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Background and Aims Uncontrolled hypothyroidism presents unique anaesthetic challenges, including risk of cardiovascular instability, altered drug metabolism, and delayed emergence. Anaesthetic strategies that minimise opioid use can mitigate these risks and enhance recovery. We describe the successful use of bilateral erector spinae plane (ESP) block to facilitate opioid-sparing general anaesthesia in a patient with markedly elevated thyroid-stimulating hormone (TSH) undergoing elective laparoscopic cholecystectomy.Methods A 44-year-old woman with hypothyroidism (TSH of 34 mIU/L on day of surgery), anaemia, and depression was scheduled for laparoscopic cholecystectomy. She had resumed levothyroxine 10 weeks back for high TSH of 86 mIU/L, yet remained clinically euthyroid. After multidisciplinary assessment, the decision was made to proceed with general anaesthesia incorporating an opioid-sparing approach. Induction included fentanyl (75 mcg), propofol (150 mg), and rocuronium (50 mg), with maintenance using sevoflurane and an additional 25 mcg of fentanyl. Bilateral ESP blocks were performed at T7 under ultrasound guidance using 20 ml of 0.25% levobupivacaine on each side.Results Intra operatively, the patient was stable with no haemodynamic instability or delayed emergence. Postoperative analgesia was effective with regular paracetamol and ibuprofen, and no additional opioids were required. Wessex pain scores remained low (mild at 1, 8, and 24 hours). The patient was monitored overnight due to endocrine history and discharged the following day without complications.Conclusions This case supports the use of ESP block to reduce perioperative opioid requirements in patients with uncontrolled hypothyroidism. In combination with multidisciplinary planning and multimodal analgesia, regional anaesthesia techniques like ESP block can optimise safety and recovery in endocrine-compromised patients.