Surgeon-Delivered Bupivacaine Achieves Analgesic Efficacy Comparable to ESP and TAP Blocks in Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, 

Congratulations on a decent study. The idea is not new and obvious for every day practitioners. Nevertheless, there are about 1800 publications favouring TAP block, wheereas in everyday practice it is visible that infiltrative anaesthesia is also similarly efficient, what I know well from my own studies concerning infiltrative anaesthesia in spine surgery. 

Stasiowski M, Missir A, Pluta A, Szumera I, Stasiak M, Szopa W, Błaszczyk B, Możdżyński B, Majchrzak K, Tymowski M, Niewiadomska E, Ładziński P, Krawczyk L, Kaspera W. Influence of infiltration anaesthesia on perioperative outcomes following lumbar discectomy under surgical pleth index-guided general anaesthesia: A preliminary report from a randomised controlled prospective trial. Adv Med Sci. 2020 Mar;65(1):149-155. doi: 10.1016/j.advms.2019.12.006. Epub 2020 Jan 13. PMID: 31945659.

In the part of publication concerning methodology, analysis concerning postoperative pain perception I would change nothing, because it is almost excellent, and concerning that part I hardly have opportunity to revise a manuscript, when desription of study purpose, background, literatures showing contemporary knowlegde is so well done. 

But I shall have some suggestions: 

1. in the limitation section mention, why you opted for bupivacaine instead of ropivacaine. Bupivacaine is dedicated to sensoric and motor blocks for regional anaesthesia only in ortopedic surgery of upper and lower extremity, where nerve are single nad thick, and proper motor block is needed, as no general anaesthesia is added. I know full well that bupivacaine is much cheaper than ropivacaine, maybe that was the reason. Moreover, duration of block using ropivacaine can be easily prolonged even to 2 days by addition od dexamethasone to anaesthetic mixture or intravenously, obtaining also antiemetic advantage - one adiuvant = two goals (prolongation of regional anaesthesia + antiemetic potency). In discussion of abovementioned literature from my publication you will come across a study showing, that ropicavaine + dexamethasone is so efficient that patients do no have any pain perception untill discharge home. As well as this, in intrafascial spaces, nerves are tiny, so even 0,2% solution of ropivacaine is enough, whereas the space is wide, so you need low concentration but high volumes of anaesthetics. In the current study it cannot be changed, but for future studies, if you have access to ropivacaine, I strongly recommend it. Only one aspect of your methodology can be debatable: infiltrative anaesthesia often requires lower volumes of bupivacaine than TAP or ESPB, what is beneficial in reduction of bupivacaine induced cardiac arrest, but hardly observed following intrafascial blocks.
2. all part concerning postoperative nausea and vomiting (PONV)  I WOULD DEFINITELY DELETE and make an additional analysis as a seperate report with secondary outcomes;-Firstly: to calculate PONV you need separate sample size calculation, if number of patients in groups is enugh. Secondly, you you tramadol postoperatively to relieve postoperative pain, but at the same time give ondansetron before emergence from general anaesthesia: I suggest that you read about their interactions indepthly. :). If you mention these two aspects in two different manuscripts I may be unnoticed but in one publication it is a methodological problem. Third aspect is group homogeneity in the aspect of PONV. There are certain risk factors of PONV. You need extra table proving that there is group homogeneity in this aspect. Marczak K, Stasiowski MJ, Lyssek-Boroń A, Zmarzły N. Adverse Events Following Vitreoretinal Surgeries Under Adequacy of Anesthesia with Combined Paracetamol/Metamizole-Additional Report. J Clin Med. 2025 Sep 4;14(17):6261. doi: 10.3390/jcm14176261. PMID: 40944019; PMCID: PMC12428795. You need an extra table to prove that in the controls you did not have more unsmoking women, with motion sickness, obese with diabetes, and other factors initially predisposing to PONV as compared to ESP TAP and IA groups. Pluta A, Stasiowski MJ, Lyssek-Boroń A, Król S, Krawczyk L, Niewiadomska E, Żak J, Kawka M, Dobrowolski D, Grabarek BO, Szumera I, Missir A, Rejdak R, Jałowiecki P. Adverse Events during Vitrectomy under Adequacy of Anesthesia-An Additional Report. J Clin Med. 2021 Sep 15;10(18):4172. doi: 10.3390/jcm10184172. PMID: 34575281; PMCID: PMC8468095.

