To compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy.

A prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial.

A single tertiary academic medical center.

126 adults aged 18–65 years undergoing elective laparoscopic cholecystectomy.

Patients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion.

The primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of −6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events.

124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117–127) for lidocaine, 124 (119–126) for ESPB, and 112 (108–117) for placebo. Lidocaine was non-inferior to ESPB (median difference  –1, 97.5% CI: −4 to ∞). Both lidocaine (median difference 9, 95% CI: 6–12, P < 0.001) and ESPB (median difference 10, 95% CI: 7–13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred.

For patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways.