In Search of Ideal Analgesia: Classical and Deep Rectus Sheath Block in Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is the gold standard of treatment for symptomatic cholelithiasis. Despite its minimally invasive nature, LC is still associated with moderate postoperative pain that may delay early mobilization, oral intake, and discharge while increasing the need for opioids. Within ERAS protocols, multimodal analgesia using regional techniques has become increasingly important. The rectus sheath block (RSB) is considered a useful option for controlling the somatic pain component related to the periumbilical port site.

A narrative literature review was conducted using PubMed, Scopus, and Google Scholar to identify studies published up to 2026. The analyses included prospective randomized and non-randomized studies, retrospective case series, anatomical investigations, and expert recommendations. In addition to the classical RSB, the deep rectus sheath block (DRSB) was evaluated as a potentially relevant technique for addressing not only somatic but also peritoneum-related pain.

Classical RSB, performed by injecting local anesthetic between the rectus abdominis muscle and the posterior rectus sheath, provides effective analgesia in the periumbilical port area, reduces postoperative pain intensity, and decreases opioid consumption during the first 24 h after LC compared with wound infiltration or systemic analgesia alone. DRSB, which targets the preperitoneal plane between the posterior rectus sheath and parietal peritoneum, has shown promising analgesic effects in isolated clinical reports after LC and epigastric hernia repair, with possible benefits for peritoneum-related pain. However, the current evidence for DRSB remains limited to case reports and small case series, and its exact mechanism of action is still debated.

RSB is a valuable component of multimodal analgesia for LC, with a demonstrated opioid-sparing effect and favorable safety profile under ultrasound guidance. DRSB appears promising, but remains experimental. Further well-designed randomized trials are needed to define its indications, optimal technique, and role in standardized analgesic protocols for LC.