Advances of regional nerve blocks for postoperative analgesia in laparoscopic gynecological surgery: precision, innovation, and future directions.

The limited duration of fascial plane blocks continues to pose a significant challenge in perioperative pain management. To address this limitation, clinical research has concentrated on three primary strategies: augmenting local anesthetics with pharmacological adjuvants, optimizing local anesthetic dosing, and developing novel, long-acting formulations. The addition of pharmacological adjuvants to local anesthetic solutions offers a promising approach to extend the duration and improve the quality of single-injection regional blocks. A systematic review by Kirksey et al. ( 56 ) provided a comprehensive overview of these agents. Dexamethasone has emerged as one of the most effective adjuvants. Zhang et al. ( 57 ) demonstrated that dexamethasone significantly prolonged analgesia, reduced opioid consumption, and lowered PONV incidence in TAPB. While its precise mechanism remains debated, evidence suggests that both perineural and intravenous administration provide comparable benefits ( 58 ). Dexmedetomidine, an alpha-2 adrenergic agonist, enhances analgesia by inducing localized vasoconstriction and inhibiting nerve fiber action potentials. However, its use must be carefully managed due to potential side effects, including sedation and bradycardia ( 59 , 60 ). Magnesium sulfate acts by modulating nociceptive signaling through NMDA receptor and calcium channel blockade. Studies have shown that magnesium sulfate prolongs analgesia and reduces morphine consumption in TAPB and QLB ( 61 , 62 ). Perineural opioids, while effective, have been limited in their use due to adverse effects, rendering them less favorable in the context of opioid-sparing strategies ( 56 ). Optimizing the dose, concentration, and volume of local anesthetics seeks to balance effective analgesia with minimal drug exposure, thereby reducing the risk of toxicity. This approach has shifted clinical practice from empirical dosing to evidence-based strategies. Wang et al. ( 63 ) employed sequential allocation methods to determine the optimal concentration of ropivacaine for QLB, identifying a dosing strategy that maximizes effectiveness while minimizing adverse effects. Similarly, Siripruekpong et al. ( 49 ) found that lower doses of bupivacaine were sufficient for RSB when used as part of multimodal analgesic pathways. This transition to dose finding studies underscores the importance of precise dosing strategies tailored to individual patient needs and surgical contexts. The development of novel, long-acting formulations of local anesthetics represents the third approach to optimizing block efficacy and duration. Liposomal bupivacaine, an extended-release formulation encapsulated within multivesicular liposomes, allows for sustained release of the drug over 72 h following a single administration ( 64 , 65 ). While some meta-analyses have demonstrated its effectiveness in reducing pain and opioid consumption, its clinical superiority over conventional formulations remains under scrutiny. Although the direct drug cost of liposomal bupivacaine is substantially higher than that of conventional formulations, emerging pharmacoeconomic evidence suggests that it may prove cost-effective at the health-system level. Studies in colorectal and orthopedic surgery have demonstrated that the use of liposomal bupivacaine can reduce total cost of care by decreasing the need for additional analgesics, lowering complication rates such as postoperative ileus, and shortening hospital length of stay ( 66 , 67 ). However, it should be noted that dedicated cost-effectiveness analyses specific to fascial plane blocks in gynecological surgery are lacking, and generalizing economic findings across surgical specialties warrants caution. Further comparative trials are required to clarify its role in fascial plane blocks, particularly in laparoscopic gynecological surgeries, where both analgesic and economic benefits remain to be definitively established ( Table 2 ). Summary of key RCTs evaluating liposomal bupivacaine in fascial plane blocks. LB, liposomal bupivacaine; TAPB, transversus abdominis plane block; PECS, pectoralis nerve block; SAPB, serratus anterior plane block; FPB, fascial plane block; LA, local anesthetics; MME, morphine milligram equivalents; OBAS, overall benefit of analgesia score.

