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Thoracic and abdominal field blocks
Eniyew.A
eniyewethio2023@gmail.com
For 3rd year anesthesia students
Outline
• Define thoracic spinal nerves
• Dermatome distribution of thoracic nerve
• Intercostal and thoracic-abdominal nerves
• Subcostal nerves
• Thoracic and abdominal nerve blocks
• Complication and caution
• Thoracic spinal nerves are 12 pair spinal
nerves originates from spinal cord
• It innervate the muscles, joints, skin, and
pleuroperitoneal lining of the thoracic and
abdominal walls.
• Thoracic nerves would be
– Enter through intercostal space and innervates
thoracic wall intercostal nerves
– Enter through intercostal space and innervates
thoracic wall partly and abdominal wall
thoracoabdominal nerves
– Never enter to intercostal space and pass to
abdominal wall and innervates under the area
subcostal nerves
Intercostal nerves
• Intercostal nerves are the anterior rami of the
upper 11 thoracic spinal nerves
• Each intercostal nerve enters the neurovascular
plane posteriorly and gives a collateral branch
that supplies the intercostal muscles of the
space
Thoracic nerve
• The first thoracic nerve(T1) give 50% supply to
brachial plexus
• It gives the first cutaneous branch of anterior chest wall
and intercostal space
• The second thoracic nerve(T2) is long thoracic nerve
and innervates intercostal space, the cutaneous chest
wall and cutaneous on the axilla
• It is called intercostobrachial nerve
Intercostal nerves
• Intercostal nerve T3-T5 are nerves remain in the
intercostal spaces throughout their course
• ICN T6-T11 are nerves initially travel in the intercostal
spaces, but then cross the costal margin and terminate
in the abdominal wall.
• These intercostal nerves called the thoracoabdominal
nerves.
ICN
• ICN travel along the inferior margin of the rib
of the corresponding number
• They are located between the deepest
(transverse thoracis muscle) and intermediate
layer (internal intercostals muscle) of muscle
• Arranged in neurovascular bundle from top to
bottom as nerve, artery and vein(VAN)
Thoracoabdominal (Intercostals T6 to
T11) Nerves
• As typical intercostal nerves but across the costal
margin into the muscles of the anterior abdominal wall.
• They innervate
– Transverse abdominis
– Internal abdominal oblique
– External abdominal oblique
– Rectus abdominis muscles.
• In addition, they innervate the skin of the anterior wall
in a metameric manner from the xiphoid process to the
umbilicus.
Subcostal Nerve
• These nerve never enters an intercostal space.
• It travels through the abdominal wall,
terminating between the umbilicus and the
pubic symphysis.
• It innervates muscle and skin along its course
• Its 50% give for lumbar plexus and form
iliohypogastric and ilioinguinal
Subcostal nerves
• The ventral ramus of T12 forms the subcostal
nerve.
• This nerve travels entirely in the abdominal
wall.
Blocks of the Thorax and Abdomen
Intercostal nerve block
Indication
• Rib fracture
• Unilateral chest and upper abdomen operation
• For better respiratory function
• Chest tube procedure and analgesia
• Breast surgery
CONTRAINDICATIONS
• Disorders of coagulation although this is not
an absolute contraindication
Local infection
• lack of expertise and resuscitating equipment
• Any metastasis lesion
Land mark
• Mid thoracic vertebral line
• Angle of the ribs
• Internal intercostal muscle
Preparation
• All resuscitative equipment and drugs
• IV lines
• Sedation and analgesia
EQUIPMENT
– Needle: Single shot: 20- to 22-gauge 4- to 5-cm needle
(adults)
– Catheter placement: 18- to 20-gauge Tuohy needle (adults)
– Syringe and needle for local infiltration
– Syringe with extension tubing
– Sterilizing materials and drapes, marking pen, pillow,
portable fluoroscope (for neurolytic blocks)
Technique
• Ribs can be counted starting from the twelfth
rib, or from the seventh rib (inferior tip of the
scapula).
• Mark the spinous process and a distance of 6–
8 cm from the mid-line at the lower ribs and 4–
7 cm from the midline at the upper ribs),
corresponding to the angles of the ribs would
be needle insertion site
• Inferior borders of the ribs to be blocked are
palpated and marked
• The needle entry sites are infiltrated with
lidocaine 1%–2%.
• A site of entry is well placed when a needle
introduced through it at 20 degrees cephalad
(sagittal plane)
• The needle is advanced until it contacts the rib at
a depth of less than 1 cm in most patients.
• A small amount of local anesthetic may be
injected to anesthetize the periosteum
• The needle is now advanced farther a few mm,
while maintaining the 20-degree tilt angle cephald
• A subtle “give” or “pop” of the fascia of the
internal intercostal muscle may be felt,
especially if a short-beveled needle is used
• At this point, on negative aspiration for blood,
3–5 mL of local anesthetic is injected
Ultrasound guide ICNB
• It can be access through out plane or in plain
technique
• The best way of understanding is identifying
of
– Upper and lower ribs
– External intercostal and internal intercostal
muscles
• 3-5 ml of local anesthetics should be injected
at the site
• Additional upper and lower of one intercostal
space block gives adequate block
Complication
• Local anesthetic toxicity
• Pneumothorax
• peritoneum and abdominal viscera injury
Paravertebral block
The block of this technique has a direct effect
of the local anesthetic
 The somatic and sympathetic nerves in the TPVS
Extension into the intercostal space laterally
The epidural space medially.
It produce ipsilateral somatic and sensory
block
TPVB
• Some degree of ipsilateral spread of local
anesthetic toward the epidural space probably
occurs in the majority of the patients
• It gives greater distribution of anesthesia than
occurs with paravertebral spread alone.
• TPVB can be done single injection large
volume or multiple injection
Indication
• Anesthesia
• Postoperative analgesia
• Chronic pain management
• Miscellaneous
Land mark
• Find C7 and T5
• Mark 2.5 cm lateral from midline of spinous
process
• Insert at the marked site
• Try to appreciate transverse process
Technique
• Loss of resistance
• Nerve stimulator
• Ultrasound Guided
Loss of resistance technique
• The classic technique
• The skin and underlying tissue is infiltrated with
lidocaine 1%
• The block needle is inserted perpendicular to the
skin in all planes to contact the transverse process
of the vertebra.
• The transverse process will be appreciated 3-4cm
• The needle should not pass beyond 1.5cm after hit
of transverse process
• Plural puncture may be happened with out hit of
transverse process
• To minimize this complication, the block needle
should initially be inserted only to a maximum
depth of 4 cm at thoracic and 5 cm at cervical and
lumbar levels
• “pop” may be appreciated as the needle
traverses the superior costotransverse process
Complication
• Relatively low and varies from 2.6%–5%.
• These include
– vascular puncture (3.8%)
– hypotension (4.6%),
– pleural puncture (1.1%)
– pneumothorax (0.5%
Abdominal field block
Regional blocks of the anterior abdominal wall
can significantly help with intraoperative and
postoperative analgesia for abdominal surgical
pain.
Abdominal wall nerve blocks, includes the
ilioinguinal, iliohypogastric, rectus sheath, and
transversus abdominis plane (TAP) blocks
Anatomy of abdominal wall
Anterior abdominal wall: Its is the area
surrounded
superiorly by costal margin and xiphoid process,
inferiorly by inguinal ligament and pelvic bone,
and
laterally by mid-axillary line.
layers
From superficial to deep:
 Skin
 Subcutaneous tissue
 External oblique muscle (EO)
 Internal Oblique muscle (IO)
 Transversus abdominis muscle (TA)
 Extra peritoneal fat and
 Parietal peritoneum.
 EO: It is the superficial layer originating from mid
and lower ribs and with fibers sloping forward and
downward to the iliac crest, forming an aponeurosis
below that level.
 IO: The internal oblique attaches to the lateral two-
thirds of the inguinal ligament and anterior iliac crest
with its fibers sloping forwards and upwards.
 TA: The transversus abdominis muscle is the innermost
layer with fibers running transverse towards the
midline.
Rectus abdominis muscle:
This paired muscle is lying medially and
separated in the midline by the linea alba.
It is wide and thin superiorly, increasing in
thickness inferiorly.
The majority of this muscle is enclosed by the
rectus sheath.
Innervation of anterior abd. wall
 The skin, muscles and the parietal peritoneum of the
anterior abdominal wall are innervated by the anterior
rami of T7 – L1 spinal nerves.
 This thoracolumbar nerves passes through a fascial plane
which is found in between the IO and TA muscles
 At the costal margins the thoracic nerves (T7 – T11) enters
the TAP plain.
