Comparative Efficacy of Regional Analgesic Interventions in Open versus Laparoscopic Hepatic Surgery: A Network Meta-Analysis

Purpose: To compare the analgesic efficacy and safety of various regional analgesic techniques in patients undergoing hepatic surgery, with prespecified subgroup analyses for open and laparoscopic approaches. Patients and Methods: This study adhered to PRISMA-NMA guidelines. Randomized controlled trials (RCTs) comparing regional analgesia techniques in adults undergoing hepatic surgery were identified from PubMed, Embase, Web of Science, and the Cochrane Library. Primary outcomes were postoperative 24-hour pain scores and opioid consumption; the secondary outcome was postoperative nausea and vomiting (PONV). Bayesian network meta-analysis was performed, and interventions were ranked using surface under the cumulative ranking curve (SUCRA) values. Results: Twenty-three RCTs (1,382 patients) were included. In the main analysis, intrathecal morphine (ITM) was ranked highest for reducing 24-hour pain scores (SUCRA 91%), and erector spinae plane block (ESPB) and transversus abdominis plane block (TAPB) significantly reduced 24-hour opioid consumption compared with control. However, no statistically significant differences were found among the active interventions in network comparisons for pain scores or opioid consumption. No intervention significantly reduced the incidence of PONV. The certainty of evidence (GRADE) for all outcomes ranged from very low to moderate. Subgroup analysis suggested ESPB was most effective for opioid reduction in open surgery, while ITM was superior for both pain and opioid reduction in laparoscopic surgery. Conclusion: Regional analgesic techniques provide opioid-sparing benefits after hepatic resection, but no technique demonstrated clear superiority over another in the main analysis. The choice of analgesic technique should be individualized. Subgroup analyses suggest ESPB may be preferred for open hepatectomy and ITM for laparoscopic procedures, although these findings are exploratory due to limited evidence certainty. Larger, high-quality RCTs are needed to strengthen the evidence for optimal analgesic strategies in hepatic surgery. Keywords: nerve block, postoperative pain, analgesia, meta-analysis, liver resection