Evaluation of the analgesic efficacy of ultrasound-guided bilateral high-volume recto-intercostal plane block in laparoscopic sleeve gastrectomy: a prospective randomized controlled trial

BACKGROUND: Postoperative pain control is important in patients with obesity undergoing laparoscopic bariatric surgery, as inadequate analgesia may increase opioid consumption and delay recovery. Ultrasound-guided fascial plane blocks are increasingly used as part of multimodal analgesia. The recto-intercostal plane block (RIPB) is a recently described technique that may provide effective upper abdominal wall analgesia when applied bilaterally with a high-volume approach. However, evidence regarding its efficacy in bariatric surgery is limited. This study aimed to evaluate whether bilateral ultrasound-guided RIPB reduces postoperative opioid consumption and improves recovery after laparoscopic sleeve gastrectomy. METHODS: This prospective, randomized, assessor-blinded controlled trial included 56 patients with obesity undergoing elective laparoscopic sleeve gastrectomy under general anesthesia. Patients were allocated to receive either bilateral ultrasound-guided RIPB at the end of surgery (RIPB group, n = 28) or standard analgesic management without regional block (Control group, n = 28). The RIPB was performed using bupivacaine diluted to a final concentration of 0.25% and a total volume of 60 mL, with 30 mL administered per side. All patients received standardized multimodal analgesia and intravenous patient-controlled analgesia with morphine. The primary outcome was cumulative intravenous morphine consumption within the first 24 postoperative hours. Secondary outcomes included pain scores, rescue opioid use, postoperative nausea and vomiting, and quality of recovery assessed using the Quality of Recovery-15 questionnaire. RESULTS: Twenty-four-hour cumulative morphine consumption was significantly lower in the RIPB group than in the Control group (median [IQR]: 5 [4-10.25] mg vs. 24.5 [21.75-30] mg; p < 0.001). Static and dynamic NRS scores were significantly lower in the RIPB group at the 1st postoperative hour, with no significant differences at later time points after correction for multiple comparisons. Quality of recovery at 24 h was significantly better in patients receiving RIPB (median [IQR]: 131.5 [123-137.25] vs. 113.0 [109-119]; p < 0.001). Rescue opioid use and postoperative nausea and vomiting rates were similar between groups. No block-related complications were observed. CONCLUSIONS: Bilateral ultrasound-guided high-volume recto-intercostal plane block significantly reduced postoperative opioid consumption and improved early recovery in patients with obesity undergoing laparoscopic sleeve gastrectomy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT07253610 .registered on 19 November 2025; Retrospectively Registered.