The advent of laparoscopic surgery in the late 20th century marked a paradigm shift in modern surgical practice. Since the introduction of laparoscopic hysterectomy in 1989, this approach has demonstrated multiple benefits, including reduced pain, shorter hospital stays, superior cosmetic outcomes, and faster recovery ( 1 ). As a result, laparoscopic techniques are now considered the standard of care for a wide range of benign and malignant gynecological conditions. Despite being classified as minimally invasive, laparoscopic procedures are frequently associated with significant postoperative pain. Ekstein et al. ( 2 ) highlighted that these procedures often require substantial analgesia during the immediate postoperative period. Among gynecological surgeries, total laparoscopic hysterectomy is associated with a particularly complex and prolonged pain profile ( 3 , 4 ), underscoring the pressing need for targeted and effective pain management strategies. Historically, postoperative pain management has relied heavily on opioids. While effective, opioids are associated with numerous adverse effects ( 5 ). The ongoing opioid crisis has prompted a shift toward opioid-sparing regimens, in alignment with Enhanced Recovery After Surgery (ERAS) protocols. These protocols prioritize multimodal analgesia to achieve superior pain control while minimizing opioid consumption ( 6–9 ). Within the context of ERAS, regional nerve blocks have emerged as a cornerstone for optimizing postoperative pain control in laparoscopic gynecological surgery. This review critically evaluates the evidence supporting major abdominal wall and truncal blocks, including the Transversus Abdominis Plane Block (TAPB), Quadratus Lumborum Block (QLB), and Erector Spinae Plane Block (ESPB), alongside techniques that specifically target visceral pain. Additionally, strategies for enhancing block efficacy through pharmacological adjuncts will be explored, providing a comprehensive guide to delivering precise and personalized analgesia for patients undergoing laparoscopic gynecological surgery. This narrative review was conducted in accordance with the SANRA (Scale for the Assessment of Narrative Review Articles) guidelines ( 10 ). A comprehensive literature search was performed using PubMed and Web of Science. The search covered publications from database inception through January 2000 to October 2025. Search terms included combinations of: ‘laparoscopic gynecological surgery,’ ‘regional nerve block,’ ‘transversus abdominis plane block,’ ‘quadratus lumborum block,’ ‘erector spinae plane block,’ ‘postoperative analgesia,’ ‘Enhanced Recovery After Surgery,’ and ‘fascial plane block.’ Additional relevant studies were identified through manual screening of reference lists of included articles and existing systematic reviews. We prioritized randomized controlled trials, systematic reviews/meta-analyses, and Cochrane reviews, while also including observational studies, cadaveric studies, and case series where higher-level evidence was limited. No formal risk of bias assessment was conducted, consistent with the narrative nature of this review.

The evolution of regional nerve blocks in laparoscopic gynecological surgery exemplifies a broader shift toward patient-centered, evidence-based pain management. This section synthesizes key findings and explores future directions for advancing regional anesthesia in this field. Regional nerve blocks have become a cornerstone of ERAS protocols, playing a crucial role in minimizing surgical stress and expediting functional recovery. One of the most significant contributions of regional blocks is their opioid-sparing effect. A network meta-analysis by Ding et al. ( 8 ) demonstrated that combining regional techniques with non-opioid analgesics significantly reduces perioperative opioid consumption. This reduction is critical in mitigating opioid-related side effects, such as nausea, sedation, and ileus, which can delay recovery and prolong hospital stays ( 68 ). Effective regional analgesia also facilitates quicker functional recovery, with evidence showing that multimodal protocols incorporating regional anesthesia promote earlier ambulation and faster return of bowel function ( 7 ). Beyond physical recovery, regional anesthesia enhances psychological well-being, yielding higher scores in quality-of-recovery assessments across domains such as physical comfort, emotional state, and pain relief ( 69 ). The clinical focus in regional anesthesia has shifted from determining whether a block should be used to identifying the most appropriate block for a given procedure and patient. This approach aims to tailor analgesic strategies to the unique “pain fingerprint” of each surgery. The concept of the surgical ‘pain fingerprint’ can be operationalized by considering three dimensions: (1) the relative contribution of somatic versus visceral pain, which is largely determined by the surgical procedure; (2) the number and location of trocar sites, which determines the required dermatomal coverage; and (3) the anticipated duration and severity of pain, which informs the choice between single-shot blocks, adjuvant-enhanced blocks, or catheter-based techniques. For