, high-quality comparative data evaluating combined block strategies in major gynecologic oncology surgery remain limited ( 5 ). In routine clinical practice at our institution, fascial plane blocks are an integral part of ERAS-based multimodal analgesia, and combined block strategies are frequently used according to anesthesiologist preference and surgical characteristics. Therefore, the present prospective observational study was designed to compare Lateral TAP block alone with Lateral TAP combined with QLB-1 or RSB with respect to postoperative pain intensity, opioid consumption, recovery parameters, and adverse effects, without altering routine clinical practice. 2. Materials and Methods 2.1 Study Design This single-center, prospective observational study was conducted at the University of Health Sciences, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital. Ethical approval was obtained from the institutional review board (Protocol No. 2023-15/536, December 20, 2023). The study was designed to evaluate the clinical effectiveness of commonly used abdominal fascial plane block strategies as implemented in routine perioperative care. Abdominal fascial plane blocks are a standard component of multimodal analgesia in our institution for open gynecologic oncologic surgery. Block strategies were applied according to a predefined institutional rotation schedule as part of routine clinical practice, independent of patient characteristics (age, BMI, clinical status, or surgical indication). The research team did not influence block selection, dosing, or technique. All patients underwent open major gynecologic oncologic surgery performed by the same surgical team through a standardized midline laparotomy incision extending both above and below the umbilicus, corresponding approximately to dermatomes T7–T12. 2.2 Participants Eligible participants were adults ≥ 18 years with ASA physical status I–IV undergoing elective open major gynecologic oncologic surgery (endometrial, ovarian, or cytoreductive procedures). Exclusion criteria included allergy to local anesthetics, chronic opioid use, coagulopathy, infection at the injection site, laparoscopic procedures, or refusal to participate. 2.3 Study Groups General anesthesia was maintained with sevoflurane (1–2%) in an oxygen–air mixture and titrated to maintain bispectral index values between 40 and 60. A continuous remifentanil infusion (0.1–0.2 µg·kg⁻¹·min⁻¹) was administered intraoperatively. All patients received intravenous paracetamol 1 g and dexamethasone 4 mg after induction, and standard antiemetic prophylaxis with ondansetron 4 mg at the end of surgery. Isotonic saline (0.9% NaCl) was infused at 6 mL·kg⁻¹·h⁻¹ intraoperatively and 2–4 mL·kg⁻¹·h⁻¹ postoperatively. Residual neuromuscular blockade was reversed with sugammadex 2 mg·kg⁻¹. At the end of surgery, all patients received intravenous morphine 0.02–0.03 mg·kg⁻¹. Postoperatively, paracetamol 1 g IV was administered every 6 h. Rescue analgesia with intravenous morphine (1-mg increments) was administered for VAS ≥ 4. Cumulative morphine consumption was recorded. Cumulative morphine consumption refers to postoperative rescue doses only. 2.4 Nerve Block Techniques All blocks were performed bilaterally under ultrasound guidance in the supine position at the end of surgery before extubation using a high-frequency linear transducer. Patients were allocated to: Lateral TAP block (n = 27) Lateral TAP + QLB-1 (n = 34) Lateral TAP + RSB (n = 33) For each individual block, 0.3 mL·kg⁻¹ of 0.175% bupivacaine was administered bilaterally. Dosing was standardized per block according to body weight to ensure consistent pharmacologic exposure within each anatomical fascial plane. As combined techniques involve injection into two distinct anatomical compartments, total injectate volume differed between groups. The total bupivacaine dose remained below 2.5 mg·kg⁻¹ in all patients. Lateral Transversus Abdominis Plane (TAP) Block A lateral transversus abdominis plane (TAP) block was performed. The ultrasound probe was positioned transversely along the midaxillary line between the 12th rib and the iliac crest. The three abdominal muscle layers—external oblique, internal oblique, and transversus abdominis—were identified. Using an in-plane technique, the needle was advanced into the fascial plane between the internal oblique and transversus abdominis muscles (Fig. 1 ). After confirming correct needle tip placement, local anesthetic was injected, and adequate spread separating the two muscle layers was visualized sonographically. Lateral Quadratus Lumborum Block (QLB-1) For the lateral QLB (QLB-1), the transducer was placed transversely just above the iliac crest along the midaxillary line, in the flank region between the costal margin and iliac crest (corresponding to Petit’s triangle). The three abdominal muscle layers were first identified. The probe was then moved posteriorly until the posterior aponeurosis of the transversus abdominis muscle and the quadratus lumborum muscle were visualized (Fig. 2 .). The needle was inserted in-plane from anterior to posterior, and local anesthetic was deposited at the lateral border of the quadratus lumborum muscle, deep to the transversus abdominis aponeurosis and superficial to the transversalis fascia. Correct placement was confirmed by observing the spread of local anesthetic along the lateral aspect of the quadratus lumborum muscle. Rectus Sheath Block (RSB) For the rectus sheath block, the ultrasound probe was positioned transversely approximately 1 cm lateral to the midline above the umbilicus while the patient was supine. The linea alba was identified, and the probe was moved laterally to visualize the rectus abdominis muscle. Using an in-plane approach from medial to lateral, the needle was advanced into the potential space between the rectus abdominis muscle and the posterior rectus sheath (Fig. 3 .). Local anesthetic was injected into this plane, and adequate spread was confirmed under ultrasound visualization. 2.4 Data Collection The primary outcome was postoperative opioid consumption, expressed as intravenous morphine-equivalent dose during the first 24 h. Secondary outcomes included VAS pain scores at 0, 15 min, 2, 6, 12, and 24 h; NSAID requirement; postoperative nausea and vomiting; time to first passage of flatus or stool; time to mobilization; time to first oral intake; and length of intensive care unit and hospital stay. Postoperative assessments were performed by anesthesiologists who were not involved in intraoperative patient management. 