Oblique Subcostal Transversus Abdominis Plane Block versus Transmuscular Quadratus Lumborum Block for Postoperative Analgesia and Quality of Recovery in Laparoscopic Gynecological Surgery: A Prospective Randomized Controlled Double-Blind Trial

Oblique Subcostal Transversus Abdominis Plane Block versus Transmuscular Quadratus Lumborum Block for Postoperative Analgesia and Quality of Recovery in Laparoscopic Gynecological Surgery: A Prospective Randomized Controlled Double-Blind Trial | 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 Oblique Subcostal Transversus Abdominis Plane Block versus Transmuscular Quadratus Lumborum Block for Postoperative Analgesia and Quality of Recovery in Laparoscopic Gynecological Surgery: A Prospective Randomized Controlled Double-Blind Trial Kübra CEBECI, Selcan AKESEN, Seda CANSABUNCU, Alp GURBET, Gürkan UNCU This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7929838/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Jan, 2026 Read the published version in BMC Anesthesiology → Version 1 posted 11 You are reading this latest preprint version Abstract Background During laparoscopic gynecological surgeries, trocar incisions, pneumoperitoneum and distention of the anterior abdominal wall can cause postoperative pain. Inadequate pain management can increase the risk of postoperative complications. The present study compared the effects of oblique subcostal transversus abdominis plane (OSTAP) block and transmuscular quadratus lumborum (TQL) block on postoperative analgesia and quality of recovery (QoR) in patients undergoing laparoscopic gynecological surgery. Methods A total of 73 patients were enrolled in this prospective, randomized, controlled, double-blind study. The patients were randomly allocated to the OSTAP group (n = 36) or the TQL group (n = 37). General anesthesia was induced following bilateral block administration with 20 ml of 0.25% bupivacaine. The primary outcome was the total consumption of paracetamol and tramadol within the first 24 h postoperatively. Secondary outcomes included the time to first analgesic requirement, visual analog scale (VAS) scores at rest and during movement, and Quality of Recovery-15 (QoR-15) scores preoperatively and 24 h postoperatively. Results The total paracetamol consumption was significantly lower in the TQL group (p = 0.002), whereas total tramadol consumption was similar between the groups. The TQL group had significantly lower VAS scores at rest and during movement at 6 h postoperatively and during movement before discharge (p = 0.019, p = 0.004, p = 0.023, respectively). The groups were similar regarding time to the first analgesic requirement and QoR-15 scores preoperatively and 24 h postoperatively. Conclusions The TQL block reduces postoperative analgesic requirements compared to the OSTAP block. However, both blocks have similar effects on QoR. Trial registration: ClinicalTrials.gov, NCT06017401. Registered on August 20, 2023. Retrospectively registered. Postoperative pain Analgesia Regional anesthesia Laparoscopic surgery Gynecological surgery Figures Figure 1 Figure 2 Figure 3 Background Laparoscopic surgery has become an essential technique in modern gynecologic surgery, providing a minimally invasive alternative to open procedures. Although visceral pain is one of the most frequently reported complaints following laparoscopic surgery, various perioperative factors such as incisions for trocar entry, pneumoperitoneum, distention of the anterior abdominal wall, dissection of the pelvic region, and residual intra-abdominal blood may also be the causes of postoperative pain [ 1 , 2 ]. Inadequate pain control negatively impacts quality of life and recovery, prolongs hospital stay, and increases the risk of postoperative complications and chronic pain development [ 3 , 4 ]. Various methods can be implemented to manage postoperative pain in laparoscopic gynecological surgeries, including paracetamol, non-steroidal anti-inflammatory drugs, pregabalin, gabapentin, opioids, local anesthetic infiltration (LAI) at the incision site, and regional anesthesia [ 5 , 6 ]. Considering the adverse effects of analgesic agents, regional anesthesia is gaining increasing prominence in multimodal pain management strategies following laparoscopic surgery [ 7 , 8 ]. The oblique subcostal transversus abdominis plane (OSTAP) block, which was first described by Hebbard et al.[ 9 ], provides analgesia in the dermatomes from T6 to L1 [ 10 ]. The quadratus lumborum (QL) block, initially described by Rafael Blanco [ 11 ], provides an analgesic effect on both the incision site and visceral region by facilitating the spread of local anesthetic from the thoracolumbar fascia to the thoracic paravertebral space [ 12 ]. The transmuscular quadratus lumborum (TQL) block, a variation of the QL block, was described by Børglum et al. [ 13 ] and covers the T4 to L1 dermatomes for analgesia [ 14 ]. This study aimed to investigate the effects of OSTAP and TQL blocks on postoperative analgesia and quality of recovery (QoR) in patients undergoing laparoscopic gynecological surgery. We hypothesized that the TQL block would be superior to the OSTAP block in providing analgesia and reducing analgesics requirement in laparoscopic gynecological surgeries. The primary aim of the study was to compare the total consumption of paracetamol and tramadol within the first 24 hours postoperatively in patients undergoing laparoscopic gynecological surgery. The secondary aims were to compare the time to first postoperative analgesic requirement, visual analog scale (VAS) scores at rest and during movement, and the Quality of Recovery-15 (QoR-15) scores preoperatively and 24 h postoperatively. Methods Study Design The present study was designed as a prospective, randomized, controlled, double-blind trial and was registered retrospectively at ClinicalTrials.gov (NCT06017401; registered on August 20, 2023) following approval by the Clinical Trials Ethics Committee of Uludag University School of Medicine (Approval No: 2023-11/9; May 16, 2023). This trial was conducted in accordance with the principles of the 2013 Declaration of Helsinki. All participants provided written consent forms for participation in the study. This manuscript adhered to the CONSORT guidelines. The study was conducted between May and November 2023 at a tertiary university hospital. Patients aged 18–65 years, who had an American Society of Anesthesiologists (ASA) physical status I-III, a body mass index (BMI) of 18–25 kg/m², and scheduled for elective laparoscopic gynecological surgery lasting 45 to 120 minutes using 3 or 4 trocars were included in the study. Patients with a known allergy to local anesthetics, known or suspected coagulopathy, infection at the injection site, severe neurological or psychiatric disorders, severe cardiovascular disease, liver failure, renal failure, or chronic opioid use (> 6 months) were excluded from the study. Patients scheduled for elective laparoscopic gynecological surgery and met the inclusion criteria were informed about the regional anesthesia they would receive. The VAS assessment was explained to the patients in detail, and their age, ASA physical status, height, weight, BMI, and preoperative QoR-15 scores were recorded. The Turkish version of the QoR-15, which has demonstrated acceptable validity, reliability, and responsiveness in Turkish patients, was used [ 15 , 16 ]. The QoR-15 questionnaire consists of 15 questions assessing five domains: pain, physical comfort, physical independence, psychological support, and emotional state. Patients marked their state on a 10 cm horizontal line. Positive items were scored on a scale ranging from 0 (none of the time) to 10 (all of the time), while negative items were scored from 0 (all of the time) to 10 (none of the time). As a result, a patient can achieve a total score ranging from 0 to 150. A higher score on the questionnaire indicates a better QoR. Randomization and blinding A total of 73 patients were randomly allocated to either the OSTAP group (n = 36) or the TQL group (n = 37) using the closed-envelope method. Randomization was performed using a randomly generated list created with Microsoft Excel (version 16.73). The envelopes, prepared according to this list, were shuffled and randomly arranged by an independent person not involved in the study. Each patient was allocated to a group by selecting an envelope during the study. Block procedures Following standard ASA monitoring (pulse oximetry, non-invasive blood pressure measurement, electrocardiography), an intravenous (IV) line was established with a 20-gauge (G) cannula, and 0.9% saline infusion was initiated at a rate of 3 mL/kg/hour. Block procedures were performed by a single anesthesiologist experienced in regional anesthesia, following premedication with 0.02 mg/kg IV midazolam and 1 mcg/kg IV fentanyl administered at least 30 min before the induction of general anesthesia. In the OSTAP group, after ensuring sterile conditions, a high-frequency (4–12 MHz) linear transducer (Xperius®, Philips Ultrasound, Inc.) was placed transversely below the xiphoid process of the sternum while the patient was in the supine position. The linea alba was visualized in the center, with the rectus abdominis muscles on either side. Transducer was moved laterally along the oblique subcostal line, parallel to the costal margin and at an oblique angle to the sagittal plane, starting from the end of the xiphoid process. Once proper visualization was achieved, the area between the posterior sheath of the rectus abdominis and the fascia of the transversus abdominis was targeted and a 22-G, 80-mm needle (Stimuplex® Ultra 360®, B-Braun) was inserted in-plane near the xiphoid process and advanced in an inferolateral direction. Hydrodissection was performed with 1–2 ml of local anesthetic to confirm the needle tip placement. Thereafter, 20 ml of 0.25% bupivacaine was administered into the space between the posterior sheath of the rectus abdominis and the fascia of the transversus abdominis, and the same procedure was repeated on the opposite side (Fig. 1 A). In The