procedures with a predominantly visceral pain component, such as total laparoscopic hysterectomy, blocks with potential paravertebral spread QLB or ESPB are preferred over TAPB. Conversely, for single-port procedures with localized somatic pain, a targeted RSB may be more appropriate than a broader fascial plane block. This framework should be considered a starting point for clinical decision-making rather than a definitive algorithm, as high-quality head-to-head comparative data for many procedure-block combinations remain limited. The choice of block depends on the nature of the procedure. For total laparoscopic hysterectomy, which involves significant visceral and back pain, regional techniques with visceral analgesic capabilities, such as the QLB or ESPB, have demonstrated efficacy ( 4 , 36 , 37 ). Conversely, procedures characterized by predominantly localized somatic pain, such as minor laparoscopic interventions, may benefit more from a RSB ( 39 ). Post-laparoscopic pain is inherently multifactorial, with components such as referred shoulder-tip pain often escaping the coverage of abdominal wall blocks. Therefore, a comprehensive strategy that combines regional techniques with interventions targeting specific pain mechanisms is essential ( 70 ). The proposed clinical framework is outlined in Table 3 . Proposed clinical framework: matching regional block selection to laparoscopic gynecological procedure type. Recommendations are based on available evidence and clinical rationale; many comparisons lack direct head-to-head RCTs in the specific gynecological context. Individual patient factors (comorbidities, anticoagulation status, body habitus, surgeon preference) should also guide block selection. All regional techniques should be integrated within a multimodal analgesic strategy. The future of regional anesthesia is being shaped by technological innovation, which promises to refine existing techniques and introduce groundbreaking advancements. The following discussion distinguishes between technologies with existing evidence base and those that remain at early stages of development. Readers should interpret the latter as identifying potential avenues of investigation rather than imminent clinical practice changes. Refined approaches, such as the modified subcostal anterior QL block, have demonstrated superior opioid-sparing effects when compared to traditional methods ( 71 ). Algorithms capable of identifying anatomical structures and guiding real-time needle placement during ultrasound-guided blocks are under development ( 72 ). These advancements could democratize regional anesthesia by shortening learning curves, standardizing performance, and improving procedural safety. Innovations in pharmacology are driving the development of ultra-long-acting local anesthetics, capable of extending the duration of single-shot blocks to 72 h or longer. The integration of robotics into regional anesthesia offers the potential for superhuman precision in needle placement and drug delivery. Further innovations include ultra-long-acting local anesthetics that extend the duration of single-shot blocks to 72 h and beyond, and the integration of robotics capable of superhuman precision in needle placement. Artificial Intelligence (AI) represents a transformative development in regional anesthesia. The application of AI to ultrasound-guided regional anesthesia has progressed beyond the conceptual stage, with several published studies demonstrating feasibility. AI for ultrasound scanning in regional anaesthesia is a rapidly developing interdisciplinary field, though there is a risk that work could be undertaken in parallel by different elements of the community with a lack of knowledge transfer between disciplines ( 72 ). AI technology in this domain has achieved an accuracy of 99.7% in identifying specific anatomical structures in some evaluations ( 73 ). The Guidance for Reporting Artificial Intelligence Technology Evaluations for Ultrasound Scanning in Regional Anesthesia (GRAITE-USRA) guideline, published in 2025, is the first international reporting framework developed for the scientific evaluation of AI applications in ultrasound-guided regional anesthesia ( 74 ). However, it is important to acknowledge the limitations of current AI technology. Most published studies evaluate AI performance in optimal conditions, and real-world clinical validation remains limited. The future of regional anesthesia with AI integration appears promising, yet obstacles such as device malfunction, data privacy, regulatory barriers, and cost concerns can deter its clinical implementation ( 75 ). Robotic-assisted needle placement in regional anesthesia remains at a pre-clinical development stage, and its clinical utility has not yet been demonstrated in randomized studies. Similarly, while ultra-long-acting formulations such as liposomal bupivacaine have been studied in various surgical contexts, their cost-effectiveness and specific role in fascial plane blocks for laparoscopic gynecological surgery await clarification in well-designed comparative trials. These technologies represent areas of active investigation rather than near-term clinical solutions.

