Surgical rectus sheath block versus laparoscopic bilateral dual transversus abdominis plane block after minimally invasive colorectal cancer surgery: randomized clinical trial of impact on recovery.

BACKGROUND: Effective multimodal analgesia is essential after minimally invasive colorectal surgery. This randomized trial evaluated whether adding surgeon-performed surgical rectus sheath block (SRSB) or laparoscopic bilateral dual transversus abdominis plane (BD-TAP) block to intravenous patient-controlled analgesia (IV-PCA) improved postoperative quality of recovery. METHODS: This single-centre, three-arm superiority trial randomized adults undergoing minimally invasive colorectal resection (1 : 1 : 1) by stratified block allocation at a Japanese cancer centre. Patients and outcome assessors were blinded. The primary outcome was the Japanese version of the 15-item Quality of Recovery questionnaire (QoR-15) score 24 h after arrival in the postanaesthesia care unit. Missing postoperative QoR-15 item responses were handled using multiple imputation, and treatment effects were estimated using ANCOVA adjusted for the four randomization stratification factors. Each primary comparison used a Bonferroni-adjusted one-sided significance level of 0.025. Secondary outcomes included the 48-h QoR-15 score, postoperative pain scores, time to first rescue analgesia, and cumulative consumption of analgesics and antiemetics over 48 h. RESULTS: Between July 2024 and December 2025, 320 patients were randomized (control, 110; SRSB, 107; and BD-TAP block, 103); 309 were analysed (105, 103, and 101 respectively). Compared with control, BD-TAP block resulted in a higher 24-h QoR-15 score (adjusted mean difference 10.44 (95% c.i. 3.06 to 17.83) points; one-sided P = 0.003), whereas superiority of SRSB was not demonstrated (adjusted mean difference 5.50 (95% c.i. -1.88 to 12.89) points; one-sided P = 0.072). At 48 h, the adjusted mean difference for BD-TAP block versus control was 8.01 (95% c.i. 0.18 to 15.83) points (two-sided P = 0.045), an exploratory finding unadjusted for multiplicity. The median time to first rescue analgesia was longer with SRSB (27.8 h) and BD-TAP block (25.3 h) than control (3.3 h), but cumulative 48-h fentanyl consumption and length of hospital stay did not differ significantly. No block-related complications were observed. CONCLUSION: BD-TAP block resulted in better 24-h recovery than IV-PCA alone. Superiority of SRSB was not demonstrated. REGISTRATION NUMBER: jRCT1031240153 (Japan Registry of Clinical Trials).