 The skin Superior to the umbilicus is supplied by nerves
from T7 – T9.
 T10 supply umbilicus.
The skin inferior to the umbilicus is supplied
by nerves from T11, the cutaneous branch of
the subcostal T12, the iliohypogastric nerve,
and the ilioinguinal nerve.
The iliohypogastric nerve:
Originates from the L1 nerve root and supplies
the sensory innervations to the skin over the
inguinal region.
Runs in the plane between the IO and TA muscles
(i.e. TAP) and later pierces the IO to lie between
this muscle and the EO before giving off
cutaneous branches.
The ilioinguinal nerve:
Originates from the L1 nerve root.
 Found inferior to the iliohypogastric nerve
perforating the IO muscle at the level of the iliac
crest running medially in a deeper plane than the
iliohypogastric nerve.
Innervates the inguinal hernia sac, medial
aspect of the thigh, anterior scrotum and labia.
Clinical use
Regional analgesia of the abdominal wall can
provide good analgesia for a variety of surgical
operations especially when used as part of a
multimodal technique.
Clinical use
Haemodynamic effects are minimal as spread
of local anaesthetic is limited to the abdominal
wall.
They have a role in decreasing analgesic
requirements
These blocks only provide analgesia of the
abdominal wall, not to the abdominal viscera.
Clinical use
 They can be a useful addition in ambulatory surgery to
improve the quality of analgesia and to reduce postoperative
opioid requirements.
 Obesity may make both the landmark and ultrasound
approaches more challenging.
 These blocks are most commonly performed as a ‘single
shot’ technique.
 Catheter techniques are also possible when more prolonged
analgesia is required but are not currently in widespread use
TAP Block
 It is a volume block: By placing a large volume of
local anaesthetic in the fascial plane between the IO
and TA which contains the nerves from T7 to L1.
 Aim: to block the sensory nerves of the anterior
abdominal wall before they pierce the musculature to
innervate the anterior abdomen.
 Onset: taking up to 60 min to reach maximal effect.
: place at the start of surgery to give adequate time.
Techniques
Approach: Landmark technique or with the aid
of ultrasound.
Landmark technique: The TAP is accessed from
the lumbar ‘triangle of Petit’, bounded anteriorly
by the EO, posteriorly by the lattisimus dorsi, and
inferiorly by the iliac crest.
A cadaveric anatomical study has noted a large
variability in the position of the ‘triangle of Petit’
and can be difficult in the obese patient.
Triangle of petit
Steps:
Identify the triangle of petit just anterior to the
lattisimus dorsi muscle.
Technique cont..
Steps:
A blunt tipped, short-bevelled needle is placed
perpendicular to the skin immediately
cephalad to the iliac crest.
The needle is advanced through the external
oblique and a first ‘pop’ sensation is felt when
the needle enters the plane between the EO and
IO.
Technique ….
 Further advancement of the needle results in a second ‘pop’
after passing through the internal oblique fascia into the
TAP.
 At this point, after careful aspiration, 20 ml of long-acting
local anaesthetic is injected in 5 ml aliquots.
 For incisions at or crossing the midline, a bilateral TAP
block is indicated.
 Ultrasound can also be used to identify the muscle layers
and ensure accurate placement of local anaesthetic.
TAP Block advantage
Advantage:
 Provides analgesia for the abdominal wall but not for the
visceral contents and is ideally used as part of a multimodal
approach to analgesia.
 Less risk of systemic side-effects.
 Good postoperative analgesia and a decrease in morphine
requirements for up to 48 h.
 Can be used for a variety of surgeries including open
colorectal surgery, retropubic prostatectomy, abdominal
hysterectomy, and Caesarean section.
Ultrasound guided TAP block
• This is more effective than blind technique
• It shows local anesthesia distribution
• Shows definite line of transversabdominal
plane
• Show vascular structures
Limitation:
It does not provide analgesia for visceral
contents.
Limited analgesic effect for incisions above
the umbilicus.
Difficult in obese patients.
Complications :
 Block failure, intravascular injection, or
injection into the peritoneal cavity, with
associated risks of damage to bowel and other
abdominal viscera.
Rectus sheath block
 It is used for analgesia after umbilical or incisional
hernia repairs and other midline surgical incisions.