TQL group, after positioning the patients in the lateral decubitus position and ensuring sterile conditions, a low-frequency (2–5 MHz) convex transducer (Xperius®, Philips Ultrasound, Inc.) was placed transversely at the L4 level, just above the iliac crest, along the mid-axillary line. After visualizing the external oblique, internal oblique, and transversus abdominis muscles, transducer was moved dorsally in a transverse orientation until the QL muscle was identified at its attachment to the lateral edge of the transverse process of the L4 vertebral body. By applying a caudal tilt, the acoustic shadow of the L4 transverse process was visualized, with the erector spinae muscle posteriorly, the QL muscle laterally, and the psoas major (PM) muscle anteriorly, forming the shamrock sign (Fig. 1 B). After a clear image of the QL muscle was obtained, a 22-G, 80-mm needle (Stimuplex® Ultra 360®, B-Braun) was directed from posterolateral to anteromedial with the in-plane technique. The needle tip passed through the QL muscle, punctured the ventral fascia of the QL muscle, and was advanced into the plane between the QL and PM muscles. Hydrodissection was performed with 1–2 ml of local anesthetic to confirm the needle tip placement. Then 20 ml of 0.25% bupivacaine was administered into the plane between the fascial layers of the QL and PM muscles, and the same procedure was repeated on the opposite side. Intraoperative and postoperative management After block administration, general anesthesia was induced in all patients with IV lidocaine 1 mg/kg, propofol 1-2.5 mg/kg, fentanyl 1 mcg/kg, and rocuronium 0.6–1.2 mg/kg, followed by endotracheal intubation. Anesthesia was maintained with a 50% air and 50% O 2 mixture, set to a minimum alveolar concentration of 1, using sevoflurane and a fresh gas flow of 2 L/min. Patients were placed in the lithotomy and trendelenburg position. Surgical procedures were performed using three or four trocars. After achieving abdominal access with the Veress needle and establishing pneumoperitoneum, intraabdominal pressure was maintained at 12–14 mmHg. Four trocars were used only in surgeries for deeply infiltrating endometriosis (DIE), whereas three trocars were used in other procedures. The 10-mm trocar was placed at the umbilicus, while the 5-mm trocars were positioned 2 cm medial to the right and left anterior superior iliac spines (ASIS). In surgeries that required four trocars, the fourth trocar was placed 5 cm above the left ASIS. All patients received 1 g IV paracetamol and 20 mg IV tenoxicam prior to the surgical incision, while 10 mg IV metoclopramide was administered 30 min before the surgery was completed. Patients were extubated after the administration 2–4 mg/kg IV sugammadex. Anesthesia time and surgical time were recorded. During the postoperative period, VAS scores at rest and during movement were recorded at 0, 30 min, 1, 2, 6, 12, 18, and 24 hours and before discharge, using a scale ranging from 0 (no pain) to 10 (worst possible pain). IV paracetamol 4x500 mg was administered if the VAS score was ≥ 4, and if it remained ≥ 4 after 30 min, IV tramadol 1 mg/kg was given as a rescue analgesic (a maximum daily dose of 400 mg). All patients were mobilized 6 hours after surgery and discharged following 24 hours of observation. Outcome measures The primary outcome of the study was the total consumption of paracetamol and tramadol during the first 24 hours postoperatively. The secondary outcomes included the time to first paracetamol and tramadol requirement, VAS scores at rest and during movement at 0, 30 min, 1, 2, 6, 12, 18, 24 h postoperatively and before discharge, and QoR-15 scores preoperatively and 24 h postoperatively. A pain management nurse, who was not involved in the block administration and was blinded to the patient’s group assignment, recorded the total analgesic consumption, the times of paracetamol and tramadol administration, VAS scores, and nausea and vomiting during the first 24 hours postoperatively. Patients completed the QoR-15 questionnaire at the 24th postoperative hour. Potential block-related adverse effects, such as hematoma or infection at the injection site, abdominal organ injury, lower extremity muscle weakness, and local anesthetic toxicity were also recorded. Sample size and statistical analyses In our study, the sample size was determined using the G*Power software (version 3.1.9.7), referencing a recent similar study [ 17 ]. To compare cumulative analgesic doses, the effect size was set at 0.70, with a significance level of 5% and a power of 80%. Based on these parameters, it was determined that at least 34 patients per group, totaling 68 patients, needed to be included in the study. Study data were analyzed using the IBM SPSS 26.0 (SPSS Statistics for Windows, version 26.0; IBM Corp., 2019) statistics program. The Kolmogorov - Smirnov test was used to evaluate normal distribution. Descriptive statistics were presented as mean ± standard deviation (SD) or median with interquartile range (IQR) for quantitative data and as number (percentage) for qualitative data. Regarding comparisons between two independent groups, the Student’s t-test was used for normally distributed data, while the Mann-Whitney U test was applied for not normally distributed data. Categorical variables were analyzed using Pearson’s Chi-square test. A p-value of < 0.05 was considered the threshold for statistical significance. Results In the OSTAP group, two patients who required conversion to laparotomy, and in the TQL group, two patients with a surgical duration exceeding 120 minutes, and one patient whose surgery was canceled due to an antibiotic allergy were excluded from the study. Consequently, after excluding five patients, data from 68 patients were analyzed (Fig. 2 ) No statistically significant differences were found between the groups in demographic characteristics, type of surgery, anesthesia time, and surgical time (Table 1 ). Table 1 Demographic and intraoperative characteristics of patients Characteristic OSTAP Group (n = 34) TQL Group (n = 34) p Age (yrs.) 40.41 ± 9,51 39.53 ± 8.25 0.684 ASA PS (I/II) 24 (70.6) / 10 (29.4) 25 (73.5) / 9 (26.5) 0.787 Height (cm) 165 (160, 168) 162.5 (159, 165) 0.054 Weight (kg) 60.28 ± 7.50 59.44 ± 5.96 0.611 BMI (kg/m 2 ) 22.29 ± 2.24 22.69 ± 1.90 0.429 Type of Surgery - TLH + BSO 15 (44.1) 14 (41.2) DIE surgery 8 (23.5) 8 (23.5) Ovarian cyst excision 5 (17.7) 5 (14.7) Bilateral salpingectomy 3 (8.8) 3 (8.8) Myomectomy 2 (5.9) 1 (2.9) Tubal recanalization 1 (2.9) 1 (2.9) Unilateral salpingectomy 0 (0.0) 1 (2.9) Bilateral tubal ligation 0 (0.0) 1 (2.9) Anesthesia time (min) 102.3 ± 26.89 96.09 ± 31.18 0.380 Surgical time (min) 90 (70, 100) 75 (50, 100) 0.140 Values are presented as mean ± SD, median (IQR) or number (percentages). ASA PS American Society of Anesthesiologists physical status, BMI Body mass index TLH + BSO Total laparoscopic hysterectomy + bilateral salpingo-oophorectomy, DIE Deeply infiltrating endometriosis, OSTAP Oblique subcostal transversus abdominis plane, TQL Transmuscular quadratus lumborum. There was also no statistically significant difference between the groups regarding the number of patients requiring paracetamol, the time of first paracetamol and tramadol requirement, and total tramadol consumption. Nevertheless, the total paracetamol consumption, and the number of patients requiring tramadol were significantly higher in the OSTAP group compared to the TQL group (p = 0.002, p = 0.006, respectively) (Table 2 ). Table 2 Postoperative analgesic consumption OSTAP Group (n = 34) TQL Group (n = 34) p Postoperative paracetamol requirement (None/Yes) 5 (14.7) / 29 (85.3) 7 (20.6) / 27 (79.4) 0.525 The time to first paracetamol requirement (hour) 1.0 (0.5, 2) 1.0 (0.63, 2) 0.946 Total paracetamol consumption (mg) 1000.0 (1000, 1500) 500 (500, 1000) 0.002 Postoperative tramadol requirement (None/Yes) 20 (58.8) / 14 (41.2) 30 (88.2) / 4 (11.8) 0.006 The time to first tramadol requirement (hour) 2.0 (2, 3) 1.5 (1, 2.75) 0.226 Total tramadol consumption (mg) 60.0 (57.5, 61.25) 55.0 (50, 67.5) 0.565 Values are presented as median (IQR) or number (percantages). OSTAP Oblique subcostal transversus abdominis plane, TQL Transmuscular quadratus lumborum. The VAS scores measured at rest at 6 hours postoperatively were statistically higher in the OSTAP group compared to the TQL group (p = 0.019). However, no statistically significant differences were found between the groups regarding the VAS scores at 0, 30 min, 1, 2, 12, 18, and 24 h postoperatively, and before discharge (Fig. 3 A). The VAS scores measured during movement at 6 h postoperatively and before discharge were significantly higher in the OSTAP group compared to the TQL group (p = 0.004, p = 0.023, respectively). However, no statistically significant differences were identified between VAS scores at 12, 18, and 24 h postoperatively (Fig. 3 B). There were no statistically significant differences between the groups regarding the total or domain-specific QoR-15 scores preoperatively and 24 h postoperatively (Table 3 ). Table 3 QoR-15 Questionnaire total and domain scores OSTAP Group (n = 34) TQL Group (n = 34) p Preoperative QoR-15 total score (0-150) 138 (126, 143.5) 137 (129.75, 143.25) 0.961 QoR-15 domain scores Pain (0–20) 20 (17.75, 20) 20 (18, 20) 0.663 Physical comfort (0–50) 46 (40, 49) 46 (40, 48.5) 0.688 Physical independence (0–20) 20 (20, 20) 20 (20, 20) 0.964 Psychological support (0–20) 20 (20, 20) 20 (20, 20) 0.626 Emotional state (0–40) 34 (29.75, 38.25) 35.5 (30, 37) 0.995 24 hours postoperative QoR-15 total score (0-150) 131.0 (127.5, 138) 134.0 (125.75, 140) 0.435 QoR-15 domain scores Pain (0–20) 16.0 (13, 18) 17.0 (15.75, 19) 0.060 Physical comfort (0–50) 45.0 (40, 48) 45 (40.75, 48) 0.912 Physical independence (0–20) 17.5 (15.75, 18) 18.0 (16, 19.25) 0.281 Psychological support (0–20) 20.0 (20, 20) 20.0 (20, 20) 0.798 Emotional state (0–40) 34.5 (32.75, 38.5) 36 (32, 39) 0.786 Values are presented as median (IQR). QoR-15 quality of recovery-15, OSTAP oblique subcostal transversus abdominis plane, TQL transmuscular quadratus