2.5 Statistical Analysis A priori power analysis was performed based on institutional pilot data on postoperative rescue morphine consumption in patients receiving fascial plane blocks after major gynecologic oncologic surgery. At our center, 24-h rescue morphine consumption after TAP block alone averages approximately 3.5 ± 1.5 mg. A clinically meaningful 30% reduction in opioid requirement was assumed for combined block strategies. With a two-sided α of 0.05 and a power of 80%, a sample size of 27 patients per group was required. Statistical analyses were performed using SPSS version 20 (IBM Corp., Armonk, NY, USA). Normality was assessed with the Shapiro–Wilk test. Continuous variables are presented as mean ± SD when normally distributed and as median (IQR) when non-normally distributed. Between-group comparisons were performed using one-way ANOVA or the Kruskal–Wallis test, as appropriate. Within-group changes in VAS scores over time were analyzed using the Friedman test with Bonferroni-adjusted post hoc comparisons. A p value < 0.05 was considered statistically significant. 3. Results A total of 94 eligible patients were enrolled. One patient in the TAP group required urgent re-laparotomy on postoperative day 1 and was excluded from further analyses. Baseline demographic and clinical characteristics were comparable among the three groups, including ASA physical status and distribution of gynecologic cancer types (Table 1 ; p > 0.05). Table 1 Baseline Demographic and Clinical Characteristics of Patients According to Fascial Plane Block Technique Characteristic TAP + QLB (n = 34) TAP + RSB (n = 33) TAP Block (n = 27) p value ASA physical status 0.688 II 19 (55.9%) 20 (60.6%) 15 (55.6%) III 15 (44.1%) 12 (36.4%) 12 (44.4%) IV 0 (0.0%) 1 (3.0%) 0 (0.0%) Cancer type 0.912 Endometrial 11 (32.4%) 13 (39.4%) 12 (44.4%) Ovarian 18 (52.9%) 16 (48.5%) 12 (44.4%) Cervical 5 (14.7%) 4 (12.1%) 3 (11.1%) Age (years) 57.1 ± 10.7 56.0 ± 12.4 56.7 ± 12.5 0.930 BMI (kg·m⁻²) 29.2 ± 6.4 29.7 ± 6.0 27.8 ± 4.0 0.419 Duration of surgery (min) 209 ± 47 222.6 ± 56.4 205.4 ± 37.4 0.334 Values are presented as mean ± SD or number (%). Categorical variables were compared using the χ² test and continuous variables using one-way analysis of variance (ANOVA). BMI, body mass index; ASA, American Society of Anesthesiologists physical status. Postoperative rescue morphine consumption was significantly higher in the TAP group than in both combined-block groups (p < 0.05). Mean morphine consumption was 3.4 ± 1.4 mg in the TAP group compared with 1.3 ± 1.6 mg in the TAP + QLB group and 1.3 ± 1.1 mg in the TAP + RSB group (Fig. 4 ). Postoperative pain intensity was consistently higher in the TAP group throughout the first 24 h. At all assessed time points (0 min, 15 min, 2 h, 6 h, 12 h, and 24 h), median VAS scores were significantly lower in both TAP + QLB and TAP + RSB groups compared with TAP alone (p < 0.05, Table 2 ). Within each group, VAS scores changed significantly over time (Friedman test, p < 0.001 for all groups). Table 2 Postoperative VAS scores according to fascial plane block strategy Time TAP + QLB (n:34) TAP + RSB (n:33) TAP Block (n:27) p-value 0 min 2 ( 1 – 2 ) 1 ( 1 – 2 ) 2 ( 1 – 4 ) < 0.001 15 min 2.5 ( 1 – 7 ) 2 ( 1 – 7 ) 5.5 ( 1 – 9 ) < 0.001 2 h 2 ( 1 – 6 ) 3 ( 1 – 6 ) 4 ( 1 – 7 ) 0.006 6 h 3 ( 1 – 6 ) 4 ( 1 – 6 ) 5 ( 1 – 7 ) 0.030 12 h 5 ( 1 – 6 ) 5 ( 1 – 6 ) 5.5 ( 2 – 8 ) 0.049 24 h 4.5 ( 1 – 6 ) 4 ( 1 – 6 ) 5 ( 2 – 7 ) 0.005 Values are presented as median (min–max). Between-group comparisons at each time point were performed using the Kruskal–Wallis test. Within-group changes in VAS scores over time were analyzed using the Friedman test with Bonferroni-adjusted post hoc comparisons. All three groups showed significant time-dependent changes in pain intensity (p < 0.001 for each group). Different superscript letters indicate statistically significant differences between groups. NSAID use was required in 14.7% of patients in the TAP + QLB group and 9.1% in the TAP + RSB group, compared with 33.3% in the TAP group. Postoperative nausea and vomiting occurred in 23.5% and 18.2% of patients in the TAP + QLB and TAP + RSB groups, respectively, but increased markedly to 70.4% in the TAP group (p < 0.05; Table 3 ). Gastrointestinal recovery was significantly delayed in the TAP group. Time to first passage of flatus or stool was comparable between the TAP + QLB and TAP + RSB groups (20.5 ± 7.7 h and 19.4 ± 6.0 h, respectively) but was significantly longer in the TAP group (31 ± 6.3 h; p < 0.05). Similarly, both mobilization and initiation of oral intake occurred later in the TAP group (p < 0.05; Table 3 ). Hospital length of stay was also longer in the TAP group, whereas ICU length of stay did not differ among groups (Table 3 ). Table 3 Postoperative Outcomes According to Fascial Plane Block Strategy Outcome TAP + QLB (n = 34) TAP + RSB (n = 33) TAP Block (n = 27) p value NSAID use 5 (14.7%) 3 (9.1%) 9 (33.3%) 0.043 Postoperative nausea and vomiting 8 (23.5%) 6 (18.2%) 19 (70.4%) < 0.001 Postoperative rescue morphine (mg) 0 (0–4) 2 (0–4) 4 ( 2 – 7 ) < 0.001 Time to flatus or stool (h) 21,5 (6–41) 20 (8–30) 30,5 (22–48) < 0.001 Time to mobilization (h) 16 (8–23) 16 (8–22) 19 (11–32) 0.001 Time to first oral intake (h) 14 (8–25) 14 (7–20) 17 (8–29) 0.002 ICU length of stay (days) 1 (0–1) 1 (0–1) 1 (0–2) 0.282 Hospital length of stay (days) 3.5 ( 3 – 6 ) 4 ( 3 – 6 ) 4 ( 3 – 7 ) 0.001 Categorical variables were compared using the χ² test. Continuous variables were analyzed using the Kruskal–Wallis test. Postoperative morphine consumption refers to rescue doses only. Values are presented as median (min–max) or number (%). TAP + QLB and TAP + RSB groups required significantly less rescue morphine and NSAIDs, experienced lower rates of postoperative nausea and vomiting, and demonstrated faster recovery of bowel function, mobilization, and oral intake compared with TAP alone. ICU stay did not differ significantly, whereas hospital length of stay was shorter in the combined-block groups. 4. Discussion This prospective observational study evaluated the clinical effectiveness of combined fascial plane block strategies compared with Lateral TAP block alone in patients undergoing open major gynecologic oncologic surgery. Within the context of standardized surgical technique and multimodal analgesia, the combined strategies (Lateral TAP + QLB-1 and Lateral TAP + RSB) were associated with lower postoperative opioid requirements, reduced NSAID consumption, and improved recovery parameters compared with Lateral TAP block alone. These findings suggest a potential additive benefit when multiple fascial compartments are targeted in routine clinical practice. Postoperative pain after major gynecologic abdominal surgery remains substantial and is strongly associated with delayed mobilization, prolonged hospitalization, and increased morbidity ( 6 ). Multimodal analgesia aims to minimize opioid-related adverse effects, including nausea, vomiting, ileus, and respiratory depression, all of which can delay postoperative recovery ( 7 , 8 ). Although TAP block is widely used as part of multimodal analgesia, its efficacy is variable, particularly