A substantial portion of postoperative discomfort following laparoscopic gynecological surgery is attributed to visceral pain, primarily transmitted via the autonomic nervous system. Such pain is often inadequately addressed by truncal blocks. This chapter explores regional techniques specifically designed to intercept visceral pain signals, with a particular focus on the Superior Hypogastric Plexus Block (SHPB) and neuraxial anesthesia. The SHPB is a targeted intervention for pelvic visceral nociception, achieved by blocking the superior hypogastric plexus. This retroperitoneal network of autonomic nerves is situated anterior to the L5 vertebra and the sacral promontory. The plexus conveys afferent pain fibers from pelvic organs such as the uterus, cervix, and proximal fallopian tubes. Rapp et al. ( 51 ), in a double-blind randomized clinical trial, demonstrated that injecting ropivacaine into the presacral space during open abdominal hysterectomy significantly reduced postoperative opioid consumption and pain scores compared to placebo. Systematic reviews by Shama et al. ( 52 ) and Salem et al. ( 53 ) corroborated these findings, confirming that SHPB effectively reduces pain scores, opioid consumption, and Postoperative Nausea and Vomiting (PONV) in hysterectomy patients. However, the SHPB’s role in laparoscopic gynecological surgery remains nuanced, with benefits appearing less pronounced than in open surgery. This reduced effect may stem from the lower intensity of visceral pain in laparoscopic procedures, widespread use of multimodal ERAS protocols, and technical challenges of laparoscopic block performance. Neuraxial anesthesia offers profound analgesia for abdominal and pelvic surgeries by concurrently blocking somatic and visceral dermatomes. Studies, such as those by Gerges et al. ( 1 ), highlight its potential advantages for laparoscopy, including faster recovery and reduced PONV. Applying neuraxial techniques to laparoscopic surgery presents unique challenges, primarily sympathetic blockade leading to hypotension (exacerbated by pneumoperitoneum) and potential motor blockade delaying ambulation-a key ERAS component. To address these challenges, modern approaches increasingly favor lower-dose, combined techniques that preserve analgesic efficacy while minimizing complications. Zdravkovic and Kamenik ( 54 ) demonstrated that combining general anesthesia with low-dose spinal anesthesia significantly reduced both intraoperative and postoperative opioid consumption without compromising hemodynamic stability. While Seki et al. ( 55 ) reported that epidural anesthesia improved patient satisfaction through its opioid-sparing effects. Neuraxial anesthesia, therefore, remains a valuable tool not as a standalone technique but as a flexible component of individualized anesthetic plans. It is particularly beneficial for complex surgeries or patients requiring superior pain control. Together with SHPB, these advanced techniques enhance the anesthesiologist’s ability to effectively manage visceral pain in gynecological procedures.

Regional anesthesia for laparoscopic gynecological surgery has advanced from basic techniques to highly precise and personalized approaches. These blocks now serve as fundamental pillars of perioperative care and integral elements of ERAS protocols, offering effective opioid-sparing analgesia and facilitating improved postoperative recovery. The current paradigm emphasizes tailoring anesthesia strategies to the specific needs of both the procedure and the individual patient.