 The aim of this technique is to block the terminal
branches of the 9th 10th, and 11th intercostal nerves
 These nerves run in between the IO and TA muscles to
penetrate the posterior wall of the rectus abdominis
muscle and end in an anterior cutaneous branch
supplying the skin of the umbilical area.
RSB
The most widely described approach is a blind
technique,
It is passing of the needle through anterior rectus
sheath and rectus abdominis muscle and injecting
the local anaesthetic on the posterior wall of the
rectus sheath.
With the patient lying supine, a point is identified
2–3 cm from midline, slightly cephalad to the
umbilicus at the apex of bulge of the rectus
abdominis muscle.
RSB
 A short- beveled 5 cm needle, directed at right angles to the
skin, is initially passed through the skin until the resistance
of the anterior sheath can be felt.
 A definitive ‘pop’ should be felt as it passes through the EO.
 The needle is advanced further until the firm resistance of
the posterior wall is felt( scratch ) and injection of 15–20 ml
local anaesthetic is made in 5 ml aliquots.
 The procedure is repeated on the opposite side of the
midline.
RSB
 With the posterior wall of the rectus sheath lying superficial
to
the peritoneal cavity, needle misplacement may lead to
complications.
 Injection into the peritoneal cavity will lead to failure of the
block and may risk bowel perforation or puncture of blood
vessels, usually the inferior epigastric vessels.
 In addition to incorrect placement of local anaesthetic,
incomplete block may result from anatomical variance, as in
up to 30% of the population, the anterior cutaneous branch
of the nerves are formed before the rectus sheath and so do
not penetrate the posterior wall of the rectus sheath
Ultrasound guided rectus sheath block
• Its safe effective and easy to perform and it
increase its efficacy while it done though US
• It blocks anterior terminal nerves befor it
penetrate and gives its cutaneous branching
• It is possible to done though in plain or out
plain technique
• 15-20 ml of local anesthetics should be
injected at each level
Ilioinguinal and iliohypogastric
nerve blocks
 Blocking the iliohypogastric and ilioinguinal nerves can provide
good analgesia for most operations in the inguinal region.
 These blocks may be very effective in reducing the need for opioids,
and in pediatric patients, they have been found to be as effective as
caudal blocks, even though a higher failure rate.
 The classical approach uses a landmark technique which blocks the
nerves once they have separated into the different facial layers.
 The injection is made at a point 2 cm medial and 2 cm cephalad to
the anterior superior iliac spine using a short-bevelled needle
advanced perpendicular to the skin.
Ilioinguinal and iliohypogastric
nerve blocks
 After an initial pop sensation as the needle penetrates the
external oblique aponeurosis, around 5 ml of local
anaesthetic is injected.
 The needle is then inserted deeper until a second pop is felt
penetrating the internal oblique, to lie between it and the
transversus abdominis muscle.
 Further 5-8 ml of local anaesthetic is injected to block the
iliohypogastric nerve.
 A fan-wise subcutaneous injection of 3– 5 ml can be made
to block any remaining sensory supply from the intercostals
and subcostal nerve.
Ilioinguinal and iliohypogastric nerve
blocks
• This approach has a success rate of 70%
• It has failure rate due to the local anaesthetic
being placed more than one anatomical layer
away from the nerves.
Ilioinguinal and iliohypogastric
nerve blocks
It is worth noting that if used as the sole technique
for inguinal herniorrhaphy.
The sac containing the peritoneum should be
infiltrated with local anesthetic by the surgeon as
it is supplied by the abdominal visceral nerves.
Ultrasound guided block of IH&II
• For this nerve block transverse in plane veiw
gives better sono anatomy
• It is best effective though US because it has
anatomical variation in most of the time
• 10-15 ml of local anesthetic is enough for adult
• For childrens 0.15ml/kg is recommended
Ilioinguinal and iliohypogastric
nerve blocks
 The placement of the needle and local anesthetic too
deep may result in block failure and inadvertent
femoral nerve block.
 Injection into the peritoneal cavity will lead to failure
of the block and may risk bowel perforation.
 Puncture of blood vessels, usually the inferior
epigastric vessels, has been described. The use of
ultrasound guidance may potentially reduce the
incidence of these complications
Assignment
1-10 TE block
11-20 caudal block
21-30 lumbar plexus block
31-40 sciatic nerve blocks
Submission date April 1/2016
Submit through: eniyewethio20232gmail.com

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Thoracic and abdominal field blocks.pptx

  • 1. Thoracic and abdominal field blocks Eniyew.A eniyewethio2023@gmail.com For 3rd year anesthesia students
  • 2. Outline • Define thoracic spinal nerves • Dermatome distribution of thoracic nerve • Intercostal and thoracic-abdominal nerves • Subcostal nerves • Thoracic and abdominal nerve blocks • Complication and caution
  • 3. • Thoracic spinal nerves are 12 pair spinal nerves originates from spinal cord • It innervate the muscles, joints, skin, and pleuroperitoneal lining of the thoracic and abdominal walls.
  • 4.
  • 5. • Thoracic nerves would be – Enter through intercostal space and innervates thoracic wall intercostal nerves – Enter through intercostal space and innervates thoracic wall partly and abdominal wall thoracoabdominal nerves – Never enter to intercostal space and pass to abdominal wall and innervates under the area subcostal nerves
  • 6. Intercostal nerves • Intercostal nerves are the anterior rami of the upper 11 thoracic spinal nerves • Each intercostal nerve enters the neurovascular plane posteriorly and gives a collateral branch that supplies the intercostal muscles of the space
  • 7. Thoracic nerve • The first thoracic nerve(T1) give 50% supply to brachial plexus • It gives the first cutaneous branch of anterior chest wall and intercostal space • The second thoracic nerve(T2) is long thoracic nerve and innervates intercostal space, the cutaneous chest wall and cutaneous on the axilla • It is called intercostobrachial nerve
  • 8. Intercostal nerves • Intercostal nerve T3-T5 are nerves remain in the intercostal spaces throughout their course • ICN T6-T11 are nerves initially travel in the intercostal spaces, but then cross the costal margin and terminate in the abdominal wall. • These intercostal nerves called the thoracoabdominal nerves.
  • 9. ICN • ICN travel along the inferior margin of the rib of the corresponding number • They are located between the deepest (transverse thoracis muscle) and intermediate layer (internal intercostals muscle) of muscle • Arranged in neurovascular bundle from top to bottom as nerve, artery and vein(VAN)
  • 10. Thoracoabdominal (Intercostals T6 to T11) Nerves • As typical intercostal nerves but across the costal margin into the muscles of the anterior abdominal wall. • They innervate – Transverse abdominis – Internal abdominal oblique – External abdominal oblique – Rectus abdominis muscles. • In addition, they innervate the skin of the anterior wall in a metameric manner from the xiphoid process to the umbilicus.
  • 11. Subcostal Nerve • These nerve never enters an intercostal space. • It travels through the abdominal wall, terminating between the umbilicus and the pubic symphysis. • It innervates muscle and skin along its course • Its 50% give for lumbar plexus and form iliohypogastric and ilioinguinal
  • 12. Subcostal nerves • The ventral ramus of T12 forms the subcostal nerve. • This nerve travels entirely in the abdominal wall.
  • 13. Blocks of the Thorax and Abdomen Intercostal nerve block Indication • Rib fracture • Unilateral chest and upper abdomen operation • For better respiratory function • Chest tube procedure and analgesia • Breast surgery
  • 14. CONTRAINDICATIONS • Disorders of coagulation although this is not an absolute contraindication Local infection • lack of expertise and resuscitating equipment • Any metastasis lesion
  • 15. Land mark • Mid thoracic vertebral line • Angle of the ribs • Internal intercostal muscle
  • 16.
  • 17. Preparation • All resuscitative equipment and drugs • IV lines • Sedation and analgesia EQUIPMENT – Needle: Single shot: 20- to 22-gauge 4- to 5-cm needle (adults) – Catheter placement: 18- to 20-gauge Tuohy needle (adults) – Syringe and needle for local infiltration – Syringe with extension tubing – Sterilizing materials and drapes, marking pen, pillow, portable fluoroscope (for neurolytic blocks)
  • 18. Technique • Ribs can be counted starting from the twelfth rib, or from the seventh rib (inferior tip of the scapula). • Mark the spinous process and a distance of 6– 8 cm from the mid-line at the lower ribs and 4– 7 cm from the midline at the upper ribs), corresponding to the angles of the ribs would be needle insertion site
  • 19. • Inferior borders of the ribs to be blocked are palpated and marked • The needle entry sites are infiltrated with lidocaine 1%–2%. • A site of entry is well placed when a needle introduced through it at 20 degrees cephalad (sagittal plane)
  • 20. • The needle is advanced until it contacts the rib at a depth of less than 1 cm in most patients. • A small amount of local anesthetic may be injected to anesthetize the periosteum • The needle is now advanced farther a few mm, while maintaining the 20-degree tilt angle cephald
  • 21. • A subtle “give” or “pop” of the fascia of the internal intercostal muscle may be felt, especially if a short-beveled needle is used • At this point, on negative aspiration for blood, 3–5 mL of local anesthetic is injected
  • 22. Ultrasound guide ICNB • It can be access through out plane or in plain technique • The best way of understanding is identifying of – Upper and lower ribs – External intercostal and internal intercostal muscles
  • 23.
