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TRANSVERSUS

ABDOMINIS PLANE

(TAP) BLOCK 

Dr.Muhammed Muhsin

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……………..

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  INTRODUCTION

•  Abdominal field blocks have been around for a long time and

have been extensively used as they are mostly technically

unchallenging.

• They, however, provide limited analgesic fields, hence multiple

injections are usually required. Traditionally these blocks have

blind endpoints pops! making their success unpredictable.

• The description of the landmark technique for performing

transversus abdominis plane TA"! block advocated a single

entry point, the triangle of "etit, to access number ofabdominal wall nerves hence providing more widespread

analgesia . #! $ore recently,ultrasound guided TA" block has

been described with promises of better locali%ation and

deposition of the local anesthetic with better accuracy

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  ANATOMY

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  &nnervation of the anterolateral abdominal wall arises from

anterior rami of spinal n&nnervation erves T' to (#.These

include the intercostal nerves T')T##!, the subcostal nerve

T#*!, and the iliohypogastric and ilioinguinal nerves.

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ANATOMY……….

• The anterior divisions of T')T## continue from intercostal

space to enter the abdominal wall between the internal obliqueand transversus abdominis muscles until they reach the rectus

abdominis, which they perforate and supply, ending as anterior

cutaneous branches supplying the skin of the front of the

abdomen.•  $idway in their course they pierce the external oblique muscle

giving off the lateral cutaneous branch which divides into

anterior and posterior branches that supply the external

oblique muscle and latissmus dorsi respectively.

• The anterior branch of T#* communicates with the

iliohypogastric nerve and gives a branch to the pyramidalis.

• &ts lateral cutaneous branch perforates the internal and

external oblique muscles and descends over the iliac crest and

supplies sensation to the front part of the gluteal region.

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ANATOMY …….

• The iliohypogastric nerve (#! divides between the internal

oblique and transversus abdominis near the iliac crest intolateral and anterior cutaneous branches, the former supplying

part of the skin of the gluteal region while the latter supplies

the hypogastric region.

• The ilioinguinal nerve (#! communicates with theiliohypogastric nerve between the internal oblique and

transversus abdominis near the anterior part of the iliac crest.

&t supplies the upper and medial part of the thigh and part of

skin over genitalia.

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  ADVANTAGES

• Provides excellent intro! nd !ost o! nl"esi#decrese o!ioid re$%ire&ent# llo' !tients to (ret)e

nd co%") &ore co&*ort(l+# nd *cilitte erl+

&o(ili,tion - disc)r"e

•  Is !rtic%lrl+ %se*%l *or cses ')en n e!id%rl is

contrindicted or re*%sed

• Cn (e !er*or&ed %nilterll+ e.". !!endicecto&+/# or

(ilterll+ ')en t)e incision crosses t)e &idline e.".P*nnenstiel/

• Sin"le in0ection or ct)eter 

•Resc%e nl"esi

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 An+ s%r"er+ involves lo'er (do&inl 'll

 (o'el s%r"er+

 !!endicecto&+

 cesren section

 )erni re!ir  %&(ilicl s%r"er+

 "+necolo"icl s%r"er+

TAP (loc1 2 Indictions

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  34OC5 TEC6NI7UE

• The aim of a TA" block is to deposit local anaesthetic in the

plane between the internal oblique and transversus

abdominis muscles targeting the spinal nerves in this plane.

The innervation to abdominal skin, muscles and parietal

peritoneum will be interrupted.• &f surgery traverses the peritoneal cavity, dull visceral pain

from spasm or inflammation following surgical insult! will

still be experienced.

• The block can be performed blind or +ltrasound guided

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  3lind tec)ni$%e

• The point of entry for the blind TA" block is the lumbar

T&A-(/ 01 "/T&T

• This is situated between the lower costal margin and iliac

crest. &t is bound anteriorly by the external oblique muscle and

posteriorly by the latissmis dorsi. This technique relies on

feeling double pops as the needle traverses the externaloblique and internal oblique muscles.

•  A blunt needle will make the loss of resistance more

appreciable

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.

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  U4TRASOUND GUIDED TAP

• The ultrasound probe is placed in a transverse plane to the

lateral abdominal wall in the midaxillary line,between thelower costal margin and iliac crest.

•  The use of ultrasound allows for accurate deposition of the

localanaesthetic in the correct neurovascular plane.

•&f prolonged analgesia is required beyond the duration of asingle shot of local anaesthetic , a catheter can be

introduced into the transversus abdominis plane through a

touhy needle. After opening up the plane with * ml of saline,

the catheter is introduced around 2 cm beyond the needle

tip . "osition is verified by injecting the local anaesthetic

bolus *3ml!. An infusion of a dilute local anaesthetic is

started at a rate of ' to #3 ml per hour.

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Per*or&in" t)e %ltrso%nd2"%ided (loc1

•   /4+&/$/-T5• +ltrasound machine with a high frequency probe #3)6

• $7%!

• )+ltrasound probe cover 

• )Antiseptic for skin disinfection

• )5terile ultrasound gel

• )-eedle8 63 mm or 93 mm needle

• )*3ml needle and injection tubing

• )*3 to 23 ml local anaesthetic any local anaesthetic

• concentration , this block relies on local anaesthetic spread

• rather than concentration,i.e. is volume dependant.!

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• :hilst the patient is in the supine position, a high frequency

ultrasound probe is placed transverse to the abdominal wall

between the costal margin and iliac crest.

• The image produced shows from above downwards! skin,

subcutaneous tissue, fat, external oblique, internal

• oblique, transversus abdominis. The peritoneum and bowel

loops may also be visuali%ed deeper to the muscles.

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• . The needle is introduced in plane of the ultrasound probe

directly under the probe and advanced until it reaches the

plane between the internal oblique and transversus

abdominis muscles. The needle can also be introduced afew centimeters medial to the probe a distance equivalent

to the depth of the plane as viewed on the ultrasound

image!.

  +pon reaching the plane, * ml of saline is injected toconfirm correct needle position after which *3 ml of local

anaesthetic solution is injected. The transversus abdominis

plane is visuali%ed expanding with the injection appears

as a hypoechoic space!

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  COM4ICATIONS

 Mostl+ seen in 3lind tec)ni$%e e".

(loc1 *il%re

 intrvsc%lr in0ection

 in0ection into !eritonel cvit+# 'it) ssocited ris1s

o* d&"e to (o'el nd ot)er (do&inl viscer

Intr)e!tic in0ection

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  ANY 7UESTIONS8

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