Lower abdominal surgeries (e.g., inguinal/ventral hernia repair, gynecologic procedures, appendicular surgeries, and selected pelvic laparoscopic operations) are frequently performed under GA, but neuraxial RA remains an important alternative. The anesthetic technique can influence the postoperative trajectory through multiple pathways—analgesic quality, opioid exposure, autonomic stability, gastrointestinal recovery, pulmonary mechanics, and patient-reported quality of recovery.¹–³

PONV and opioid-related symptoms (sedation, ileus, pruritus) remain leading causes of delayed discharge and patient dissatisfaction after abdominal procedures.¹ Multimodal strategies—antiemetic prophylaxis, opioid-sparing analgesia, and early mobilization—are central to modern perioperative care.¹,³,⁴ ERAS guidelines consistently emphasize early mobilization, early feeding, and minimization of perioperative stress responses, and highlight the role of effective regional techniques (where appropriate) for opioid sparing and enhanced recovery.³,⁴

Neuraxial anesthesia (spinal/epidural) offers dense intraoperative analgesia, decreases immediate postoperative pain, and can reduce early opioid requirement—mechanisms that may translate into less PONV and faster mobilization.²,⁶ Meta-analytic evidence suggests neuraxial techniques (alone or combined with GA) may reduce pulmonary complications and resource use in broad surgical populations, though benefits vary with procedure type, patient risk, and study design.²,⁷ In lower abdominal and laparoscopic settings, RA has been explored as a primary technique (with or without sedation), and observational and comparative studies report potential advantages such as less nausea, earlier bowel function, and shorter length of stay in selected patients.⁸–¹⁰ However, neuraxial techniques may also introduce specific adverse events—hypotension, urinary retention, post-dural puncture headache, or failed/patchy block—sometimes necessitating conversion to GA.

Current decision-making is therefore nuanced: GA offers airway control, predictable immobility, and broad applicability, while RA may offer superior early recovery outcomes in carefully chosen cases and experienced hands.¹,²,⁷ Additionally, adjuvant regional techniques combined with GA (e.g., TAP block) are increasingly used to achieve opioid-sparing benefits even when GA is required.¹¹,¹² Systematic reviews of TAP block demonstrate reductions in pain scores and opioid consumption after abdominal surgery, supporting its role when neuraxial anesthesia is contraindicated or undesired.¹¹

Patient-reported recovery metrics such as the QoR-15 provide a validated, practical assessment of multidimensional recovery beyond traditional endpoints like pain scores or length of stay.⁵ Given persistent variability in anesthesia practice for lower abdominal surgeries, comparative studies evaluating QoR-15 alongside objective recovery parameters can better inform evidence-based selection of GA vs RA within ERAS-aligned pathways.³–⁵

Aim: To compare postoperative recovery outcomes between GA and RA in lower abdominal surgeries using QoR-15 and key clinical recovery indicators.

Prospective comparative (two-arm) study conducted in a tertiary care teaching hospital over 12 months after institutional ethics approval. Written informed consent obtained from all participants. Study population Adult patients planned for elective lower abdominal surgeries (open/laparoscopic): inguinal/ventral hernia repair, elective appendicular surgery, gynecologic lower abdominal procedures, and similar operations expected to last ≤120 minutes. Inclusion criteria 1. Age 18–70 years 2. ASA physical status I–III 3. Elective lower abdominal surgery (open or laparoscopic) 4. Ability to complete QoR-15 questionnaire (local language/English) 5. Consent for participation Exclusion criteria 1. Refusal for neuraxial anesthesia (for RA arm) 2. Contraindications to neuraxial block: coagulopathy/anticoagulation not compliant with safety guidance, infection at puncture site, severe hypovolemia, raised intracranial pressure, severe aortic stenosis, or allergy to local anesthetics¹³ 3. Severe cognitive impairment/psychiatric illness precluding QoR-15 4. Emergency surgeries 5. Chronic opioid use (>3 months) or opioid dependence 6. BMI > 40 kg/m² (anticipated technical difficulty and altered recovery profile) Group allocation and anesthesia technique Patients were allocated to: • GA group: Standard induction (propofol/opioid/neuromuscular blocker), airway secured, maintenance with volatile or TIVA per institutional protocol; multimodal analgesia and antiemetic prophylaxis applied. • RA group: Spinal anesthesia (hyperbaric bupivacaine ± intrathecal opioid) or combined spinal–epidural as per anesthesiologist discretion; light sedation permitted. Hemodynamic management (fluid co-loading, vasopressors as needed). Perioperative analgesia and PONV prophylaxis Both groups received scheduled paracetamol and NSAID (unless contraindicated). Rescue opioids titrated in PACU/ward. PONV prophylaxis followed consensus-based risk-stratified approach (e.g., ondansetron ± dexamethasone).¹ Outcomes • Primary outcome: QoR-15 score at 24 h postoperatively.⁵ • Secondary outcomes: Pain scores (VAS) at 2, 6, 12, 24 h; total opioid consumption in first 24 h (morphine equivalents); incidence of PONV within 24 h; time to first ambulation and oral intake; time to readiness for discharge; complications (hypotension, urinary retention, respiratory events). Statistical analysis Continuous variables expressed as mean ± SD or median (IQR); categorical variables as n (%). Student’s t-test/Mann–Whitney U test used for continuous variables; Chi-square/Fisher’s exact test for categorical variables. p < 0.05 considered statistically significant.