lumborum. There was no statistically significant difference between the groups in the incidence of nausea and vomiting within the first 24 hours postoperatively, with only two patients in each group experiencing vomiting once. None of the patients included in the study experienced a block-related complication. Discussion This study compared the effect of OSTAP and TQL blocks on postoperative analgesia and QoR in laparoscopic gynecological surgery. Paracetamol consumption within the first 24 h was significantly lower in the TQL group, whereas tramadol consumption was similar between the groups. VAS scores at rest and during movement at 6 h, and during movement before discharge, were significantly lower in the TQL group, with no differences at other time points. Hebbard et al. [ 9 ] described OSTAP block in their study, where they administered 40–80 ml of local anesthetic, blocking the lateral and anterior branches of the T6–L1 spinal nerves, thereby providing analgesia to the anterior abdominal wall [ 9 , 10 ]. Chen et al. [ 18 ] directed the needle inferolaterally and performed OSTAP block with 20 ml of 0.375% ropivacaine; a cold test 30 minutes later confirmed complete T7–T12 blockade. This approach provided effective analgesia with a lower volume of anesthetic compared to the technique described by Hebbard et al. [ 9 ]. In present study, similar to studies in the literature, block was administered bilaterally using 20 ml of 0.25% bupivacaine, directing the needle inferolaterally [ 18 – 20 ]. There are only a limited number of studies on the OSTAP block for postoperative analgesia in laparoscopic gynecological surgeries. Toker et al. [ 21 ] indicated in patients undergoing total laparoscopic hysterectomy (TLH) that the OSTAP group had significantly lower VAS scores during coughing and consumed significantly lower amounts of tramadol compared to the control group. Based on these limited data and the reported efficacy of OSTAP, we chose this block for our study. Although Børglum et al. [ 13 ] reported that the TQL block provides analgesia covering the dermatomes T4 to L1, studies in the literature have not reached a consensus on the precise levels where analgesia is effective. In the cadaver study by Dam et al. [ 14 ], the investigators examined the spread of the TQL block applied at the L4 level and reported that the dye spread over the diaphragm in all cases. In 50% of the cases, the dye spread over the medial and lateral arcuate ligaments, while in 30% it extended via the lateral arcuate ligament into the thoracic paravertebral space. The highest level reached by the dye was at the T9 vertebral level. The anterior branches of the spinal nerves and the thoracic sympathetic chain were dyed, with the dye surrounding the subcostal, iliohypogastric, and ilioinguinal nerves in all cases, while the genitofemoral and lateral femoral cutaneous nerves were dyed to varying degrees. Carline et al. [ 22 ] concluded in their cadaver study that the TQL block consistently blocked the lumbar nerve roots and had the potential to provide analgesia from T10 to L4, making it a reliable option for postoperative analgesia. Considering the existing data, the TQL block was chosen for our study because of its efficacy and safety in postoperative pain management following laparoscopic gynecological surgery. In the study conducted by Huang et al. [ 17 ] to investigate the postoperative analgesic efficacy of TQL and OSTAP blocks in patients undergoing TLH, total morphine consumption within 24 h was significantly lower in the TQL group. While this finding aligns with our study, a key difference was that the time to first rescue analgesia was significantly longer in the TQL group compared to the OSTAP group. Visceral numerical rating scale (NRS) scores at rest and during movement were significantly lower in the TQL group, while no significant difference was observed between the groups regarding incisional NRS scores at rest and during movement. These findings suggest that the effectiveness of the TQL block in providing visceral analgesia may be attributed to its broader blockade, affecting both somatic nerves and sympathetic nerve fibers [ 14 ]. The impact of the TQL block on the sympathetic chain could offer a particular advantage in visceral pain management, especially in laparoscopic gynecological surgeries. In contrast, the OSTAP block primarily targets somatic nerves and provides analgesia to the anterior abdominal wall [ 9 ]. Therefore, the OSTAP block emerges as an effective technique for managing incisional pain. However, potential adverse effects during the TQL block procedure should be considered. In their cadaver study comparing the spread of the TQL block administered at the L4 level with the transversus oblique paramedian (TOP) TQL block administered at the L2 level, Dam et al. [ 14 ] demonstrated that if the psoas major muscle is penetrated, the local anesthetic can easily reach the L3 level and the femoral nerve. Kadoya et al. [ 23 ] reported a 13.3% incidence of quadriceps muscle weakness following TQL block performed at the L2 level. This phenomenon was suggested to be associated with the spread of local anesthetic to the lumbar plexus via the PM muscle or its passage into the paravertebral space through the arcuate ligament. The findings of these studies highlight the importance of preserving the PM muscle during the TQL block procedure and underscore the need for careful monitoring of patients following block application. In this study, we used the QoR-15 questionnaire to assess patients’ QoR. The QoR-15 is a shortened version of the QoR-40 questionnaire developed by Myles et al. [ 24 ] to assess postoperative recovery from the patient’s perspective. The original QoR-40 includes five dimensions of health status, namely pain, physical comfort, physical independence, psychological support, and emotional state, and consists of 40 questions. However, due to the time-consuming nature of the full version, Stark et al. [ 25 ] introduced the more efficient 15-item QoR-15 in 2013 as an alternative. The QoR-15 evaluates similar aspects of recovery, and its convenience made it the preferred choice for our study. The validity and reliability of the Turkish version of the QoR-15 were established by Kara et al. [ 15 ] and Selvi et al. [ 16 ]. This shorter version allowed for an effective evaluation of patients’ QoR in our study. In our study, no significant differences were observed between the groups in the total or domain-specific QoR-15 scores preoperatively and 24 h postoperatively. Consistently, Suzuka et al. [ 26 ] compared the OSTAP block and the modified thoracoabdominal nerve block through the perichondrial approach in TLH and reported no significant differences in total QoR-15 scores preoperatively and on postoperative day 1. The QoR-15 questionnaire is a subjective assessment tool evaluating postoperative recovery across five dimensions. The lack of a significant difference in QoR-15 scores between the two groups suggests that recovery is influenced not only by pain levels but also by the patient’s physical and psychosocial state. The incidence of nausea and vomiting within the first 24 hours postoperatively was very low, with only two out of 34 patients in each group experiencing vomiting once. Saleh et al.[ 27 ] adopted a similar approach, where patients received 1 gram IV paracetamol every 8 hours postoperatively, and pethidine was used as a rescue analgesic. Compared to the control group, both subcostal TAP and TQL groups had significantly lower pethidine use and incidence of vomiting. We believe the primary factor in keeping nausea and vomiting rates so low was our approach of prioritizing regional anesthesia and paracetamol for pain management while minimizing opioid use as much as possible. Limitations of the study Our study has some limitations to acknowledge. First, we excluded patients with a BMI > 25 kg/m² and those with a surgical duration exceeding 120 minutes. Second, since the patients were monitored only up to 24 hours in the postoperative period, we could not assess the long-term effects of the blocks on pain scores and complications. Conclusions Patients who received the TQL block in laparoscopic gynecological surgeries had lower analgesic requirements and VAS scores compared to those who received the OSTAP block. However, both blocks provided adequate analgesia, and no significant difference was found in QoR between the two groups. These findings suggest that both TQL and OSTAP blocks could be effective options in multimodal analgesia protocols, with the choice of the block being guided by factors such as the patient characteristics, the anesthesiologist’s experience, and the specific surgical procedure. Abbreviations OSTAP Oblique Subcostal Transversus Abdominis Plane QL Quadratus Lumborum TQL Transmuscular Quadratus Lumborum QoR Quality Of Recovery VAS Visual Analog Scale QoR-15 Quality of Recovery-15 ASA American Society of Anesthesiologists BMI Body Mass Index IV Intravenous G Gauge PM Psoas Major DIE Deeply Infiltrating Endometriosis ASIS Anterior Superior Iliac Spines SD Standard Deviation IQR Interquartile Range TLH Total Laparoscopic Hysterectomy NRS Numerical Rating Scale TOP Transversus Oblique Paramedian Declarations Ethics approval and consent to participate Ethical approval was obtained from Clinical Trials Ethics Committee of Uludag University School of Medicine (2023-11/9) on May 16, 2023. All participants provided written consent forms for participation in the study. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding The authors did not receive any funding for conducting this study. Author Contribution KC contributed to conceptualization, data curation, methodology, project administration, writing – original draft, writing – review & editing. SA contributed to data curation, methodology, supervision, writing – original draft, writing – review & editing. SC contributed to data curation. AG and GU contributed to methodology, supervision, writing – review & editing. All authors read and approved the final manuscript. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Choi JB, Kang K, Song MK, Seok S, Kim YH, Kim JE. Pain characteristics after total laparoscopic hysterectomy. Int J Med Sci. 2016;13(8):562–8. https://doi.org/10.7150/ijms.15875 . Gerbershagen HJ, Aduckathil S, van Wijck AJM, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. 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Reg Anesth Pain Med. 2018;43(2):174–9. https://doi.org/10.1097/AAP.0000000000000715 . Breazu C, Margarit S, Bartos A, Ionescu D. Postoperative analgesia after laparoscopic cholecystectomy - prospective, randomized, double blind, control trial. Chirurgia (Romania). 2022;117(5):563–71. https://doi.org/10.21614/chirurgia.2769 . Basaran B, Basaran A, Kozanhan B, Kasdogan E, Eryilmaz MA, Ozmen S. Analgesia and respiratory function after laparoscopic cholecystectomy in patients receiving ultrasound-guided bilateral oblique subcostal transversus abdominis plane block: a randomized double-blind study. Med Sci Monit. 2015;21:1304–12. https://doi.org/10.12659/MSM.893593 . Toker MK, Altıparmak B, Uysal Aİ, Demirbilek SG. The analgesic efficacy of oblique subcostal transversus abdominis plane block after laparoscopic hysterectomy: a randomized, controlled, observer-blinded study. Medicine. 2019;98(1):E13994. https://doi.org/10.1097/MD.0000000000013994 . Carline L, McLeod GA, Lamb C. A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. Br J Anaesth. 2016;117(3):387–94. https://doi.org/10.1093/bja/aew224 . Kadoya Y, Tanaka N, Suzuka T, Yamanaka T, Iwata M, Ozu N, et al. Anterior quadratus lumborum block and quadriceps strength: a prospective cohort study. J Clin Med. 2023;12(11). https://doi.org/10.3390/jcm12113837 . Myles PS, Weitkamp B, Jones K, Melick J, Hensen S. Validity and reliability of a postoperative quality of recovery score: The QoR-40. Br J Anaesth. 2000;84(1):11–5. https://doi.org/10.1093/oxfordjournals.bja.a013366 . Stark PA, Myles PS, Burke JA. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15. Anesthesiology. 2013;118(6):1332–40. https://doi.org/10.1097/ALN.0b013e318289b84b . Suzuka T, Tanaka N, Kadoya Y, Ida M, Iwata M, Ozu N, et al. Comparison of quality of recovery between modified thoracoabdominal nerves block through perichondrial approach versus oblique subcostal transversus abdominis plane block in patients undergoing total laparoscopic hysterectomy: a Pilot Randomized Controlled Trial. J Clin Med. 2024;13(3). https://doi.org/10.3390/jcm13030712 . Saleh AH, Abdallah MW, Mahrous AM, Ali NA. Quadratus lumborum block (transmuscular approach) versus transversus abdominis plane block (unilateral subcostal approach) for perioperative analgesia in patients undergoing open nephrectomy: a randomized, double-blinded, controlled trial. Braz J Anesthesiol. 2021;71(4):367–75. https://doi.org/10.1016/j.bjane.2021.01.009 . Additional Declarations No competing interests reported. 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08:29:56","extension":"xml","order_by":27,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108851,"visible":true,"origin":"","legend":"","description":"","filename":"e3eb2a1b7044468d8688a72f971d7fc01structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7929838/v1/7c30e4ba17f8524229046d33.xml"},{"id":96251793,"identity":"34be70f3-bc0d-437f-b616-334f9ec28fba","added_by":"auto","created_at":"2025-11-19 07:40:02","extension":"html","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120789,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7929838/v1/112071038f94cfeb4caba648.html"},{"id":96156487,"identity":"ed5bd90e-8a9c-4600-b1f8-a09ac7a8112f","added_by":"auto","created_at":"2025-11-18 08:29:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":191235,"visible":true,"origin":"","legend":"\u003cp\u003eSonogram of the oblique subcostal transversus abdominis plane and transmuscular quadratus lumborum block. (A) Sonogram of the oblique subcostal transversus abdominis plane block. (B) Sonogram of the transmuscular quadratus lumborum block. \u003cem\u003eRA\u003c/em\u003e Rectus abdominis muscle, \u003cem\u003eTA\u003c/em\u003eTransversus abdominis muscle, \u003cem\u003eQL\u003c/em\u003e Quadratus lumborum muscle, \u003cem\u003ePM \u003c/em\u003ePsoas major muscle, \u003cem\u003eES\u003c/em\u003e Erector spinae muscle, \u003cem\u003eTP\u003c/em\u003e Transverse process.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7929838/v1/1baab3e46927875529a8bc45.png"},{"id":96250680,"identity":"6b153d74-d8b5-4abd-b543-fed5a3bf63e3","added_by":"auto","created_at":"2025-11-19 07:38:52","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64809,"visible":true,"origin":"","legend":"\u003cp\u003eConsolidated Standards of Reporting Trials (CONSORT) flow diagram of the study, \u003cem\u003eOSTAP\u003c/em\u003e Oblique subcostal transversus abdominis plane, \u003cem\u003eTQL\u003c/em\u003eTransmuscular quadratus lumborum.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7929838/v1/234a2955f36170518a9cc3f0.jpg"},{"id":96250916,"identity":"35a2f3fe-edfc-4248-926c-577112ad84bf","added_by":"auto","created_at":"2025-11-19 07:39:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":53567,"visible":true,"origin":"","legend":"\u003cp\u003eTime-dependent line graphs of VAS scores measured at rest and during movement (A) VAS scores measured at rest, (B) VAS scores measured during movement. \u003cem\u003eOSTAP\u003c/em\u003e oblique subcostal transversus abdominis plane, \u003cem\u003eTQL\u003c/em\u003eTransmuscular quadratus lumborum.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7929838/v1/5c2462e2079685e36f1c8601.png"},{"id":101151824,"identity":"ea11bd75-a402-4fbc-b3e9-4b29a51a3870","added_by":"auto","created_at":"2026-01-26 16:06:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1253395,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7929838/v1/f44e950f-9b21-40fd-8b32-cc15a4d76e7f.pdf"},{"id":96156486,"identity":"1dc4a5e0-24b0-4b21-9443-41d2c6a0e5f6","added_by":"auto","created_at":"2025-11-18 08:29:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":33277,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025editablechecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7929838/v1/2484515588ae6550f1ac7046.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Oblique Subcostal Transversus Abdominis Plane Block versus Transmuscular Quadratus Lumborum Block for Postoperative Analgesia and Quality of Recovery in Laparoscopic Gynecological Surgery: A Prospective Randomized Controlled Double-Blind Trial","fulltext":[{"header":"Background","content":"\u003cp\u003eLaparoscopic surgery has become an essential technique in modern gynecologic surgery, providing a minimally invasive alternative to open procedures. Although visceral pain is one of the most frequently reported complaints following laparoscopic surgery, various perioperative factors such as incisions for trocar entry, pneumoperitoneum, distention of the anterior abdominal wall, dissection of the pelvic region, and residual intra-abdominal blood may also be the causes of postoperative pain [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Inadequate pain control negatively impacts quality of life and recovery, prolongs hospital stay, and increases the risk of postoperative complications and chronic pain development [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eVarious methods can be implemented to manage postoperative pain in laparoscopic gynecological surgeries, including paracetamol, non-steroidal anti-inflammatory drugs, pregabalin, gabapentin, opioids, local anesthetic infiltration (LAI) at the incision site, and regional anesthesia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Considering the adverse effects of analgesic agents, regional anesthesia is gaining increasing prominence in multimodal pain management strategies following laparoscopic surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe oblique subcostal transversus abdominis plane (OSTAP) block, which was first described by Hebbard et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], provides analgesia in the dermatomes from T6 to L1 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe quadratus lumborum (QL) block, initially described by Rafael Blanco [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], provides an analgesic effect on both the incision site and visceral region by facilitating the spread of local anesthetic from the thoracolumbar fascia to the thoracic paravertebral space [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The transmuscular quadratus lumborum (TQL) block, a variation of the QL block, was described by B\u0026oslash;rglum et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and covers the T4 to L1 dermatomes for analgesia [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study aimed to investigate the effects of OSTAP and TQL blocks on postoperative analgesia and quality of recovery (QoR) in patients undergoing laparoscopic gynecological surgery. We hypothesized that the TQL block would be superior to the OSTAP block in providing analgesia and reducing analgesics requirement in laparoscopic gynecological surgeries. The primary aim of the study was to compare the total consumption of paracetamol and tramadol within the first 24 hours postoperatively in patients undergoing laparoscopic gynecological surgery. The secondary aims were to compare the time to first postoperative analgesic requirement, visual analog scale (VAS) scores at rest and during movement, and the Quality of Recovery-15 (QoR-15) scores preoperatively and 24 h postoperatively.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003e The present study was designed as a prospective, randomized, controlled, double-blind trial and was registered retrospectively at ClinicalTrials.gov (NCT06017401; registered on August 20, 2023) following approval by the Clinical Trials Ethics Committee of Uludag University School of Medicine (Approval No: 2023-11/9; May 16, 2023). This trial was conducted in accordance with the principles of the 2013 Declaration of Helsinki. All participants provided written consent forms for participation in the study. This manuscript adhered to the CONSORT guidelines.