Stasiowski MJ, Pluta A, Lyssek-Boroń A, Król S, Krawczyk L, Niewiadomska E, Żak J, Kawka M, Dobrowolski D, Grabarek BO, Szumera I, Koss MJ, Missir A, Rejdak R, Jałowiecki P. Adverse Events during Vitreoretinal Surgery under Adequacy of Anesthesia Guidance-Risk Factor Analysis. Pharmaceuticals (Basel). 2022 Feb 16;15(2):237. doi: 10.3390/ph15020237. PMID: 35215349; PMCID: PMC8879673.

without such table, indepth analysis in discussion section your results make no sense, but if you add it, the word count limit is an another problem. 

Coming back to intravenous ondansetron at emergence from general anaesthesia, it is also methodologically incorrect. You either give no antiemetic prophylaxis to investigate potency of studied groups IA, TAP and ESP to reduce incidence of PONV by reduction of demand for rescue analgesia based on opioids like oxycodone or morphine, or follow lastest guidelines, that require base prophylaxis using two drugs: Kienbaum P, Schaefer MS, Weibel S, Schlesinger T, Meybohm P, Eberhart LH, Kranke P. Update PONV – Was gibt es Neues bei der Prophylaxe und Therapie von postoperativer Übelkeit und postoperativem Erbrechen? : Zusammenfassung rezenter Konsensusempfehlungen sowie Cochrane-Reviews zu Prophylaxe und Therapie postoperativer Übelkeit und postoperativen Erbrechens [Update on PONV-What is new in prophylaxis and treatment of postoperative nausea and vomiting? : Summary of recent consensus recommendations and Cochrane reviews on prophylaxis and treatment of postoperative nausea and vomiting]. Anaesthesist. 2022 Feb;71(2):123-128. German. doi: 10.1007/s00101-021-01045-z. Epub 2021 Oct 1. PMID: 34596699.

Therefore, I would add in limitation section, that secondary outcomes will be separately reported. I would instead add a section in the discussion showing that infiltrative anaesthesia delivered by operator is equally efficient in other types of surgeries also. we observe it in laparoscopic hysterectomies, surgeries for hernias, etc. 

As MDPI will soon start special issue: Advances in general and regional anaesthesia, I will gladly invite your separate analysis of PONV. 

Before I forget, Tramadol is a pro-drug that is activated in the liver, in patients lacking special converting enzyme to active drug tramadol has proemetic capacity. In monotherapy it is seldom used but works best in abdominal surgery together with metamizole or paracetamol showing supraadditive effect. Stasiowski MJ, Król S, Wodecki P, Zmarzły N, Grabarek BO. Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception. Pharmaceuticals (Basel). 2024 Nov 7;17(11):1497. doi: 10.3390/ph17111497. PMID: 39598408; PMCID: PMC11597749.

Such knowlegde helps design future studies better, what seeing your enthusiasm should not be abandoned. 

Knowledge of PONV, risk factors, mechanisms of action of antiemetics, proemetic capacity of anaesthetics is complex and takes time to learn to produce a decent manuscript, whereas 

FINIS coronat opus. 

Best wishes with either major or minor revision dependent on the way you will follow; either one huge manuscript or two smaller but of better quality for Editorial BOArd, more clinical relevance and usefullness for every day practitioners, especially young doctors who want to use the new skills to every patient under their care, but sometimes older method is better for the patients' need, economic frugality of operating theatre. 

Good luck. 