  • 24.
  • 25. • 3-5 ml of local anesthetics should be injected at the site • Additional upper and lower of one intercostal space block gives adequate block
  • 26. Complication • Local anesthetic toxicity • Pneumothorax • peritoneum and abdominal viscera injury
  • 27. Paravertebral block The block of this technique has a direct effect of the local anesthetic  The somatic and sympathetic nerves in the TPVS Extension into the intercostal space laterally The epidural space medially. It produce ipsilateral somatic and sensory block
  • 28. TPVB • Some degree of ipsilateral spread of local anesthetic toward the epidural space probably occurs in the majority of the patients • It gives greater distribution of anesthesia than occurs with paravertebral spread alone. • TPVB can be done single injection large volume or multiple injection
  • 29. Indication • Anesthesia • Postoperative analgesia • Chronic pain management • Miscellaneous
  • 30. Land mark • Find C7 and T5 • Mark 2.5 cm lateral from midline of spinous process • Insert at the marked site • Try to appreciate transverse process
  • 31.
  • 32. Technique • Loss of resistance • Nerve stimulator • Ultrasound Guided
  • 33. Loss of resistance technique • The classic technique • The skin and underlying tissue is infiltrated with lidocaine 1% • The block needle is inserted perpendicular to the skin in all planes to contact the transverse process of the vertebra. • The transverse process will be appreciated 3-4cm
  • 34. • The needle should not pass beyond 1.5cm after hit of transverse process • Plural puncture may be happened with out hit of transverse process • To minimize this complication, the block needle should initially be inserted only to a maximum depth of 4 cm at thoracic and 5 cm at cervical and lumbar levels
  • 35. • “pop” may be appreciated as the needle traverses the superior costotransverse process
  • 36. Complication • Relatively low and varies from 2.6%–5%. • These include – vascular puncture (3.8%) – hypotension (4.6%), – pleural puncture (1.1%) – pneumothorax (0.5%
  • 37. Abdominal field block Regional blocks of the anterior abdominal wall can significantly help with intraoperative and postoperative analgesia for abdominal surgical pain. Abdominal wall nerve blocks, includes the ilioinguinal, iliohypogastric, rectus sheath, and transversus abdominis plane (TAP) blocks
  • 38.
  • 39. Anatomy of abdominal wall Anterior abdominal wall: Its is the area surrounded superiorly by costal margin and xiphoid process, inferiorly by inguinal ligament and pelvic bone, and laterally by mid-axillary line.
  • 40. layers From superficial to deep:  Skin  Subcutaneous tissue  External oblique muscle (EO)  Internal Oblique muscle (IO)  Transversus abdominis muscle (TA)  Extra peritoneal fat and  Parietal peritoneum.
  • 41.  EO: It is the superficial layer originating from mid and lower ribs and with fibers sloping forward and downward to the iliac crest, forming an aponeurosis below that level.  IO: The internal oblique attaches to the lateral two- thirds of the inguinal ligament and anterior iliac crest with its fibers sloping forwards and upwards.  TA: The transversus abdominis muscle is the innermost layer with fibers running transverse towards the midline.
  • 42. Rectus abdominis muscle: This paired muscle is lying medially and separated in the midline by the linea alba. It is wide and thin superiorly, increasing in thickness inferiorly. The majority of this muscle is enclosed by the rectus sheath.
  • 43. Innervation of anterior abd. wall  The skin, muscles and the parietal peritoneum of the anterior abdominal wall are innervated by the anterior rami of T7 – L1 spinal nerves.  This thoracolumbar nerves passes through a fascial plane which is found in between the IO and TA muscles  At the costal margins the thoracic nerves (T7 – T11) enters the TAP plain.  The skin Superior to the umbilicus is supplied by nerves from T7 – T9.  T10 supply umbilicus.