with respect to dermatomal coverage and duration of analgesia ( 9 ). In contrast, combining fascial plane blocks may enhance the spread of local anesthetics and provide more comprehensive somatic and visceral analgesia. Consistent with previous studies—such as Yu et al., who demonstrated improved analgesia with TAP combined with RSB ( 10 ), and Kumar et al., who reported superior pain control with QLB compared with TAP ( 11 )—our results show significantly lower VAS scores and reduced rescue opioid consumption in both combined-block groups. The clinical advantages of combined block strategies likely arise from their complementary anatomical mechanisms. RSB enhances anterior midline analgesia and overcomes the medial limitation of TAP block, while QLB may provide broader and deeper analgesia through thoracolumbar fascial continuity and potential paravertebral spread, extending analgesic coverage to both somatic and visceral components of pain ( 12 – 15 ). Given the standardized midline supra- and infraumbilical incision in all patients, broader dermatomal coverage may have contributed to improved analgesic outcomes in the combined-block groups. Enhanced Recovery After Surgery (ERAS) pathways emphasize opioid-sparing multimodal analgesia to facilitate early mobilization and gastrointestinal recovery ( 16 ). In this context, the combined-block groups demonstrated recovery profiles more consistent with ERAS principles, including earlier mobilization, faster return of bowel function, and shorter hospital stay. The markedly lower incidence of postoperative nausea and vomiting in the combined-block groups further supports the opioid-sparing effect of these techniques. While causality cannot be inferred due to the observational design, the associations observed in this cohort support further investigation of combined fascial plane strategies within ERAS-based care. An important consideration is the difference in total local anesthetic volume between groups. Combined techniques inherently required greater total injectate volumes because they target anatomically distinct fascial compartments. Equalizing total volume across groups would not have reflected routine clinical implementation and might have resulted in suboptimal dosing within individual planes. Nevertheless, the potential influence of total local anesthetic volume on analgesic outcomes cannot be entirely excluded. Larger injectate volumes may enhance fascial spread and prolong analgesia ( 17 , 18 ). Therefore, although the findings likely reflect complementary dermatomal coverage rather than a purely volume-dependent effect, future randomized volume-controlled studies are needed to further clarify this issue. Several limitations should be acknowledged. Because of the prospective observational design, causal relationships between block strategy and postoperative outcomes cannot be definitively established. First, the observational design precludes causal inference. Although block allocation followed a predefined institutional rotation schedule independent of patient characteristics, unmeasured confounding cannot be entirely excluded. Second, sensory mapping was not formally performed to document dermatomal spread. Third, total injectate volume differed between groups due to the anatomical requirements of combined techniques. Sensory dermatomal mapping was not systematically performed after the block; therefore, the exact extent of sensory coverage could not be objectively confirmed. Finally, the results may not be generalizable beyond open gynecologic oncologic surgery. Conclusion Combined fascial plane block strategies, specifically Lateral TAP + QLB-1 and Lateral TAP + RSB may provide improved postoperative analgesia and enhanced recovery compared with Lateral TAP block alone in major gynecologic cancer surgery. Reduced opioid consumption, improved recovery parameters, and shorter hospital stay support the incorporation of combined fascial plane blocks into ERAS-based multimodal analgesia pathways. Further randomized controlled trials are warranted to refine dosing strategies and to standardize the use of combined block techniques in this patient population. Declarations Ethical approval This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital Ethics Committee (Protocol No: 2023-15/536, Date: 20.12.2023). Written informed consent was obtained from all participants. Competing interests The authors declare that they have no competing interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Author Contribution A.M. Çakır: Study design, data collection, data interpretation, manuscript drafting. M. Kaya: Data collection, statistical analysis, manuscript revision Acknowledgements The authors thank the anesthesia and gynecologic oncology surgical teams at Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital for their support in routine clinical care during which data were collected. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. References Reisli R, Akkaya ÖT, Arıcan Ş, Can ÖS, Çetingök H, Güleç MS, Talu GK. Pharmacologic treatment of acute postoperative pain: a clinical practice guideline of the Turkish Society of Algology. Agri 2021;33(1):1–51. 10.14744/agri.2021.60243 Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al. 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Available from: https://pubmed.ncbi.nlm.nih.gov/26757238/(cited 2025 Apr 4). Mallan D, Sharan S, Saxena S, Singh TK, Faisal. Anesthetic techniques: focus on transversus abdominis plane (TAP) blocks. Local Reg Anesth. 2019;12:81–8. 10.2147/LRA.S138537 . Salinas FV. How I do it: ultrasound-guided bilateral rectus sheath blocks. ASRA Updates [Internet]. 2019 Aug 7 [cited 2025 Nov 19]. Available from: https://asra.com/news-publications/asra-updates/blog-landing/legacy-b-blog-posts/2019/08/07/how-i-do-it-ultrasound-guided-bilateral-rectus-sheath-blocks Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9080781","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627206273,"identity":"cc98e2b1-97d9-4109-8303-90af6cf139fc","order_by":0,"name":"Ayşe Menekşe Çakır","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYJACxgYY6yOYxdh4gGgtjDMbGCRAfOK1MPOCtTAw4NWi29578OGMPzYM/DPSHz623WFTp9t+GGhLjU00Li1mZ84lG25sS2OQuJFjbJx7Jk3C7EwiUMuxtNwGXFpu5JhJPmw4zMBwI4dNOrftsITZAaAWxobDuLXcf2P+88Gf/wzyN9Kf/7YEaTn/kICWGzxmjBvYDjAY3EgwY2YEablByJYzOcaSM9uSeQzPvDGW7G1Lk9x2A2hLAj6/HD9j+LHnj52c3PH0hx9+ttnwm51Pf/jgQ40NTi0wwMMgkIDETcChDBXwHyBK2SgYBaNgFIxAAACjMWZvM7/s8wAAAABJRU5ErkJggg==","orcid":"","institution":"Ankara Onkoloji Eğitim ve Araştırma Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"Ayşe","middleName":"Menekşe","lastName":"Çakır","suffix":""},{"id":627206274,"identity":"2824c5c8-1c3a-4dba-aecf-6be641817ea0","order_by":1,"name":"Menşure Kaya","email":"","orcid":"","institution":"Ankara Onkoloji Eğitim ve