 

 

 

 

 

Author Response

Response to Reviewer 1

We sincerely thank the reviewer for the very encouraging comments regarding the quality of our methodology and analysis. We are particularly grateful for the recognition that our study purpose, background, and literature review were “almost excellent.” We also highly appreciate the reviewer’s own contribution to the field with their study on infiltration anaesthesia in spine surgery (Stasiowski et al., Adv Med Sci 2020). We have carefully considered this valuable work and now cited it in the Discussion to emphasize that our findings in laparoscopic cholecystectomy are consistent with evidence from spine surgery, thereby reinforcing the broader clinical relevance and versatility of infiltration techniques.

1. Reviewer comment. in the limitation section mention, why you opted for bupivacaine instead of ropivacaine. Bupivacaine is dedicated to sensoric and motor blocks for regional anaesthesia only in ortopedic surgery of upper and lower extremity, where nerve are single nad thick, and proper motor block is needed, as no general anaesthesia is added. I know full well that bupivacaine is much cheaper than ropivacaine, maybe that was the reason. Moreover, duration of block using ropivacaine can be easily prolonged even to 2 days by addition od dexamethasone to anaesthetic mixture or intravenously, obtaining also antiemetic advantage - one adiuvant = two goals (prolongation of regional anaesthesia + antiemetic potency). In discussion of abovementioned literature from my publication you will come across a study showing, that ropicavaine + dexamethasone is so efficient that patients do no have any pain perception untill discharge home. As well as this, in intrafascial spaces, nerves are tiny, so even 0,2% solution of ropivacaine is enough, whereas the space is wide, so you need low concentration but high volumes of anaesthetics. In the current study it cannot be changed, but for future studies, if you have access to ropivacaine, I strongly recommend it. Only one aspect of your methodology can be debatable: infiltrative anaesthesia often requires lower volumes of bupivacaine than TAP or ESPB, what is beneficial in reduction of bupivacaine induced cardiac arrest, but hardly observed following intrafascial blocks.

• Response:
  We sincerely thank the reviewer for this valuable comment. The primary reason for choosing bupivacaine was its cost-effectiveness and ready availability in our institution, whereas ropivacaine was not routinely accessible during the study period. We appreciate the reviewer’s suggestion regarding the potential benefits of ropivacaine, especially in combination with dexamethasone, which is indeed enlightening for future research planning.

Concerning the volume of local anaesthetic, we acknowledge the reviewer’s important safety-oriented remark. In our trial, we deliberately used the same total volume across all active groups (40 mL of 0.25% bupivacaine for infiltration; 20 mL per side for ESP and TAP blocks) to maintain methodological standardization and minimize bias. This technical decision has now been clarified in the revised manuscript.

 

1. 2) Reviewer comment:
   all part concerning postoperative nausea and vomiting (PONV)  I WOULD DEFINITELY DELETE and make an additional analysis as a seperate report with secondary outcomes;-Firstly: to calculate PONV you need separate sample size calculation, if number of patients in groups is enugh. Secondly, you you tramadol postoperatively to relieve postoperative pain, but at the same time give ondansetron before emergence from general anaesthesia: I suggest that you read about their interactions indepthly. :). If you mention these two aspects in two different manuscripts I may be unnoticed but in one publication it is a methodological problem. Third aspect is group homogeneity in the aspect of PONV. There are certain risk factors of PONV. You need extra table proving that there is group homogeneity in this aspect. Marczak K, Stasiowski MJ, Lyssek-Boroń A, Zmarzły N. Adverse Events Following Vitreoretinal Surgeries Under Adequacy of Anesthesia with Combined Paracetamol/Metamizole-Additional Report. J Clin Med. 2025 Sep 4;14(17):6261. doi: 10.3390/jcm14176261. PMID: 40944019; PMCID: PMC12428795. You need an extra table to prove that in the controls you did not have more unsmoking women, with motion sickness, obese with diabetes, and other factors initially predisposing to PONV as compared to ESP TAP and IA groups. Pluta A, Stasiowski MJ, Lyssek-Boroń A, Król S, Krawczyk L, Niewiadomska E, Żak J, Kawka M, Dobrowolski D, Grabarek BO, Szumera I, Missir A, Rejdak R, Jałowiecki P. Adverse Events during Vitrectomy under Adequacy of Anesthesia-An Additional Report. J Clin Med. 2021 Sep 15;10(18):4172. doi: 10.3390/jcm10184172. PMID: 34575281; PMCID: PMC8468095.