\u003c/p\u003e\u003cp\u003eThe study was conducted between May and November 2023 at a tertiary university hospital. Patients aged 18\u0026ndash;65 years, who had an American Society of Anesthesiologists (ASA) physical status I-III, a body mass index (BMI) of 18\u0026ndash;25 kg/m\u0026sup2;, and scheduled for elective laparoscopic gynecological surgery lasting 45 to 120 minutes using 3 or 4 trocars were included in the study. Patients with a known allergy to local anesthetics, known or suspected coagulopathy, infection at the injection site, severe neurological or psychiatric disorders, severe cardiovascular disease, liver failure, renal failure, or chronic opioid use (\u0026gt;\u0026thinsp;6 months) were excluded from the study.\u003c/p\u003e\u003cp\u003ePatients scheduled for elective laparoscopic gynecological surgery and met the inclusion criteria were informed about the regional anesthesia they would receive. The VAS assessment was explained to the patients in detail, and their age, ASA physical status, height, weight, BMI, and preoperative QoR-15 scores were recorded. The Turkish version of the QoR-15, which has demonstrated acceptable validity, reliability, and responsiveness in Turkish patients, was used [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The QoR-15 questionnaire consists of 15 questions assessing five domains: pain, physical comfort, physical independence, psychological support, and emotional state. Patients marked their state on a 10 cm horizontal line. Positive items were scored on a scale ranging from 0 (none of the time) to 10 (all of the time), while negative items were scored from 0 (all of the time) to 10 (none of the time). As a result, a patient can achieve a total score ranging from 0 to 150. A higher score on the questionnaire indicates a better QoR.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRandomization and blinding\u003c/h3\u003e\n\u003cp\u003eA total of 73 patients were randomly allocated to either the OSTAP group (n\u0026thinsp;=\u0026thinsp;36) or the TQL group (n\u0026thinsp;=\u0026thinsp;37) using the closed-envelope method. Randomization was performed using a randomly generated list created with Microsoft Excel (version 16.73). The envelopes, prepared according to this list, were shuffled and randomly arranged by an independent person not involved in the study. Each patient was allocated to a group by selecting an envelope during the study.\u003c/p\u003e\n\u003ch3\u003eBlock procedures\u003c/h3\u003e\n\u003cp\u003eFollowing standard ASA monitoring (pulse oximetry, non-invasive blood pressure measurement, electrocardiography), an intravenous (IV) line was established with a 20-gauge (G) cannula, and 0.9% saline infusion was initiated at a rate of 3 mL/kg/hour. Block procedures were performed by a single anesthesiologist experienced in regional anesthesia, following premedication with 0.02 mg/kg IV midazolam and 1 mcg/kg IV fentanyl administered at least 30 min before the induction of general anesthesia.\u003c/p\u003e\u003cp\u003eIn the OSTAP group, after ensuring sterile conditions, a high-frequency (4\u0026ndash;12 MHz) linear transducer (Xperius\u0026reg;, Philips Ultrasound, Inc.) was placed transversely below the xiphoid process of the sternum while the patient was in the supine position. The linea alba was visualized in the center, with the rectus abdominis muscles on either side. Transducer was moved laterally along the oblique subcostal line, parallel to the costal margin and at an oblique angle to the sagittal plane, starting from the end of the xiphoid process. Once proper visualization was achieved, the area between the posterior sheath of the rectus abdominis and the fascia of the transversus abdominis was targeted and a 22-G, 80-mm needle (Stimuplex\u0026reg; Ultra 360\u0026reg;, B-Braun) was inserted in-plane near the xiphoid process and advanced in an inferolateral direction. Hydrodissection was performed with 1\u0026ndash;2 ml of local anesthetic to confirm the needle tip placement. Thereafter, 20 ml of 0.25% bupivacaine was administered into the space between the posterior sheath of the rectus abdominis and the fascia of the transversus abdominis, and the same procedure was repeated on the opposite side (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003eIn The TQL group, after positioning the patients in the lateral decubitus position and ensuring sterile conditions, a low-frequency (2\u0026ndash;5 MHz) convex transducer (Xperius\u0026reg;, Philips Ultrasound, Inc.) was placed transversely at the L4 level, just above the iliac crest, along the mid-axillary line. After visualizing the external oblique, internal oblique, and transversus abdominis muscles, transducer was moved dorsally in a transverse orientation until the QL muscle was identified at its attachment to the lateral edge of the transverse process of the L4 vertebral body. By applying a caudal tilt, the acoustic shadow of the L4 transverse process was visualized, with the erector spinae muscle posteriorly, the QL muscle laterally, and the psoas major (PM) muscle anteriorly, forming the shamrock sign (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). After a clear image of the QL muscle was obtained, a 22-G, 80-mm needle (Stimuplex\u0026reg; Ultra 360\u0026reg;, B-Braun) was directed from posterolateral to anteromedial with the in-plane technique. The needle tip passed through the QL muscle, punctured the ventral fascia of the QL muscle, and was advanced into the plane between the QL and PM muscles. Hydrodissection was performed with 1\u0026ndash;2 ml of local anesthetic to confirm the needle tip placement. Then 20 ml of 0.25% bupivacaine was administered into the plane between the fascial layers of the QL and PM muscles, and the same procedure was repeated on the opposite side.\u003c/p\u003e\n\u003ch3\u003eIntraoperative and postoperative management\u003c/h3\u003e\n\u003cp\u003eAfter block administration, general anesthesia was induced in all patients with IV lidocaine 1 mg/kg, propofol 1-2.5 mg/kg, fentanyl 1 mcg/kg, and rocuronium 0.6\u0026ndash;1.2 mg/kg, followed by endotracheal intubation. Anesthesia was maintained with a 50% air and 50% O\u003csub\u003e2\u003c/sub\u003e mixture, set to a minimum alveolar concentration of 1, using sevoflurane and a fresh gas flow of 2 L/min.\u003c/p\u003e\u003cp\u003ePatients were placed in the lithotomy and trendelenburg position. Surgical procedures were performed using three or four trocars. After achieving abdominal access with the Veress needle and establishing pneumoperitoneum, intraabdominal pressure was maintained at 12\u0026ndash;14 mmHg. Four trocars were used only in surgeries for deeply infiltrating endometriosis (DIE), whereas three trocars were used in other procedures. The 10-mm trocar was placed at the umbilicus, while the 5-mm trocars were positioned 2 cm medial to the right and left anterior superior iliac spines (ASIS). In surgeries that required four trocars, the fourth trocar was placed 5 cm above the left ASIS.\u003c/p\u003e\u003cp\u003eAll patients received 1 g IV paracetamol and 20 mg IV tenoxicam prior to the surgical incision, while 10 mg IV metoclopramide was administered 30 min before the surgery was completed. Patients were extubated after the administration 2\u0026ndash;4 mg/kg IV sugammadex. Anesthesia time and surgical time were recorded.\u003c/p\u003e\u003cp\u003eDuring the postoperative period, VAS scores at rest and during movement were recorded at 0, 30 min, 1, 2, 6, 12, 18, and 24 hours and before discharge, using a scale ranging from 0 (no pain) to 10 (worst possible pain). IV paracetamol 4x500 mg was administered if the VAS score was \u0026ge;\u0026thinsp;4, and if it remained\u0026thinsp;\u0026ge;\u0026thinsp;4 after 30 min, IV tramadol 1 mg/kg was given as a rescue analgesic (a maximum daily dose of 400 mg).\u003c/p\u003e\u003cp\u003eAll patients were mobilized 6 hours after surgery and discharged following 24 hours of observation.\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of the study was the total consumption of paracetamol and tramadol during the first 24 hours postoperatively. The secondary outcomes included the time to first paracetamol and tramadol requirement, VAS scores at rest and during movement at 0, 30 min, 1, 2, 6, 12, 18, 24 h postoperatively and before discharge, and QoR-15 scores preoperatively and 24 h postoperatively. A pain management nurse, who was not involved in the block administration and was blinded to the patient\u0026rsquo;s group assignment, recorded the total analgesic consumption, the times of paracetamol and tramadol administration, VAS scores, and nausea and vomiting during the first 24 hours postoperatively. Patients completed the QoR-15 questionnaire at the 24th postoperative hour. Potential block-related adverse effects, such as hematoma or infection at the injection site, abdominal organ injury, lower extremity muscle weakness, and local anesthetic toxicity were also recorded.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSample size and statistical analyses\u003c/h2\u003e\u003cp\u003eIn our study, the sample size was determined using the G*Power software (version 3.1.9.7), referencing a recent similar study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To compare cumulative analgesic doses, the effect size was set at 0.70, with a significance level of 5% and a power of 80%. Based on these parameters, it was determined that at least 34 patients per group, totaling 68 patients, needed to be included in the study.\u003c/p\u003e\u003cp\u003eStudy data were analyzed using the IBM SPSS 26.0 (SPSS Statistics for Windows, version 26.0; IBM Corp., 2019) statistics program. The Kolmogorov - Smirnov test was used to evaluate normal distribution. Descriptive statistics were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median with interquartile range (IQR) for quantitative data and as number (percentage) for qualitative data. Regarding comparisons between two independent groups, the Student\u0026rsquo;s t-test was used for normally distributed data, while the Mann-Whitney U test was applied for not normally distributed data. Categorical variables were analyzed using Pearson\u0026rsquo;s Chi-square test. A p-value of \u0026lt;\u0026thinsp;0.05 was considered the threshold for statistical significance.