Comment on: Laparoscopic-assisted transversus abdominis plane block versus port-site infiltration in appendicectomy: multicentre randomized clinical trial

Correspondence to: Claus Anders Bertelsen (email: claus.anders.bertelsen@regionh.dk)

Department of Surgery

Copenhagen University Hospital – North Zealand

Dyrehavevej 29

3400 Hillerød

Denmark

BJS, https://doi.org/10.1093/bjs/znaf257, published 09 January 2026

We read with interest Daly et al.’s1 study on laparoscopically-assisted transversus abdominis plane blocks (L-TAP) for laparoscopic appendectomy (LA). While L-TAP is a simple, non-inferior alternative to ultrasound-guided blocks,2, 3 with similar cutaneous sensory block areas,4, 5 this study raises several methodological concerns.

A monthly screening rate of only 12 patients from a catchment of 700,000 questions the study's generalisability. Furthermore, the lack of surgeon blinding may have introduced performance bias; complete blinding remains feasible even in acute surgical settings.

The authors analysed Numeric Rating Scale (NRS) data using parametric methods (t-tests, linear regression), reporting mean ± SD. This violates fundamental assumptions: NRS represents ordinal, not continuous data, and pain scores are characteristically skewed. The control group mean of 2.4 (SD 1.74) implies a 95% confidence interval lower bound of 2.4−1.96×1.74=−1.0, which is impossible for a 0–10 scale. This confirms a violation of normality, necessitating medians, interquartile ranges, and non-parametric analysis.

Imputing a Visual Analogue Scale (VAS) score of 0 for early discharges introduces systematic bias; these should be treated as missing data and handled via sensitivity analyses.

Investigating analgesic interventions in inherently low-pain procedures (control group mean NRS 2.7 at 3 hours) creates substantial signal-to-noise ratio challenges. While the 1.7-point time-weighted difference might exceed minimal clinically important difference thresholds, the clinical meaningfulness remains questionable when baseline pain is mild and benefits disappear by 24 hours (p=0.125).

Future research should focus on procedures with clinically relevant pain levels or employ adaptive designs allocating interventions preferentially to patients experiencing moderate-to-severe pain (NRS≥4), thereby increasing the signal-to-noise ratio and better reflecting clinical practice.

Finally, the intervention is inadequately described to allow replication; detailed procedural accounts are essential for reproducibility.

While acknowledging this contribution, methodologically rigorous trials with appropriate statistical handling are required before establishing L-TAP as standard care for LA.