Stasiowski MJ, Pluta A, Lyssek-Boroń A, Król S, Krawczyk L, Niewiadomska E, Żak J, Kawka M, Dobrowolski D, Grabarek BO, Szumera I, Koss MJ, Missir A, Rejdak R, Jałowiecki P. Adverse Events during Vitreoretinal Surgery under Adequacy of Anesthesia Guidance-Risk Factor Analysis. Pharmaceuticals (Basel). 2022 Feb 16;15(2):237. doi: 10.3390/ph15020237. PMID: 35215349; PMCID: PMC8879673.

without such table, indepth analysis in discussion section your results make no sense, but if you add it, the word count limit is an another problem. 

Coming back to intravenous ondansetron at emergence from general anaesthesia, it is also methodologically incorrect. You either give no antiemetic prophylaxis to investigate potency of studied groups IA, TAP and ESP to reduce incidence of PONV by reduction of demand for rescue analgesia based on opioids like oxycodone or morphine, or follow lastest guidelines, that require base prophylaxis using two drugs: Kienbaum P, Schaefer MS, Weibel S, Schlesinger T, Meybohm P, Eberhart LH, Kranke P. Update PONV – Was gibt es Neues bei der Prophylaxe und Therapie von postoperativer Übelkeit und postoperativem Erbrechen? : Zusammenfassung rezenter Konsensusempfehlungen sowie Cochrane-Reviews zu Prophylaxe und Therapie postoperativer Übelkeit und postoperativen Erbrechens [Update on PONV-What is new in prophylaxis and treatment of postoperative nausea and vomiting? : Summary of recent consensus recommendations and Cochrane reviews on prophylaxis and treatment of postoperative nausea and vomiting]. Anaesthesist. 2022 Feb;71(2):123-128. German. doi: 10.1007/s00101-021-01045-z. Epub 2021 Oct 1. PMID: 34596699.

Therefore, I would add in limitation section, that secondary outcomes will be separately reported. I would instead add a section in the discussion showing that infiltrative anaesthesia delivered by operator is equally efficient in other types of surgeries also. we observe it in laparoscopic hysterectomies, surgeries for hernias, etc. 

As MDPI will soon start special issue: Advances in general and regional anaesthesia, I will gladly invite your separate analysis of PONV. 

Before I forget, Tramadol is a pro-drug that is activated in the liver, in patients lacking special converting enzyme to active drug tramadol has proemetic capacity. In monotherapy it is seldom used but works best in abdominal surgery together with metamizole or paracetamol showing supraadditive effect. Stasiowski MJ, Król S, Wodecki P, Zmarzły N, Grabarek BO. Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception. Pharmaceuticals (Basel). 2024 Nov 7;17(11):1497. doi: 10.3390/ph17111497. PMID: 39598408; PMCID: PMC11597749.

Such knowlegde helps design future studies better, what seeing your enthusiasm should not be abandoned. 

Knowledge of PONV, risk factors, mechanisms of action of antiemetics, proemetic capacity of anaesthetics is complex and takes time to learn to produce a decent manuscript, whereas 

Response:
We sincerely thank the reviewer for this detailed and thoughtful recommendation. After carefully reconsidering our dataset in light of your remarks, we recognized that several baseline risk factors for PONV (e.g., sex distribution, smoking status, obesity, diabetes, history of motion sickness) could compromise group homogeneity. Therefore, we agree that analyzing PONV within the present trial would be methodologically inappropriate.

Accordingly, we have removed all PONV-related results and discussion from the revised manuscript. We fully acknowledge that an adequately powered and specifically designed trial is required to address PONV outcomes reliably. Your suggestion has been invaluable in helping us refine our research focus.

