2. When?
Have you ever faced a situation where
you can’t give epidural to your patient
who is going for laparotomy?
1. Patient refusal
2. In emergency
3. Deranged haemostasis
4. Abnormal anatomy
5. Infection
3. 1. First described as a landmark-guided
technique involving needle insertion at the
triangle of Petit (TOP).
Area bounded by:
A. – latissimus dorsi (LD) muscle posteriorly,
B. – external oblique (EO) muscle anteriorly and
C. – iliac crest inferiorly (the base of the triangle).
D. Best approach at the mid-axillary line
4.
5. What can you use it for?
Pain relief for:
1. – Abdominal surgery
2. – Obstetric and Gynaecology
6. Good postoperative analgesia
for a variety of procedures
McDonnell JG, O'Donnell B, Curley G, et al. “The analgesic
efficacy of transversus abdominis plane block after abdominal
surgery: a prospective randomized controlled trial” Anesth
Analg 2007;104(1):193.
Carney J, McDonnell JG, Ochana A, et al. “The transversus
abdominis plane block provides effective postoperative
analgesia in patients undergoing total abdominal hysterectomy”
Anesth Analg 2008;107(6):2056.
7. McDonnell JG, Curley G, Carney J, et al.”The analgesic
efficacy of transversus abdominis plane block after
cesarean delivery: a randomized controlled trial”
Anesth Analg 2008;106(1):186.
8. More recently, ultrasoundguided
techniques of TAP block
Hebbard P, Fujiwara Y, Shibata Y, et al. Ultrasoundguided
transversus abdominis plane (TAP) block. Anaesth Intensive
Care 2007;35(4):616.
– Walter EJ, Smith P, Albertyn R, et al. Ultrasound
imaging for transversus abdominis blocks. Anaesthesia
2008;63(2):211.
9. – Tran TM, Ivanusic JJ, Hebbard P, et al.
Determination of spread of injectate after
ultrasound-guided transversus abdominis plane
block: a cadaveric study. Br J
Anaesth2009;102(1):123.
10. Is it for upper Abdominal surgery?
The subcostal TAP block, has also been described; it is
designed to provide more reliable coverage of the
upper abdominal wall.
(Hebbard P. Subcostal transversus abdominis plane
block under ultrasound guidance. Anesth Analg
2008;106(2):674)
11. A meta-analysis on the clinical effectiveness
of transversus abdominis plane block
TAP block
1. reduces the need for postoperative opioid use
2. it increases the time first request for further
analgesia
3. it provides more effective pain relief
4. and it reduces opioid-associated side effects.
12. The transversus abdominis plane block: a
valuable option for postoperative analgesia? A
topical review.
A systematic search of the literature identified a total of seven
randomized clinical trials investigating the effect of TAP block
on post-operative pain
including a total of 364 patients, of whom 180 received TAP
blockade
The surgical procedures included large bowel resection with a
midline abdominal incision, caesarean delivery via the
Pfannenstiel incision, abdominal hysterectomy via a transverse
lower abdominal wall incision, open appendectomy and
laparoscopic cholecystectomy..
13. 1.Overall, the results are encouraging and most studies
have demonstrated clinically significant reductions of
post-operative opioid requirements and pain, as well
as some effects on opioid-related side effects
(sedation and post-operative nausea and vomiting).
2. Further studies are warranted to support the findings
of the primary published trials and to establish general
recommendations for the use of a TAP block.
14. Transversus abdominis plane block: a
systematic review.
Eighteen intermediate- to good-quality randomized
trials that included diverse surgical procedures were
identified. Improved analgesia was noted in patients
undergoing laparotomy for colorectal surgery,
laparoscopic cholecystectomy, and open and
laparoscopic appendectomy.
15. There was a trend toward superior analgesic
outcomes when 15 mL of local anesthetic or more was
used per side compared with lesser volumes.
All 5 trials investigating TAP block performed in the
triangle of Petit and 7 of 12 trials performed along the
midaxillary line demonstrated some analgesic
advantages.
16. Eight of 9 trials using preincisional TAP block and 4 of
9 with postincisional block revealed better analgesic
outcomes.
Although the majority of trials reviewed suggest
superior early pain control, we were unable to
definitively identify the surgical procedures, dosing,
techniques, and timing that provide optimal analgesia
following TAP block
17. This review suggests that our understanding of the
TAP block and its role in contemporary practice
remains limited.
25. 1. This intermuscular plane is called the
transversus abdominis plane (TAP).
2. Injection of local anesthetic within the
TAP can therefore potentially provide
unilateral analgesia to the skin,muscles,
and parietal peritoneum of the anterior
abdominal wall from T7 to L1.
26. BLOCK TECHNIQUE
A needle is inserted perpendicular to all planes,
looking for a tactile endpoint of two pops.
1. The first pop indicates penetration of the
external oblique fascia and entry into the plane
between external and internal oblique muscles.
2. The second pop signifies entry into the TAP
plane between internal oblique and
transversus abdominis muscles.
27. Scanning Technique
1. The ultrasound guided TAP block is
considered a BASIC skill level block.
2. It is relatively simple to identify the plane
between the internal oblique and transversus
abdominis muscles.
28. 1. The patient is placed in a supine position and
the abdomen is exposed between the costal
margin and the iliac crest.
2. A linear, high-frequency transducer is
recommended for this block, as the relevant
anatomical structures are relatively shallow.
29. The transducer is placed in an axial
(transverse) plane, above the iliac
crest, and in the region of the anterior
axillary line.
31. The peritoneal cavity may be identified by the
peristaltic movements of bowel loops.
32. What if there is difficulty in identifying
the three muscle layers?
1. It is helpful to start the scan in the
2. midline over the rectus abdominis
Muscle.the rectus abdominis muscle is
the only muscular layer in the midline
33. 1.The rectus a abdominis muscle tapers laterally
to a junction that leads to the three muscle
layers
2.The TAP are easily identified at this
point, and can be traced laterally to
the region above the iliac crest where
the block is to be performed
34. Needle Insertion
1.An 80-120 mm 22 G short beveled block
needle is inserted in-plane with the transducer,
in an anterior-posterior direction
2.Alternatively, a spinal needle or Tuohy needle
may be used and connected to the syringe via
short extension tubing.
36. What to do for patients with
aprotuberant abdomen?
37. Tips
1.It is important to deposit local anesthetic deep to the
fascial layer that separates the internal oblique and
transversus abdominis Muscles
2.Accurate placement of the needle tip may be facilitated
by injection of a small amount of fluid (1-2 mL of saline
to “hydro dissect” the appropriate plane.
38. Injection above the fascial plane
separating the internal oblique and
transversus abdominis muscles
39. Tips
If the needle tip is intramuscular instead of in the
correct plane, a pattern of fluid spread
consistent with intramuscular fluid injection will
be seen instead.
40. Does
1.A total of 20-30 mL of local anesthetic (e.g.,
Bupivacaine or Chirocaine 0.5 to 0.25%) is
injected into this plane on each side.
2.The maximum recommended dose of local
anaesthetic should not be exceeded.
41. Tips
1.During local anesthetic injection, it is advisable to scan
the abdomen cephalad and caudad to determine the
extent of longitudinal spread.
2.Medial and lateral scanning will determine the extent
of horizontal spread.
43. Conclusion and Future
1. Easy technique to perform
2. Simple and safe
3. Can be performed pre or post op
4. Can be repeated if failed (max. dose)
5. More studies need to be done