Araştırma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Menşure","middleName":"","lastName":"Kaya","suffix":""}],"badges":[],"createdAt":"2026-03-10 07:53:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9080781/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9080781/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107839123,"identity":"3701465e-8f3d-4866-9b5e-8a4d33d0b6e3","added_by":"auto","created_at":"2026-04-26 17:15:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":672958,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound-guided Lateral Transversus Abdominis Plane (TAP) Block\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9080781/v1/9c2a03bd07f502a6662d988a.png"},{"id":107870460,"identity":"849d664f-4f8b-4cc9-91df-b616e8fddf59","added_by":"auto","created_at":"2026-04-27 07:39:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":769406,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound-guided Lateral Quadratus Lumborum Block (QLB-1)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9080781/v1/1479209deebaaa0653a1b46f.png"},{"id":107839126,"identity":"d1b2f3a6-e1ea-4db9-9af7-aefd4534af54","added_by":"auto","created_at":"2026-04-26 17:15:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":660124,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound-guided Rectus Sheath Block (RSB)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9080781/v1/2dd9163ee50031c20b4385c7.png"},{"id":107839127,"identity":"b771e048-881d-4507-86c9-59864771b8d4","added_by":"auto","created_at":"2026-04-26 17:15:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":44643,"visible":true,"origin":"","legend":"\u003cp\u003eTotal Morphine Consumption According to Fascial Plane Block Strategy\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9080781/v1/ed812a15c4d0ad4162306d0a.png"},{"id":108006162,"identity":"70caa9f0-f3e1-41f2-9c62-4f3a2581cff7","added_by":"auto","created_at":"2026-04-28 12:54:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3264927,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9080781/v1/e9b658e9-d356-47a8-8f94-875c4ac1a062.pdf"},{"id":107869786,"identity":"9a9bc01e-79ae-4532-a3be-89638ebc4623","added_by":"auto","created_at":"2026-04-27 07:38:09","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":94221,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEChecklistFormatted.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9080781/v1/bb1423148894fb983cd30fbe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Combined Fascial Plane Blocks for Postoperative Pain in Gynecologic Cancer Surgery: A Prospective Observational Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePostoperative pain remains a major clinical challenge following gynecologic oncologic surgery, as inadequate analgesia is associated with delayed mobilization, prolonged hospitalization, and increased opioid-related adverse effects (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Effective pain control is therefore a key component of perioperative care, and Enhanced Recovery After Surgery (ERAS) guidelines strongly recommend multimodal, opioid-sparing analgesic strategies in this patient population (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong regional anesthesia techniques, ultrasound-guided fascial plane blocks\u0026mdash;including the lateral transversus abdominis plane (TAP) block, quadratus lumborum block (QLB-1), and rectus sheath block (RSB)\u0026mdash;have gained widespread acceptance because of their favorable safety profile and their ability to provide both somatic and, in some cases, visceral analgesia (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although each of these blocks has demonstrated analgesic efficacy when used alone, recent studies suggest that combining different fascial plane blocks may further enhance analgesic coverage. However, high-quality comparative data evaluating combined block strategies in major gynecologic oncology surgery remain limited (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn routine clinical practice at our institution, fascial plane blocks are an integral part of ERAS-based multimodal analgesia, and combined block strategies are frequently used according to anesthesiologist preference and surgical characteristics. Therefore, the present prospective observational study was designed to compare Lateral TAP block alone with Lateral TAP combined with QLB-1 or RSB with respect to postoperative pain intensity, opioid consumption, recovery parameters, and adverse effects, without altering routine clinical practice.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eThis single-center, prospective observational study was conducted at the University of Health Sciences, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital. Ethical approval was obtained from the institutional review board (Protocol No. 2023-15/536, December 20, 2023).\u003c/p\u003e \u003cp\u003eThe study was designed to evaluate the clinical effectiveness of commonly used abdominal fascial plane block strategies as implemented in routine perioperative care. Abdominal fascial plane blocks are a standard component of multimodal analgesia in our institution for open gynecologic oncologic surgery.\u003c/p\u003e \u003cp\u003eBlock strategies were applied according to a predefined institutional rotation schedule as part of routine clinical practice, independent of patient characteristics (age, BMI, clinical status, or surgical indication). The research team did not influence block selection, dosing, or technique.\u003c/p\u003e \u003cp\u003eAll patients underwent open major gynecologic oncologic surgery performed by the same surgical team through a standardized midline laparotomy incision extending both above and below the umbilicus, corresponding approximately to dermatomes T7\u0026ndash;T12.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participants\u003c/h2\u003e \u003cp\u003eEligible participants were adults\u0026thinsp;\u0026ge;\u0026thinsp;18 years with ASA physical status I\u0026ndash;IV undergoing elective open major gynecologic oncologic surgery (endometrial, ovarian, or cytoreductive procedures).\u003c/p\u003e \u003cp\u003eExclusion criteria included allergy to local anesthetics, chronic opioid use, coagulopathy, infection at the injection site, laparoscopic procedures, or refusal to participate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study Groups\u003c/h2\u003e \u003cp\u003eGeneral anesthesia was maintained with sevoflurane (1\u0026ndash;2%) in an oxygen\u0026ndash;air mixture and titrated to maintain bispectral index values between 40 and 60. A continuous remifentanil infusion (0.1\u0026ndash;0.2 \u0026micro;g\u0026middot;kg⁻\u0026sup1;\u0026middot;min⁻\u0026sup1;) was administered intraoperatively. All patients received intravenous paracetamol 1 g and dexamethasone 4 mg after induction, and standard antiemetic prophylaxis with ondansetron 4 mg at the end of surgery. Isotonic saline (0.9% NaCl) was infused at 6 mL\u0026middot;kg⁻\u0026sup1;\u0026middot;h⁻\u0026sup1; intraoperatively and 2\u0026ndash;4 mL\u0026middot;kg⁻\u0026sup1;\u0026middot;h⁻\u0026sup1; postoperatively. Residual neuromuscular blockade was reversed with sugammadex 2 mg\u0026middot;kg⁻\u0026sup1;. At the end of surgery, all patients received intravenous morphine 0.02\u0026ndash;0.03 mg\u0026middot;kg⁻\u0026sup1;.