We also appreciate the reviewer’s reference to recent methodological and pharmacological insights, including the complex interactions between tramadol and ondansetron. These are indeed important considerations for the design of future studies. In line with this, we plan to launch a separate, dedicated analysis of PONV and will closely follow the upcoming MDPI Special Issue: Advances in General and Regional Anaesthesia as a potential venue for dissemination.

Closing

We again thank the reviewer for the insightful comments that clearly strengthened the manuscript’s methodological transparency and clinical focus. We hope the revisions satisfactorily address all concerns.

 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for submitting this article.

There are some fondamental ethical concern

1/related to the absence of IRB approval until the end of the study for a study represented as a prospective study. 

2/ The patients didn't really provide an informed consent for a study. They consented for the surgery and they consented for a nerve block.

Also of concern is the fact that the study was conducted between 2020 and 2022 and the manuscript is submitted 3n year later.

Details

Introduction is long and the rational is not very compelling

Method,

Details related to the block techniques are missing, the patient position, type of sedation, where were performed the blocks.

Table 3 report a significant difference between the duration to performed the blocks? 

The difference between the time is really very small. This reviewer would like to suggest the authors to confirm their statical analysis

Discussion,

The clinical significance between the group A-C and D are really minimum Morphine equivalent of 1.5 mg over 24 hrs

line 261- 267; 284-291; 292-299  please delete irrelevant. 284-291. The authors should recognize that surgeons routinely performed TAP blocks. 

301-328 references 23 and 35 represent a case report and a letter to the editor> Their use in the context is not really appropriate.

A paragraph detailing the limitation to this study is missing 

 

Author Response

Reviewer 2

We would like to sincerely thank Reviewer 2 for the meticulous and constructive feedback, which greatly contributed to improving the scientific clarity, ethical transparency, and overall quality of our manuscript.

Comment 1:

“Related to the absence of IRB approval until the end of the study for a study represented as a prospective study.”

Response:

We thank the reviewer for raising this important ethical concern. The study was prospectively planned and conducted between 2020 and 2022. However, due to administrative challenges specific to our country—particularly the prolonged process for obtaining IRB approval for studies involving medications, as well as the mandatory requirement for individually insuring each patient prior to interventional studies—formal approval could only be secured in July 2022, after patient enrollment had been completed. Consequently, the prospectively collected data were transformed into a manuscript following the IRB approval. Importantly, all interventions (infiltration, ESP, TAP blocks) were established clinical techniques already incorporated in routine perioperative practice, and therefore patients were not exposed to untested or experimental risks. This point has been clarified in the Materials and Methods section and highlighted as a limitation in the Discussion.

Comment 2:

The patients didn't really provide an informed consent for a study. They consented for the surgery and they consented for a nerve block.

Response:

We thank the reviewer for raising this important ethical concern. The study was prospectively planned and conducted between 2020 and 2022; however, due to local regulatory requirements and administrative delays during the COVID-19 period, formal IRB approval was obtained later (July 2022). Importantly, prior to surgery, all patients were thoroughly informed about laparoscopic cholecystectomy, general anesthesia, and the regional block techniques, and written informed consent was obtained for each of these procedures. Since infiltration, ESP, and TAP blocks are all well-established perioperative techniques, patients were not exposed to untested or experimental risks. This clarification has been added to the Materials and Methods section, and the timing of the ethics approval has also been acknowledged as a limitation in the Discussion.

Comment 3:

“The study was conducted between 2020 and 2022 and the manuscript is submitted 3 years later.”

Response:

We understand the reviewer’s concern regarding the time gap between patient enrollment and manuscript submission. While the COVID-19 pandemic partially contributed to delays in data analysis and academic processes, the main reason was that the manuscript had previously been submitted sequentially to several high-impact journals. As you may appreciate, in accordance with publication ethics, a manuscript under review cannot be submitted simultaneously to another journal, and the extended review periods substantially prolonged the overall timeline. We have clarified this context in our response and respectfully acknowledge the reviewer’s observation.

