While the study of Urmale Kusse et al. [1] makes a valuable contribution to the topic, I believe that several aspects warrant further discussion.

First, the sample size was based on a randomised controlled trial investigating postoperative analgesia in patients undergoing laparoscopic cholecystectomy [2]. The trial compared rectus sheath block with rectus sheath block and erector spinae plane block, which differs from the comparison in the current study. Thus, using this reference to calculate the sample size may not be appropriate. Additionally, the blinding in this study presents challenges, as the puncture sites for erector spinae plane block and rectus sheath block are located on the back and abdomen, respectively, compromising blinding for both patients and postoperative caregivers. The inclusion of placebo or sham blocks would have improved blinding.

Second, regarding the evaluation of postoperative analgesic outcomes, the study measured total opioid consumption and converted the 24-h opioid use into standardised morphine milligram equivalents (MME). The results showed mean (SD) opioid consumption of 3.5 (8.7) MME in the erector spinae plane block group vs. 8.2 (2.8) MME in the rectus sheath block group (p = 0.003). However, the minimum clinically important difference for 24-h postoperative opioid consumption is 10 MME [3], indicating that the observed difference between the two groups did not meet this threshold. I believe this may be attributed to the analgesic protocol employed, which involved administering medication based on pain assessment rather than patient-control. This approach may have resulted in delayed opioid administration, potentially compromising pain control, as a significant proportion of patients experienced moderate to severe pain (NRS 4–7) postoperatively. This could be related to the constraints typical of low- and middle-income settings.

Finally, I have concerns regarding the timeline of the nerve block procedures. Both blocks were performed while patients were anaesthetised. While rectus sheath block can be administered with the patient in a supine position, erector spinae plane block requires the patient to be in the lateral decubitus position. This necessitates repositioning the anaesthetised patient from supine to lateral and then back to supine, which is complex and time-consuming. However, the reported mean (SD) anaesthesia duration of 164 (16) min for the erector spinae plane block group and 159 (14) min for the rectus sheath block group; and the surgery duration of 150 (14) min for the erector spinae plane block group and 143 (18) min for the rectus sheath block group, do not indicate a longer non-surgical anaesthesia time for the erector spinae plane block group.

虽然 Urmale Kusse 等人 [1] 的研究对这个话题做出了宝贵的贡献，但我认为有几个方面值得进一步讨论。

首先，样本量基于一项随机对照试验，该试验调查了腹腔镜胆囊切除术患者的术后镇痛情况 [2]。该试验将直肌鞘阻滞与竖直肌鞘阻滞和竖脊肌平面阻滞进行了比较，这与当前研究中的比较不同。因此，使用此参考来计算样本量可能不合适。此外，本研究中的盲法带来了挑战，因为竖脊肌平面阻滞和直肌鞘阻滞的穿刺部位分别位于背部和腹部，从而影响了患者和术后护理人员的盲法。纳入安慰剂或假阻滞将改善盲法。

其次，关于术后镇痛结局的评估，该研究测量了阿片类药物的总消耗量，并将 24 小时的阿片类药物使用量转换为标准化吗啡毫克当量 （MME）。结果显示竖脊肌平面阻滞组的平均 （SD） 阿片类药物消耗量为 3.5 （8.7） MME，而直肌鞘阻滞组为 8.2 （2.8） MME （p = 0.003）。然而，术后 24 小时阿片类药物消耗量的最小临床重要差异为 10 MME [3]，表明观察到的两组之间的差异未达到该阈值。我相信这可能归因于所采用的镇痛方案，其中涉及根据疼痛评估而不是患者控制进行给药。这种方法可能导致阿片类药物给药延迟，从而可能影响疼痛控制，因为很大一部分患者在术后出现中度至重度疼痛 （NRS 4-7）。这可能与低收入和中等收入国家的典型制约因素有关。

最后，我对神经阻滞手术的时间表感到担忧。两个块都是在患者麻醉时进行的。虽然直肌鞘阻滞可以在患者仰卧位的情况下进行，但竖脊肌平面阻滞需要患者处于侧卧位。这需要将被麻醉的患者从仰卧位重新定位到侧位，然后再回到仰卧位，这既复杂又耗时。然而，据报道，竖脊肌平面阻滞组的平均 （SD） 麻醉持续时间为 164 （16） 分钟，直肌鞘阻滞组为 159 （14） 分钟;竖脊肌平面阻滞组的手术持续时间为 150 （14） 分钟，直肌鞘阻滞组为 143 （18） 分钟，并不表示竖脊肌平面阻滞组的非手术麻醉时间较长。