\u003c/p\u003e \u003cp\u003ePostoperatively, paracetamol 1 g IV was administered every 6 h. Rescue analgesia with intravenous morphine (1-mg increments) was administered for VAS\u0026thinsp;\u0026ge;\u0026thinsp;4. Cumulative morphine consumption was recorded. Cumulative morphine consumption refers to postoperative rescue doses only.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Nerve Block Techniques\u003c/h2\u003e \u003cp\u003eAll blocks were performed bilaterally under ultrasound guidance in the supine position at the end of surgery before extubation using a high-frequency linear transducer.\u003c/p\u003e \u003cp\u003ePatients were allocated to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLateral TAP block (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLateral TAP\u0026thinsp;+\u0026thinsp;QLB-1 (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLateral TAP\u0026thinsp;+\u0026thinsp;RSB (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFor each individual block, 0.3 mL\u0026middot;kg⁻\u0026sup1; of 0.175% bupivacaine was administered bilaterally. Dosing was standardized per block according to body weight to ensure consistent pharmacologic exposure within each anatomical fascial plane. As combined techniques involve injection into two distinct anatomical compartments, total injectate volume differed between groups. The total bupivacaine dose remained below 2.5 mg\u0026middot;kg⁻\u0026sup1; in all patients.\u003c/p\u003e \u003cp\u003eLateral Transversus Abdominis Plane (TAP) Block\u003c/p\u003e \u003cp\u003eA lateral transversus abdominis plane (TAP) block was performed. The ultrasound probe was positioned transversely along the midaxillary line between the 12th rib and the iliac crest.\u003c/p\u003e \u003cp\u003eThe three abdominal muscle layers\u0026mdash;external oblique, internal oblique, and transversus abdominis\u0026mdash;were identified. Using an in-plane technique, the needle was advanced into the fascial plane between the internal oblique and transversus abdominis muscles (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After confirming correct needle tip placement, local anesthetic was injected, and adequate spread separating the two muscle layers was visualized sonographically.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eLateral Quadratus Lumborum Block (QLB-1)\u003c/p\u003e \u003cp\u003eFor the lateral QLB (QLB-1), the transducer was placed transversely just above the iliac crest along the midaxillary line, in the flank region between the costal margin and iliac crest (corresponding to Petit\u0026rsquo;s triangle).\u003c/p\u003e \u003cp\u003eThe three abdominal muscle layers were first identified. The probe was then moved posteriorly until the posterior aponeurosis of the transversus abdominis muscle and the quadratus lumborum muscle were visualized (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e.).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe needle was inserted in-plane from anterior to posterior, and local anesthetic was deposited at the lateral border of the quadratus lumborum muscle, deep to the transversus abdominis aponeurosis and superficial to the transversalis fascia. Correct placement was confirmed by observing the spread of local anesthetic along the lateral aspect of the quadratus lumborum muscle.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRectus Sheath Block (RSB)\u003c/p\u003e \u003cp\u003eFor the rectus sheath block, the ultrasound probe was positioned transversely approximately 1 cm lateral to the midline above the umbilicus while the patient was supine.\u003c/p\u003e \u003cp\u003eThe linea alba was identified, and the probe was moved laterally to visualize the rectus abdominis muscle. Using an in-plane approach from medial to lateral, the needle was advanced into the potential space between the rectus abdominis muscle and the posterior rectus sheath (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003e.). Local anesthetic was injected into this plane, and adequate spread was confirmed under ultrasound visualization.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection\u003c/h2\u003e \u003cp\u003eThe primary outcome was postoperative opioid consumption, expressed as intravenous morphine-equivalent dose during the first 24 h. Secondary outcomes included VAS pain scores at 0, 15 min, 2, 6, 12, and 24 h; NSAID requirement; postoperative nausea and vomiting; time to first passage of flatus or stool; time to mobilization; time to first oral intake; and length of intensive care unit and hospital stay. Postoperative assessments were performed by anesthesiologists who were not involved in intraoperative patient management.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e \u003cp\u003eA priori power analysis was performed based on institutional pilot data on postoperative rescue morphine consumption in patients receiving fascial plane blocks after major gynecologic oncologic surgery. At our center, 24-h rescue morphine consumption after TAP block alone averages approximately 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 mg. A clinically meaningful 30% reduction in opioid requirement was assumed for combined block strategies. With a two-sided α of 0.05 and a power of 80%, a sample size of 27 patients per group was required.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 20 (IBM Corp., Armonk, NY, USA). Normality was assessed with the Shapiro\u0026ndash;Wilk test. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD when normally distributed and as median (IQR) when non-normally distributed. Between-group comparisons were performed using one-way ANOVA or the Kruskal\u0026ndash;Wallis test, as appropriate. Within-group changes in VAS scores over time were analyzed using the Friedman test with Bonferroni-adjusted post hoc comparisons. A p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 94 eligible patients were enrolled. One patient in the TAP group required urgent re-laparotomy on postoperative day 1 and was excluded from further analyses. Baseline demographic and clinical characteristics were comparable among the three groups, including ASA physical status and distribution of gynecologic cancer types (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Demographic and Clinical Characteristics of Patients According to Fascial Plane Block Technique\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTAP\u0026thinsp;+\u0026thinsp;QLB (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTAP\u0026thinsp;+\u0026thinsp;RSB (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTAP Block (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA physical status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (55.