  • 44. The skin inferior to the umbilicus is supplied by nerves from T11, the cutaneous branch of the subcostal T12, the iliohypogastric nerve, and the ilioinguinal nerve.
  • 45. The iliohypogastric nerve: Originates from the L1 nerve root and supplies the sensory innervations to the skin over the inguinal region. Runs in the plane between the IO and TA muscles (i.e. TAP) and later pierces the IO to lie between this muscle and the EO before giving off cutaneous branches.
  • 46. The ilioinguinal nerve: Originates from the L1 nerve root.  Found inferior to the iliohypogastric nerve perforating the IO muscle at the level of the iliac crest running medially in a deeper plane than the iliohypogastric nerve. Innervates the inguinal hernia sac, medial aspect of the thigh, anterior scrotum and labia.
  • 47.
  • 48.
  • 49. Clinical use Regional analgesia of the abdominal wall can provide good analgesia for a variety of surgical operations especially when used as part of a multimodal technique.
  • 50.
  • 51. Clinical use Haemodynamic effects are minimal as spread of local anaesthetic is limited to the abdominal wall. They have a role in decreasing analgesic requirements These blocks only provide analgesia of the abdominal wall, not to the abdominal viscera.
  • 52. Clinical use  They can be a useful addition in ambulatory surgery to improve the quality of analgesia and to reduce postoperative opioid requirements.  Obesity may make both the landmark and ultrasound approaches more challenging.  These blocks are most commonly performed as a ‘single shot’ technique.  Catheter techniques are also possible when more prolonged analgesia is required but are not currently in widespread use
  • 53. TAP Block  It is a volume block: By placing a large volume of local anaesthetic in the fascial plane between the IO and TA which contains the nerves from T7 to L1.  Aim: to block the sensory nerves of the anterior abdominal wall before they pierce the musculature to innervate the anterior abdomen.  Onset: taking up to 60 min to reach maximal effect. : place at the start of surgery to give adequate time.
  • 54. Techniques Approach: Landmark technique or with the aid of ultrasound. Landmark technique: The TAP is accessed from the lumbar ‘triangle of Petit’, bounded anteriorly by the EO, posteriorly by the lattisimus dorsi, and inferiorly by the iliac crest. A cadaveric anatomical study has noted a large variability in the position of the ‘triangle of Petit’ and can be difficult in the obese patient.
  • 56. Steps: Identify the triangle of petit just anterior to the lattisimus dorsi muscle.
  • 57. Technique cont.. Steps: A blunt tipped, short-bevelled needle is placed perpendicular to the skin immediately cephalad to the iliac crest. The needle is advanced through the external oblique and a first ‘pop’ sensation is felt when the needle enters the plane between the EO and IO.
  • 58.
  • 59. Technique ….  Further advancement of the needle results in a second ‘pop’ after passing through the internal oblique fascia into the TAP.  At this point, after careful aspiration, 20 ml of long-acting local anaesthetic is injected in 5 ml aliquots.  For incisions at or crossing the midline, a bilateral TAP block is indicated.  Ultrasound can also be used to identify the muscle layers and ensure accurate placement of local anaesthetic.
  • 60. TAP Block advantage Advantage:  Provides analgesia for the abdominal wall but not for the visceral contents and is ideally used as part of a multimodal approach to analgesia.  Less risk of systemic side-effects.  Good postoperative analgesia and a decrease in morphine requirements for up to 48 h.  Can be used for a variety of surgeries including open colorectal surgery, retropubic prostatectomy, abdominal hysterectomy, and Caesarean section.
  • 61. Ultrasound guided TAP block • This is more effective than blind technique • It shows local anesthesia distribution • Shows definite line of transversabdominal plane • Show vascular structures
  • 62.
  • 63.
  • 64. Limitation: It does not provide analgesia for visceral contents. Limited analgesic effect for incisions above the umbilicus. Difficult in obese patients.
  • 65. Complications :  Block failure, intravascular injection, or injection into the peritoneal cavity, with associated risks of damage to bowel and other abdominal viscera.