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the OSTAP group, two patients who required conversion to laparotomy, and in the TQL group, two patients with a surgical duration exceeding 120 minutes, and one patient whose surgery was canceled due to an antibiotic allergy were excluded from the study. Consequently, after excluding five patients, data from 68 patients were analyzed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eNo statistically significant differences were found between the groups in demographic characteristics, type of surgery, anesthesia time, and surgical time (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eDemographic and intraoperative characteristics of patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\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\u003eOSTAP Group (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTQL Group (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\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\u003eAge\u003c/b\u003e (yrs.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40.41\u0026thinsp;\u0026plusmn;\u0026thinsp;9,51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.53\u0026thinsp;\u0026plusmn;\u0026thinsp;8.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.684\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eASA PS\u003c/b\u003e (I/II)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (70.6) / 10 (29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (73.5) / 9 (26.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.787\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHeight\u003c/b\u003e (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e165 (160, 168)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e162.5 (159, 165)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.054\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60.28\u0026thinsp;\u0026plusmn;\u0026thinsp;7.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.611\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.29\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.429\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eType of Surgery\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\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTLH\u0026thinsp;+\u0026thinsp;BSO\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (44.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (41.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eDIE surgery\u003c/em\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\u003e8 (23.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOvarian cyst excision\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (14.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBilateral salpingectomy\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (8.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (8.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMyomectomy\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTubal recanalization\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eUnilateral salpingectomy\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBilateral tubal ligation\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnesthesia time (min)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e102.3\u0026thinsp;\u0026plusmn;\u0026thinsp;26.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.09\u0026thinsp;\u0026plusmn;\u0026thinsp;31.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.380\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical time (min)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (70, 100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75 (50, 100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.140\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, median (IQR) or number (percentages). \u003cem\u003eASA PS\u003c/em\u003e American Society of Anesthesiologists physical status, \u003cem\u003eBMI\u003c/em\u003e Body mass index \u003cem\u003eTLH\u0026thinsp;+\u0026thinsp;BSO\u003c/em\u003e Total laparoscopic hysterectomy\u0026thinsp;+\u0026thinsp;bilateral salpingo-oophorectomy, \u003cem\u003eDIE\u003c/em\u003e Deeply infiltrating endometriosis, \u003cem\u003eOSTAP\u003c/em\u003e Oblique subcostal transversus abdominis plane, \u003cem\u003eTQL\u003c/em\u003e Transmuscular quadratus lumborum.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere was also no statistically significant difference between the groups regarding the number of patients requiring paracetamol, the time of first paracetamol and tramadol requirement, and total tramadol consumption. Nevertheless, the total paracetamol consumption, and the number of patients requiring tramadol were significantly higher in the OSTAP group compared to the TQL group (p\u0026thinsp;=\u0026thinsp;0.002, p\u0026thinsp;=\u0026thinsp;0.006, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003ePostoperative analgesic consumption\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOSTAP Group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTQL Group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\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\u003ePostoperative paracetamol requirement\u003c/b\u003e (None/Yes)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (14.7) / 29 (85.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (20.6) / 27 (79.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.525\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe time to first paracetamol requirement\u003c/b\u003e (hour)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.0 (0.5, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0 (0.63, 2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.946\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal paracetamol consumption\u003c/b\u003e (mg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1000.0 (1000, 1500)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e500 (500, 1000)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative tramadol requirement\u003c/b\u003e (None/Yes)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (58.8) / 14 (41.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (88.2) / 4 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\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\u003e\u003cb\u003eThe time to first tramadol requirement\u003c/b\u003e (hour)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.0 (2, 3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.5 (1, 2.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.226\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal tramadol consumption\u003c/b\u003e (mg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.0 (57.5, 61.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55.0 (50, 67.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.565\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are presented as median (IQR) or number (percantages). \u003cem\u003eOSTAP\u003c/em\u003e Oblique subcostal transversus abdominis plane, \u003cem\u003eTQL\u003c/em\u003e Transmuscular quadratus lumborum.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe VAS scores measured at rest at 6 hours postoperatively were statistically higher in the OSTAP group compared to the TQL group (p\u0026thinsp;=\u0026thinsp;0.019). However, no statistically significant differences were found between the groups regarding the VAS scores at 0, 30 min, 1, 2, 12, 18, and 24 h postoperatively, and before discharge (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003eThe VAS scores measured during movement at 6 h postoperatively and before discharge were significantly higher in the OSTAP group compared to the TQL group (p\u0026thinsp;=\u0026thinsp;0.004, p\u0026thinsp;=\u0026thinsp;0.023, respectively). However, no statistically significant differences were identified between VAS scores at 12, 18, and 24 h postoperatively (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003eThere were no statistically significant differences between the groups regarding the total or domain-specific QoR-15 scores preoperatively and 24 h postoperatively (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\u003eQoR-15 Questionnaire total and domain scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOSTAP Group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTQL Group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoR-15 total score (0-150)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138 (126, 143.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e137 (129.75, 143.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.961\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoR-15 domain scores\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePain (0\u0026ndash;20)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (17.75, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (18, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.663\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysical comfort (0\u0026ndash;50)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (40, 49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (40, 48.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.688\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysical independence (0\u0026ndash;20)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (20, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (20, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.964\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePsychological support (0\u0026ndash;20)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (20, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (20, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.626\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eEmotional state (0\u0026ndash;40)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34 (29.75, 38.