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (60.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15 (55.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (44.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCancer type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (32.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (39.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (52.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (48.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (12.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.930\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg\u0026middot;m⁻\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.419\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of surgery (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209\u0026thinsp;\u0026plusmn;\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e222.6\u0026thinsp;\u0026plusmn;\u0026thinsp;56.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e205.4\u0026thinsp;\u0026plusmn;\u0026thinsp;37.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or number (%). Categorical variables were compared using the χ\u0026sup2; test and continuous variables using one-way analysis of variance (ANOVA). BMI, body mass index; ASA, American Society of Anesthesiologists physical status.\u003c/p\u003e \u003cp\u003ePostoperative rescue morphine consumption was significantly higher in the TAP group than in both combined-block groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Mean morphine consumption was 3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 mg in the TAP group compared with 1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mg in the TAP\u0026thinsp;+\u0026thinsp;QLB group and 1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 mg in the TAP\u0026thinsp;+\u0026thinsp;RSB group (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperative pain intensity was consistently higher in the TAP group throughout the first 24 h. At all assessed time points (0 min, 15 min, 2 h, 6 h, 12 h, and 24 h), median VAS scores were significantly lower in both TAP\u0026thinsp;+\u0026thinsp;QLB and TAP\u0026thinsp;+\u0026thinsp;RSB groups compared with TAP alone (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Within each group, VAS scores changed significantly over time (Friedman test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all groups).\u003c/p\u003e \u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003e Postoperative VAS scores according to fascial plane block strategy\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eTAP\u0026thinsp;+\u0026thinsp;QLB\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(n:34)\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eTAP\u0026thinsp;+\u0026thinsp;RSB\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(n:33)\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eTAP Block\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e(n:27)\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2.5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5.5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e3\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e3\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5.5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.049\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4.5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eValues are presented as median (min\u0026ndash;max). Between-group comparisons at each time point were performed using the Kruskal\u0026ndash;Wallis test. \u003cb\u003eWithin-group changes in VAS scores over time were analyzed using the Friedman test with Bonferroni-adjusted post hoc comparisons. All three groups showed significant time-dependent changes in pain intensity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for each group).\u003c/b\u003e Different superscript letters indicate statistically significant differences between groups.\u003c/p\u003e \u003cp\u003eNSAID use was required in 14.7% of patients in the TAP\u0026thinsp;+\u0026thinsp;QLB group and 9.1% in the TAP\u0026thinsp;+\u0026thinsp;RSB group, compared with 33.3% in the TAP group. Postoperative nausea and vomiting occurred in 23.5% and 18.2% of patients in the TAP\u0026thinsp;+\u0026thinsp;QLB and TAP\u0026thinsp;+\u0026thinsp;RSB groups, respectively, but increased markedly to 70.4% in the TAP group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGastrointestinal recovery was significantly delayed in the TAP group. Time to first passage of flatus or stool was comparable between the TAP\u0026thinsp;+\u0026thinsp;QLB and TAP\u0026thinsp;+\u0026thinsp;RSB groups (20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 h and 19.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0 h, respectively) but was significantly longer in the TAP group (31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 h; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarly, both mobilization and initiation of oral intake occurred later in the TAP group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Hospital length of stay was also longer in the TAP group, whereas ICU length of stay did not differ among groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ePostoperative Outcomes According to Fascial Plane Block Strategy\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTAP\u0026thinsp;+\u0026thinsp;QLB (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTAP\u0026thinsp;+\u0026thinsp;RSB (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTAP Block (n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNSAID use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (14.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative nausea and vomiting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (70.