  • 66. Rectus sheath block  It is used for analgesia after umbilical or incisional hernia repairs and other midline surgical incisions.  The aim of this technique is to block the terminal branches of the 9th 10th, and 11th intercostal nerves  These nerves run in between the IO and TA muscles to penetrate the posterior wall of the rectus abdominis muscle and end in an anterior cutaneous branch supplying the skin of the umbilical area.
  • 67. RSB The most widely described approach is a blind technique, It is passing of the needle through anterior rectus sheath and rectus abdominis muscle and injecting the local anaesthetic on the posterior wall of the rectus sheath. With the patient lying supine, a point is identified 2–3 cm from midline, slightly cephalad to the umbilicus at the apex of bulge of the rectus abdominis muscle.
  • 68. RSB  A short- beveled 5 cm needle, directed at right angles to the skin, is initially passed through the skin until the resistance of the anterior sheath can be felt.  A definitive ‘pop’ should be felt as it passes through the EO.  The needle is advanced further until the firm resistance of the posterior wall is felt( scratch ) and injection of 15–20 ml local anaesthetic is made in 5 ml aliquots.  The procedure is repeated on the opposite side of the midline.
  • 69. RSB  With the posterior wall of the rectus sheath lying superficial to the peritoneal cavity, needle misplacement may lead to complications.  Injection into the peritoneal cavity will lead to failure of the block and may risk bowel perforation or puncture of blood vessels, usually the inferior epigastric vessels.  In addition to incorrect placement of local anaesthetic, incomplete block may result from anatomical variance, as in up to 30% of the population, the anterior cutaneous branch of the nerves are formed before the rectus sheath and so do not penetrate the posterior wall of the rectus sheath
  • 70. Ultrasound guided rectus sheath block • Its safe effective and easy to perform and it increase its efficacy while it done though US • It blocks anterior terminal nerves befor it penetrate and gives its cutaneous branching • It is possible to done though in plain or out plain technique
  • 71.
  • 72. • 15-20 ml of local anesthetics should be injected at each level
  • 73.
  • 74. Ilioinguinal and iliohypogastric nerve blocks  Blocking the iliohypogastric and ilioinguinal nerves can provide good analgesia for most operations in the inguinal region.  These blocks may be very effective in reducing the need for opioids, and in pediatric patients, they have been found to be as effective as caudal blocks, even though a higher failure rate.  The classical approach uses a landmark technique which blocks the nerves once they have separated into the different facial layers.  The injection is made at a point 2 cm medial and 2 cm cephalad to the anterior superior iliac spine using a short-bevelled needle advanced perpendicular to the skin.
  • 75. Ilioinguinal and iliohypogastric nerve blocks  After an initial pop sensation as the needle penetrates the external oblique aponeurosis, around 5 ml of local anaesthetic is injected.  The needle is then inserted deeper until a second pop is felt penetrating the internal oblique, to lie between it and the transversus abdominis muscle.  Further 5-8 ml of local anaesthetic is injected to block the iliohypogastric nerve.  A fan-wise subcutaneous injection of 3– 5 ml can be made to block any remaining sensory supply from the intercostals and subcostal nerve.
  • 76. Ilioinguinal and iliohypogastric nerve blocks • This approach has a success rate of 70% • It has failure rate due to the local anaesthetic being placed more than one anatomical layer away from the nerves.
  • 77. Ilioinguinal and iliohypogastric nerve blocks It is worth noting that if used as the sole technique for inguinal herniorrhaphy. The sac containing the peritoneum should be infiltrated with local anesthetic by the surgeon as it is supplied by the abdominal visceral nerves.
  • 78. Ultrasound guided block of IH&II • For this nerve block transverse in plane veiw gives better sono anatomy • It is best effective though US because it has anatomical variation in most of the time • 10-15 ml of local anesthetic is enough for adult • For childrens 0.15ml/kg is recommended
  • 79.
  • 80.
  • 81. Ilioinguinal and iliohypogastric nerve blocks  The placement of the needle and local anesthetic too deep may result in block failure and inadvertent femoral nerve block.  Injection into the peritoneal cavity will lead to failure of the block and may risk bowel perforation.  Puncture of blood vessels, usually the inferior epigastric vessels, has been described. The use of ultrasound guidance may potentially reduce the incidence of these complications
  • 82.
  • 83. Assignment 1-10 TE block 11-20 caudal block 21-30 lumbar plexus block 31-40 sciatic nerve blocks Submission date April 1/2016 Submit through: eniyewethio20232gmail.com