Comment 4:

“Introduction is long and the rationale is not very compelling.”

Response:
We agree and have shortened the Introduction, focusing on the most relevant background information and clearly articulating the rationale for comparing surgeon-delivered infiltration with ESP and TAP blocks.

Comment 5:

“Method: Details related to the block techniques are missing, the patient position, type of sedation, where were performed the blocks.”

Response:
We appreciate this observation. The Materials and Methods section has been updated to include these missing details:

• Patient position during ESP (prone/ lateral decubitus at T8) and TAP block (supine, subcostal approach).
• Sedation: All blocks were performed under general anesthesia after induction, prior to skin incision.
• Location and technique: Ultrasound device model, probe frequency, needle type, and volume of local anesthetic are now fully described

Comment 6:

“Table 3 reports a significant difference between the duration to perform the blocks. The difference between the time is really very small. Please confirm statistical analysis.”

Response:
We thank the reviewer for this careful observation. Upon re-checking the analysis, we realized that there was a reporting error. In fact, there is no statistically significant difference between the duration of ESP and TAP blocks (mean 6.2 vs. 6.5 minutes, p = 0.31). We have corrected this error in the Results section and revised the text accordingly.

Comment 7:

“Discussion: The clinical significance between group A-C and D are really minimum, morphine equivalent of 1.5 mg over 24 hrs.”

Response:
We appreciate this critical perspective. We have revised the Discussion to emphasize that although the absolute opioid-sparing effect was modest, the reduction in rescue analgesia requirement and the higher patient satisfaction represent clinically meaningful outcomes.

Comment 8:

“Lines 261–267; 284–291; 292–299 please delete irrelevant. 284–291 The authors should recognize that surgeons routinely performed TAP blocks.”

Response:
We have carefully revised the Discussion:

• The specified sections have been shortened or deleted as requested.
• We explicitly acknowledge that TAP blocks are increasingly performed by surgeons, especially laparoscopic-guided, as supported by recent literature.

Comment 9:

“References 23 and 35 represent a case report and a letter to the editor. Their use in the context is not really appropriate.”

Response:
We thank the reviewer for this valuable observation. We have removed References 23 and 35, which indeed represented a case report and a letter to the editor, and replaced them with higher-quality evidence. Specifically, we incorporated two robust randomized controlled trials: Reference [28] (Rahimzadeh et al., 2022), which demonstrated that a unilateral ESP block can provide effective analgesia after laparoscopic cholecystectomy due to contralateral spread, and Reference [37] (Vrsajkov et al., 2018), which confirmed the efficacy of a properly performed subcostal TAP block. These replacements strengthen the scientific validity of our discussion and directly support the statement in question.

Comment 10:

“A paragraph detailing the limitation to this study is missing.”

Response:
We thank the reviewer for pointing this out. A Limitations paragraph has been added to the Discussion, addressing:

• IRB approval timing,
• Lack of study-specific informed consent,
• Pain scores recorded only at rest (not during mobilization),
• Short 24-h follow-up period,
• Single-center design with experienced surgeons and anesthesiologists, which may limit generalizability.

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript “Surgeon-Delivered Bupivacaine Achieves Analgesic Efficacy Comparable to ESP and TAP Blocks in Laparoscopic Cholecystectomy: A Randomized Controlled Trial” addresses an important clinical question: whether surgeon-delivered local anesthetic infiltration can provide analgesia comparable to more technically complex regional techniques (ESP and TAP blocks) following laparoscopic cholecystectomy. The topic is highly relevant, particularly in settings where resources or expertise for advanced regional anesthesia are limited. The trial design is prospective, randomized, and controlled. The research question is important and timely. The study design is clearly described, and the aims are well defined. The primary and secondary outcomes are appropriately stated.