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative rescue morphine (mg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime to flatus or stool (h)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21,5 (6\u0026ndash;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (8\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30,5 (22\u0026ndash;48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime to mobilization (h)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (8\u0026ndash;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (8\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (11\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime to first oral intake (h)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (8\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (7\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (8\u0026ndash;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU length of stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital length of stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5 (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCategorical variables were compared using the χ\u0026sup2; test. Continuous variables were analyzed using the Kruskal\u0026ndash;Wallis test. Postoperative morphine consumption refers to rescue doses only. Values are presented as median (min\u0026ndash;max) or number (%). TAP\u0026thinsp;+\u0026thinsp;QLB and TAP\u0026thinsp;+\u0026thinsp;RSB groups required significantly less rescue morphine and NSAIDs, experienced lower rates of postoperative nausea and vomiting, and demonstrated faster recovery of bowel function, mobilization, and oral intake compared with TAP alone. ICU stay did not differ significantly, whereas hospital length of stay was shorter in the combined-block groups.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis prospective observational study evaluated the clinical effectiveness of combined fascial plane block strategies compared with Lateral TAP block alone in patients undergoing open major gynecologic oncologic surgery. Within the context of standardized surgical technique and multimodal analgesia, the combined strategies (Lateral TAP\u0026thinsp;+\u0026thinsp;QLB-1 and Lateral TAP\u0026thinsp;+\u0026thinsp;RSB) were associated with lower postoperative opioid requirements, reduced NSAID consumption, and improved recovery parameters compared with Lateral TAP block alone. These findings suggest a potential additive benefit when multiple fascial compartments are targeted in routine clinical practice.\u003c/p\u003e \u003cp\u003ePostoperative pain after major gynecologic abdominal surgery remains substantial and is strongly associated with delayed mobilization, prolonged hospitalization, and increased morbidity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Multimodal analgesia aims to minimize opioid-related adverse effects, including nausea, vomiting, ileus, and respiratory depression, all of which can delay postoperative recovery (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Although TAP block is widely used as part of multimodal analgesia, its efficacy is variable, particularly with respect to dermatomal coverage and duration of analgesia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In contrast, combining fascial plane blocks may enhance the spread of local anesthetics and provide more comprehensive somatic and visceral analgesia. Consistent with previous studies\u0026mdash;such as Yu et al., who demonstrated improved analgesia with TAP combined with RSB (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and Kumar et al., who reported superior pain control with QLB compared with TAP (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u0026mdash;our results show significantly lower VAS scores and reduced rescue opioid consumption in both combined-block groups.\u003c/p\u003e \u003cp\u003eThe clinical advantages of combined block strategies likely arise from their complementary anatomical mechanisms. RSB enhances anterior midline analgesia and overcomes the medial limitation of TAP block, while QLB may provide broader and deeper analgesia through thoracolumbar fascial continuity and potential paravertebral spread, extending analgesic coverage to both somatic and visceral components of pain (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Given the standardized midline supra- and infraumbilical incision in all patients, broader dermatomal coverage may have contributed to improved analgesic outcomes in the combined-block groups.\u003c/p\u003e \u003cp\u003eEnhanced Recovery After Surgery (ERAS) pathways emphasize opioid-sparing multimodal analgesia to facilitate early mobilization and gastrointestinal recovery (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In this context, the combined-block groups demonstrated recovery profiles more consistent with ERAS principles, including earlier mobilization, faster return of bowel function, and shorter hospital stay. The markedly lower incidence of postoperative nausea and vomiting in the combined-block groups further supports the opioid-sparing effect of these techniques. While causality cannot be inferred due to the observational design, the associations observed in this cohort support further investigation of combined fascial plane strategies within ERAS-based care.\u003c/p\u003e \u003cp\u003eAn important consideration is the difference in total local anesthetic volume between groups. Combined techniques inherently required greater total injectate volumes because they target anatomically distinct fascial compartments. Equalizing total volume across groups would not have reflected routine clinical implementation and might have resulted in suboptimal dosing within individual planes. Nevertheless, the potential influence of total local anesthetic volume on analgesic outcomes cannot be entirely excluded. Larger injectate volumes may enhance fascial spread and prolong analgesia (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Therefore, although the findings likely reflect complementary dermatomal coverage rather than a purely volume-dependent effect, future randomized volume-controlled studies are needed to further clarify this issue.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. Because of the prospective observational design, causal relationships between block strategy and postoperative outcomes cannot be definitively established. First, the observational design precludes causal inference. Although block allocation followed a predefined institutional rotation schedule independent of patient characteristics, unmeasured confounding cannot be entirely excluded. Second, sensory mapping was not formally performed to document dermatomal spread. Third, total injectate volume differed between groups due to the anatomical requirements of combined techniques. Sensory dermatomal mapping was not systematically performed after the block; therefore, the exact extent of sensory coverage could not be objectively confirmed. Finally, the results may not be generalizable beyond open gynecologic oncologic surgery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCombined fascial plane block strategies, specifically Lateral TAP\u0026thinsp;+\u0026thinsp;QLB-1 and Lateral TAP\u0026thinsp;+\u0026thinsp;RSB may provide improved postoperative analgesia and enhanced recovery compared with Lateral TAP block alone in major gynecologic cancer surgery. Reduced opioid consumption, improved recovery parameters, and shorter hospital stay support the incorporation of combined fascial plane blocks into ERAS-based multimodal analgesia pathways. Further randomized controlled trials are warranted to refine dosing strategies and to standardize the use of combined block techniques in this patient population.