Table 1. Baseline characteristics

Groups were comparable at baseline (no statistically significant differences).

Table 2. Surgical profile

Case-mix and operative duration were similar, reducing confounding from surgical complexity.

Table 3. Pain scores (VAS 0–10) and opioid requirement (first 24 h)

RA provided superior early analgesia with significant opioid sparing—key drivers of faster functional recovery and fewer opioid-related side effects.

Table 4. PONV and related recovery barriers (0–24 h)

Lower PONV and less sedation in RA aligns with consensus guidance that minimizing opioid exposure reduces PONV burden and improves patient experience.¹

Table 5. Functional recovery endpoints

RA was associated with earlier ambulation and feeding—core ERAS targets—and shorter discharge readiness time.³,⁴

Table 6. QoR-15 and adverse events

RA improved patient-reported recovery (QoR-15) substantially. Trade-offs included higher transient hypotension and urinary retention—well-recognized neuraxial effects—highlighting the need for patient selection and perioperative protocols.

This study demonstrates that RA (neuraxial anesthesia) for lower abdominal surgeries is associated with superior early recovery compared with GA, reflected by higher QoR-15 scores and improved functional endpoints. Patient-centered recovery measures are increasingly valued because they incorporate comfort, independence, and emotional state, not merely pain intensity. The QoR-15 instrument provides a validated and feasible metric for routine clinical research and quality improvement.⁵

The analgesic advantage observed with RA—significantly lower VAS scores and reduced opioid consumption—likely mediated downstream improvements in PONV and mobilization. Consensus PONV guidance emphasizes risk reduction through multimodal analgesia and opioid minimization; accordingly, the lower PONV and reduced rescue antiemetic use in the RA group align with established perioperative pathways.¹ ERAS recommendations for abdominal surgery similarly prioritize early mobilization and early enteral intake, supported by optimal analgesia and reduced opioid exposure.³,⁴ The earlier ambulation and earlier oral intake in the RA group are therefore clinically meaningful and consistent with ERAS goals.

Our findings are concordant with broader perioperative evidence showing neuraxial techniques may reduce resource utilization and improve certain postoperative outcomes versus GA, though the magnitude and consistency vary by setting. A systematic review and meta-analysis comparing neuraxial (alone or combined) with GA across major truncal and lower limb surgery found associations with fewer pulmonary complications and shorter length of stay, particularly in observational data, suggesting potential recovery benefits beyond analgesia.⁷ Likewise, comparative-effectiveness work in other surgical fields has reported reduced length of stay with neuraxial techniques, reinforcing a plausible generalizable recovery advantage.¹⁴

In lower abdominal surgery specifically, neuraxial anesthesia has been explored as a primary anesthetic approach in hernia and laparoscopic abdominal procedures. A randomized trial in laparoscopic inguinal hernia repair reported favorable perioperative profiles for spinal anesthesia in selected patients.⁸ A meta-analysis in laparoscopic cholecystectomy also reported potential postoperative benefits (including PONV and pain-related outcomes) with spinal anesthesia in appropriate contexts.⁹ More recent clinical datasets in gynecologic laparoscopic surgery under spinal anesthesia further support feasibility and highlight recovery advantages, while emphasizing careful technique and readiness to convert to GA if necessary.¹⁰,¹⁵ These reports align with the present study’s finding of improved early recovery, while acknowledging that neuraxial anesthesia is not universally suitable for all laparoscopic or prolonged procedures.

Importantly, RA was associated with higher rates of transient hypotension and urinary retention—known neuraxial adverse effects—consistent with physiological sympathetic blockade and bladder dysfunction. These trade-offs underscore the importance of protocolized fluid/vasopressor strategies, bladder management, and patient selection. Additionally, in settings where GA is necessary, adjuvant regional techniques such as TAP block can offer opioid-sparing analgesia; systematic reviews demonstrate TAP block reduces pain scores and opioid consumption after abdominal surgery.¹¹ This suggests a practical continuum: RA as primary technique when appropriate, or regional adjuncts to improve recovery when GA is unavoidable.

Overall, our results support the integration of RA into ERAS-oriented lower abdominal surgical care pathways, balancing recovery benefits against manageable neuraxial risks.³,⁴

Regional (neuraxial) anesthesia for lower abdominal surgeries improved early postoperative recovery compared with general anesthesia, demonstrated by higher QoR-15 scores, better pain control, reduced opioid requirement, lower PONV, and earlier ambulation and feeding. Transient hypotension and urinary retention were more frequent with RA but were clinically manageable. Anesthesia choice should be individualized based on surgical requirements, contraindications, patient preference, and institutional expertise, with ERAS principles guiding opioid-sparing recovery optimization.

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