However, several points should be addressed:

1. The authors should provide a more detailed description of the anesthesia and surgical techniques applied. For all devices and medications used in the study, the manufacturer, city, and country should be specified.

2. Please clarify whether the same surgeons and anesthesiologists performed all procedures to reduce variability.

3. VAS scores were recorded only at rest. It would be valuable to include data on VAS scores during movement, as this may better reflect functional recovery.

4. Tramadol use is presented as group means. To strengthen the results, please also report the proportion of patients requiring rescue analgesia and the time to first request.

5. The discussion could be expanded to compare the present findings with previous trials or meta-analyses, highlighting the novel contribution of this study.

6. Please ensure the reference list is formatted according to the journal’s instructions.

 

 

Author Response

Response to Reviewer 3

We are sincerely grateful to Reviewer 3 for the thoughtful, incisive, and constructive feedback, which has significantly sharpened our methodology, strengthened the results presentation, and enhanced the overall rigor of the manuscript.

Comment 1:
The authors should provide a more detailed description of the anesthesia and surgical techniques applied. For all devices and medications used in the study, the manufacturer, city, and country should be specified.

Response 1:
We thank the reviewer for this important suggestion. We have now expanded the Materials and Methods section to include full details of anesthesia and surgical techniques. Manufacturer information for all medications and devices has been added as follows:

• Bupivacaine (Marcaine®, AstraZeneca, Södertälje, Sweden)
• Ultrasound device (DC-60, Mindray, Shenzhen, China)
• Needle (22-gauge, Braun, Melsungen, Germany)

Comment 2:
Please clarify whether the same surgeons and anesthesiologists performed all procedures to reduce variability.

Response 2:
We agree that this information is crucial for methodological clarity. We have added the following statement in the Materials and Methods, Section 2.4:

“All procedures were performed by the same surgeon and the same anesthesiologist to minimize variability.”

Comment 3:
VAS scores were recorded only at rest. It would be valuable to include data on VAS scores during movement, as this may better reflect functional recovery.

Response 3:
We acknowledge this limitation. Pain scores were recorded only at rest in this study. This has now been clearly stated in the Limitations section of the Discussion.

Comment 4:
Tramadol use is presented as group means. To strengthen the results, please also report the proportion of patients requiring rescue analgesia and the time to first request.

Response 4:
We appreciate this constructive comment. These data were already available in our tables. To highlight them more clearly, we have added the following sentences in the Results section:

“In addition to mean tramadol consumption, 15% of patients in Groups A–C versus 34% in Group D required rescue analgesia (Table 3). Furthermore, the mean time to first analgesic request was significantly longer in the intervention groups (~5 h) compared with the control group (3.4 h, p < 0.001; Table 2).”

 

Comment 5:
The discussion could be expanded to compare the present findings with previous trials or meta-analyses, highlighting the novel contribution of this study.

Response 5:
Thank you for this valuable suggestion. We have revised the Discussion to include more detailed comparisons with recent randomized trials and meta-analyses, emphasizing that our study supports the equivalence between surgeon-delivered infiltration and ESP/TAP blocks. For example, recent RCTs were cited to strengthen head-to-head comparisons ([10], [18], [20]), and meta-analyses supporting our findings were highlighted ([14], [15], [17], [33–35]). These additions underline the novel contribution of our study, showing that surgeon-delivered infiltration can achieve comparable efficacy to both ESP and TAP blocks.

Comment 6:
Please ensure the reference list is formatted according to the journal’s instructions.

Response 6:
We appreciate this observation. The entire reference list has been carefully checked and revised to comply with the Surgeries journal guidelines, including the addition of DOI numbers. A few entries (e.g., [17], [18], [19]) initially lacked DOI formatting or had incomplete citation details; these have been corrected according to MDPI style.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The authors corrected the manuscript according to the suggestions. but please format figures (font) and make it back and white. Correct the reference list according to the instuctions:

• Journal Articles:
  1. Author 1, A.B.; Author 2, C.D. Title of the article. Abbreviated Journal Name Year, Volume, page range.