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital Ethics Committee (Protocol No: 2023-15/536, Date: 20.12.2023). Written informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003e \u003cem\u003eThe authors declare that they have no competing interests.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.M. \u0026Ccedil;akır: Study design, data collection, data interpretation, manuscript drafting. M. Kaya: Data collection, statistical analysis, manuscript revision\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003e\u003cem\u003e The authors thank the anesthesia and gynecologic oncology surgical teams at Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital for their support in routine clinical care during which data were collected.\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReisli R, Akkaya \u0026Ouml;T, Arıcan Ş, Can \u0026Ouml;S, \u0026Ccedil;eting\u0026ouml;k H, G\u0026uuml;le\u0026ccedil; MS, Talu GK. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/26757238/(cited\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/26757238/(cited\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e 2025 Apr 4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMallan D, Sharan S, Saxena S, Singh TK, Faisal. Anesthetic techniques: focus on transversus abdominis plane (TAP) blocks. Local Reg Anesth. 2019;12:81\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/LRA.S138537\u003c/span\u003e\u003cspan address=\"10.2147/LRA.S138537\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalinas FV. How I do it: ultrasound-guided bilateral rectus sheath blocks. ASRA Updates [Internet]. 2019 Aug 7 [cited 2025 Nov 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://asra.com/news-publications/asra-updates/blog-landing/legacy-b-blog-posts/2019/08/07/how-i-do-it-ultrasound-guided-bilateral-rectus-sheath-blocks\u003c/span\u003e\u003cspan address=\"https://asra.com/news-publications/asra-updates/blog-landing/legacy-b-blog-posts/2019/08/07/how-i-do-it-ultrasound-guided-bilateral-rectus-sheath-blocks\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Fascial plane block, gynecologic oncology, postoperative pain, observational study","lastPublishedDoi":"10.21203/rs.3.rs-9080781/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9080781/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eFascial plane blocks are widely incorporated into multimodal analgesia for major gynecologic cancer surgery; however, comparative data on combined block strategies in real-world clinical practice remain limited.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis prospective observational study included adult patients undergoing open gynecologic oncologic surgery through a standardized midline supra- and infraumbilical laparotomy incision. Patients were categorized into three groups according to the block strategy routinely used in clinical practice: Lateral TAP alone (n\u0026thinsp;=\u0026thinsp;27), Lateral TAP\u0026thinsp;+\u0026thinsp;quadratus lumborum block (QLB-1) (n\u0026thinsp;=\u0026thinsp;34), or Lateral TAP\u0026thinsp;+\u0026thinsp;rectus sheath block (RSB) (n\u0026thinsp;=\u0026thinsp;33). All blocks were performed under ultrasound guidance at the end of surgery. Postoperative pain scores (visual analog scale, VAS), cumulative rescue morphine consumption, NSAID use, postoperative nausea and vomiting, recovery of bowel function, time to mobilization, time to oral intake, and length of hospital stay were recorded during the first 24 hours.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eTotal morphine consumption was significantly higher in the Lateral TAP group (3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 mg) compared with the Lateral TAP\u0026thinsp;+\u0026thinsp;QLB-1 (1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mg) and Lateral TAP\u0026thinsp;+\u0026thinsp;RSB (1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 mg) groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). VAS scores at all postoperative time points were significantly greater in the Lateral TAP group. Postoperative nausea and vomiting occurred in 70.4% of patients in the Lateral TAP group, compared with 23.5% and 18.2% in the Lateral TAP\u0026thinsp;+\u0026thinsp;QLB-1 and Lateral TAP\u0026thinsp;+\u0026thinsp;RSB groups, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Recovery of bowel function, mobilization, and initiation of oral intake occurred significantly earlier in both combined-block groups, and hospital stay was reduced by approximately 1 day compared with Lateral TAP block alone.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eIn routine clinical practice, combined fascial plane block strategies (Lateral TAP\u0026thinsp;+\u0026thinsp;QLB-1 and Lateral TAP\u0026thinsp;+\u0026thinsp;RSB) were associated with improved postoperative analgesia and enhanced recovery compared with Lateral TAP alone after major gynecologic cancer surgery. These findings support the integration of combined fascial plane block approaches into ERAS-based multimodal analgesia pathways.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Combined Fascial Plane Blocks for Postoperative Pain in Gynecologic Cancer Surgery: A Prospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-26 17:15:45","doi":"10.21203/rs.3.rs-9080781/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"167271950340006027587201947772253765144","date":"2026-05-17T06:21:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T15:07:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232128564026069578405935377846027492254","date":"2026-04-30T09:17:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243431091422415975477844277349304145175","date":"2026-04-21T16:25:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-17T14:07:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-13T04:44:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-13T04:44:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2026-03-10T07:41:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3aa39ede-e7e0-4da1-86d9-6b6ef070819c","owner":[],"postedDate":"April 26th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"167271950340006027587201947772253765144","date":"2026-05-17T06:21:48+00:00","index":118,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T15:07:38+00:00","index":73,"fulltext":""},{"type":"reviewerAgreed","content":"232128564026069578405935377846027492254","date":"2026-04-30T09:17:37+00:00","index":71,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T17:15:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-26 17:15:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9080781","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9080781","identity":"rs-9080781","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}