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.5 (30, 37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.995\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e24 hours postoperative\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoR-15 total score (0-150)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e131.0 (127.5, 138)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134.0 (125.75, 140)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.435\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQoR-15 domain scores\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePain (0\u0026ndash;20)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.0 (13, 18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.0 (15.75, 19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.060\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysical comfort (0\u0026ndash;50)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45.0 (40, 48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (40.75, 48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.912\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePhysical independence (0\u0026ndash;20)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.5 (15.75, 18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.0 (16, 19.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.281\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePsychological support (0\u0026ndash;20)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.0 (20, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.0 (20, 20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.798\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eEmotional state (0\u0026ndash;40)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34.5 (32.75, 38.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (32, 39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.786\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are presented as median (IQR). \u003cem\u003eQoR-15\u003c/em\u003e quality of recovery-15, \u003cem\u003eOSTAP\u003c/em\u003e oblique subcostal transversus abdominis plane, \u003cem\u003eTQL\u003c/em\u003e transmuscular quadratus lumborum.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere was no statistically significant difference between the groups in the incidence of nausea and vomiting within the first 24 hours postoperatively, with only two patients in each group experiencing vomiting once. None of the patients included in the study experienced a block-related complication.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study compared the effect of OSTAP and TQL blocks on postoperative analgesia and QoR in laparoscopic gynecological surgery. Paracetamol consumption within the first 24 h was significantly lower in the TQL group, whereas tramadol consumption was similar between the groups. VAS scores at rest and during movement at 6 h, and during movement before discharge, were significantly lower in the TQL group, with no differences at other time points.\u003c/p\u003e\u003cp\u003eHebbard et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] described OSTAP block in their study, where they administered 40\u0026ndash;80 ml of local anesthetic, blocking the lateral and anterior branches of the T6\u0026ndash;L1 spinal nerves, thereby providing analgesia to the anterior abdominal wall [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Chen et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] directed the needle inferolaterally and performed OSTAP block with 20 ml of 0.375% ropivacaine; a cold test 30 minutes later confirmed complete T7\u0026ndash;T12 blockade. This approach provided effective analgesia with a lower volume of anesthetic compared to the technique described by Hebbard et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In present study, similar to studies in the literature, block was administered bilaterally using 20 ml of 0.25% bupivacaine, directing the needle inferolaterally [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. There are only a limited number of studies on the OSTAP block for postoperative analgesia in laparoscopic gynecological surgeries. Toker et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] indicated in patients undergoing total laparoscopic hysterectomy (TLH) that the OSTAP group had significantly lower VAS scores during coughing and consumed significantly lower amounts of tramadol compared to the control group. Based on these limited data and the reported efficacy of OSTAP, we chose this block for our study.\u003c/p\u003e\u003cp\u003eAlthough B\u0026oslash;rglum et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported that the TQL block provides analgesia covering the dermatomes T4 to L1, studies in the literature have not reached a consensus on the precise levels where analgesia is effective. In the cadaver study by Dam et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], the investigators examined the spread of the TQL block applied at the L4 level and reported that the dye spread over the diaphragm in all cases. In 50% of the cases, the dye spread over the medial and lateral arcuate ligaments, while in 30% it extended via the lateral arcuate ligament into the thoracic paravertebral space. The highest level reached by the dye was at the T9 vertebral level. The anterior branches of the spinal nerves and the thoracic sympathetic chain were dyed, with the dye surrounding the subcostal, iliohypogastric, and ilioinguinal nerves in all cases, while the genitofemoral and lateral femoral cutaneous nerves were dyed to varying degrees. Carline et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] concluded in their cadaver study that the TQL block consistently blocked the lumbar nerve roots and had the potential to provide analgesia from T10 to L4, making it a reliable option for postoperative analgesia. Considering the existing data, the TQL block was chosen for our study because of its efficacy and safety in postoperative pain management following laparoscopic gynecological surgery.\u003c/p\u003e\u003cp\u003eIn the study conducted by Huang et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] to investigate the postoperative analgesic efficacy of TQL and OSTAP blocks in patients undergoing TLH, total morphine consumption within 24 h was significantly lower in the TQL group. While this finding aligns with our study, a key difference was that the time to first rescue analgesia was significantly longer in the TQL group compared to the OSTAP group. Visceral numerical rating scale (NRS) scores at rest and during movement were significantly lower in the TQL group, while no significant difference was observed between the groups regarding incisional NRS scores at rest and during movement. These findings suggest that the effectiveness of the TQL block in providing visceral analgesia may be attributed to its broader blockade, affecting both somatic nerves and sympathetic nerve fibers [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The impact of the TQL block on the sympathetic chain could offer a particular advantage in visceral pain management, especially in laparoscopic gynecological surgeries. In contrast, the OSTAP block primarily targets somatic nerves and provides analgesia to the anterior abdominal wall [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, the OSTAP block emerges as an effective technique for managing incisional pain. However, potential adverse effects during the TQL block procedure should be considered. In their cadaver study comparing the spread of the TQL block administered at the L4 level with the transversus oblique paramedian (TOP) TQL block administered at the L2 level, Dam et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] demonstrated that if the psoas major muscle is penetrated, the local anesthetic can easily reach the L3 level and the femoral nerve. Kadoya et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported a 13.3% incidence of quadriceps muscle weakness following TQL block performed at the L2 level. This phenomenon was suggested to be associated with the spread of local anesthetic to the lumbar plexus via the PM muscle or its passage into the paravertebral space through the arcuate ligament. The findings of these studies highlight the importance of preserving the PM muscle during the TQL block procedure and underscore the need for careful monitoring of patients following block application.\u003c/p\u003e\u003cp\u003eIn this study, we used the QoR-15 questionnaire to assess patients\u0026rsquo; QoR. The QoR-15 is a shortened version of the QoR-40 questionnaire developed by Myles et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] to assess postoperative recovery from the patient\u0026rsquo;s perspective. The original QoR-40 includes five dimensions of health status, namely pain, physical comfort, physical independence, psychological support, and emotional state, and consists of 40 questions. However, due to the time-consuming nature of the full version, Stark et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] introduced the more efficient 15-item QoR-15 in 2013 as an alternative. The QoR-15 evaluates similar aspects of recovery, and its convenience made it the preferred choice for our study. The validity and reliability of the Turkish version of the QoR-15 were established by Kara et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and Selvi et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This shorter version allowed for an effective evaluation of patients\u0026rsquo; QoR in our study. In our study, no significant differences were observed between the groups in the total or domain-specific QoR-15 scores preoperatively and 24 h postoperatively. Consistently, Suzuka et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] compared the OSTAP block and the modified thoracoabdominal nerve block through the perichondrial approach in TLH and reported no significant differences in total QoR-15 scores preoperatively and on postoperative day 1. The QoR-15 questionnaire is a subjective assessment tool evaluating postoperative recovery across five dimensions. The lack of a significant difference in QoR-15 scores between the two groups suggests that recovery is influenced not only by pain levels but also by the patient\u0026rsquo;s physical and psychosocial state.\u003c/p\u003e\u003cp\u003eThe incidence of nausea and vomiting within the first 24 hours postoperatively was very low, with only two out of 34 patients in each group experiencing vomiting once. Saleh et al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] adopted a similar approach, where patients received 1 gram IV paracetamol every 8 hours postoperatively, and pethidine was used as a rescue analgesic. Compared to the control group, both subcostal TAP and TQL groups had significantly lower pethidine use and incidence of vomiting. We believe the primary factor in keeping nausea and vomiting rates so low was our approach of prioritizing regional anesthesia and paracetamol for pain management while minimizing opioid use as much as possible.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLimitations of the study\u003c/h2\u003e\u003cp\u003eOur study has some limitations to acknowledge. First, we excluded patients with a BMI\u0026thinsp;\u0026gt;\u0026thinsp;25 kg/m\u0026sup2; and those with a surgical duration exceeding 120 minutes. Second, since the patients were monitored only up to 24 hours in the postoperative period, we could not assess the long-term effects of the blocks on pain scores and complications.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePatients who received the TQL block in laparoscopic gynecological surgeries had lower analgesic requirements and VAS scores compared to those who received the OSTAP block. However, both blocks provided adequate analgesia, and no significant difference was found in QoR between the two groups. These findings suggest that both TQL and OSTAP blocks could be effective options in multimodal analgesia protocols, with the choice of the block being guided by factors such as the patient characteristics, the anesthesiologist\u0026rsquo;s experience, and the specific surgical procedure.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOSTAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOblique Subcostal Transversus Abdominis Plane\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuadratus Lumborum\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTQL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTransmuscular Quadratus Lumborum\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQoR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality Of Recovery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual Analog Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQoR-15\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of Recovery-15\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntravenous\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGauge\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePsoas Major\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDIE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDeeply Infiltrating Endometriosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnterior Superior Iliac Spines\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterquartile Range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTLH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTotal Laparoscopic Hysterectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNumerical Rating Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTOP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTransversus Oblique Paramedian\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e Ethical approval was obtained from Clinical Trials Ethics Committee of Uludag University School of Medicine (2023-11/9) on May 16, 2023. All participants provided written consent forms for participation in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors did not receive any funding for conducting this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKC contributed to conceptualization, data curation, methodology, project administration, writing \u0026ndash; original draft, writing \u0026ndash; review \u0026amp; editing. SA contributed to data curation, methodology, supervision, writing \u0026ndash; original draft, writing \u0026ndash; review \u0026amp; editing. SC contributed to data curation. AG and GU contributed to methodology, supervision, writing \u0026ndash; review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChoi JB, Kang K, Song MK, Seok S, Kim YH, Kim JE. Pain characteristics after total laparoscopic hysterectomy. Int J Med Sci. 2016;13(8):562\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7150/ijms.15875\u003c/span\u003e\u003cspan address=\"10.7150/ijms.15875\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGerbershagen HJ, Aduckathil S, van Wijck AJM, Peelen LM, Kalkman CJ, Meissner W. 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J Clin Med. 2024;13(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/jcm13030712\u003c/span\u003e\u003cspan address=\"10.3390/jcm13030712\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaleh AH, Abdallah MW, Mahrous AM, Ali NA. Quadratus lumborum block (transmuscular approach) versus transversus abdominis plane block (unilateral subcostal approach) for perioperative analgesia in patients undergoing open nephrectomy: a randomized, double-blinded, controlled trial. Braz J Anesthesiol. 2021;71(4):367\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bjane.2021.01.009\u003c/span\u003e\u003cspan address=\"10.1016/j.bjane.2021.01.009\" targettype=\"DOI\" 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":true,"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":"Postoperative pain, Analgesia, Regional anesthesia, Laparoscopic surgery, Gynecological surgery","lastPublishedDoi":"10.21203/rs.3.rs-7929838/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7929838/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDuring laparoscopic gynecological surgeries, trocar incisions, pneumoperitoneum and distention of the anterior abdominal wall can cause postoperative pain. Inadequate pain management can increase the risk of postoperative complications. The present study compared the effects of oblique subcostal transversus abdominis plane (OSTAP) block and transmuscular quadratus lumborum (TQL) block on postoperative analgesia and quality of recovery (QoR) in patients undergoing laparoscopic gynecological surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA total of 73 patients were enrolled in this prospective, randomized, controlled, double-blind study. The patients were randomly allocated to the OSTAP group (n\u0026thinsp;=\u0026thinsp;36) or the TQL group (n\u0026thinsp;=\u0026thinsp;37). General anesthesia was induced following bilateral block administration with 20 ml of 0.25% bupivacaine. The primary outcome was the total consumption of paracetamol and tramadol within the first 24 h postoperatively. Secondary outcomes included the time to first analgesic requirement, visual analog scale (VAS) scores at rest and during movement, and Quality of Recovery-15 (QoR-15) scores preoperatively and 24 h postoperatively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe total paracetamol consumption was significantly lower in the TQL group (p\u0026thinsp;=\u0026thinsp;0.002), whereas total tramadol consumption was similar between the groups. The TQL group had significantly lower VAS scores at rest and during movement at 6 h postoperatively and during movement before discharge (p\u0026thinsp;=\u0026thinsp;0.019, p\u0026thinsp;=\u0026thinsp;0.004, p\u0026thinsp;=\u0026thinsp;0.023, respectively). The groups were similar regarding time to the first analgesic requirement and QoR-15 scores preoperatively and 24 h postoperatively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe TQL block reduces postoperative analgesic requirements compared to the OSTAP block. However, both blocks have similar effects on QoR.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eClinicalTrials.gov, NCT06017401. Registered on August 20, 2023. Retrospectively registered.\u003c/p\u003e","manuscriptTitle":"Oblique Subcostal Transversus Abdominis Plane Block versus Transmuscular Quadratus Lumborum Block for Postoperative Analgesia and Quality of Recovery in Laparoscopic Gynecological Surgery: A Prospective Randomized Controlled Double-Blind Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-18 08:29:50","doi":"10.21203/rs.3.rs-7929838/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-12T10:16:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-10T00:09:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196557187598984857446133628479580732686","date":"2025-11-25T08:45:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288054795705518667760330503087832235478","date":"2025-11-23T20:04:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-09T23:27:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37442285552443427667525297609649317122","date":"2025-11-09T17:25:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-05T12:51:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-05T12:32:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-03T03:34:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-31T18:09:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2025-10-31T18:06:23+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":"e0c7ee2f-fa6e-4fc9-a21a-baf0506ff5e5","owner":[],"postedDate":"November 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:02:47+00:00","versionOfRecord":{"articleIdentity":"rs-7929838","link":"https://doi.org/10.1186/s12871-026-03643-z","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2026-01-24 15:57:10","publishedOnDateReadable":"January 24th, 2026"},"versionCreatedAt":"2025-11-18 08:29:50","video":"","vorDoi":"10.1186/s12871-026-03643-z","vorDoiUrl":"https://doi.org/10.1186/s12871-026-03643-z","workflowStages":[]},"version":"v1","identity":"rs-7929838","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7929838","identity":"rs-7929838","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}