TAP block .pptx

ultrasound guided TAP block for beginners with sonoanatomical description

1. R adhwan Hazem Alkhashab C onsultant anaesthesia & ICU 2022 TAP block TRANSVERSUS ABDOMINIS PLANE BLOCk

2. Introduction Abdominal field blocks have been extensively used for a variety of surgical procedures for many years. They are simple to perform and have a good safety profile. Technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall .

3. Indication of TAP block This block is indicated for any l ower abdominal surgery including A  unilateral block  is used for a one-sided procedure, such as appendectomy, cholecystectomy, nephrectomy, and renal transplant. Bilateral blocks  are used for midline and transverse abdominal incisions, such as ventral hernia repair, umbilical hernia repair, exploratory laparotomies, colostomy closures, cesarean delivery, hysterectomy, radical retropubic prostatectomy, bariatric surgeries, inguinal hernia repair, and laparoscopic surgeries.

4. Anatomy Innervation of the anterolateral abdominal wall arises from the anterior rami of spinal nerves T7 to L1. These include the intercostal nerves (T7-T11), the subcostal nerve (T12), and the iliohypogastric and ilioinguinal nerves (L1 ). The anterior divisions of T7-T11 continue from the intercostal space to enter the abdominal wall between the internal oblique and 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.

5. Midway 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 iliohypogastric nerve (L1) divides between the internal oblique and transversus abdominis near the iliac crest into lateral and anterior cutaneous branches, the former supplying part of the skin of the gluteal region while the latter supplies the hypogastric region.

6. The ilioinguinal nerve (L1) communicates with the iliohypogastric nerve between the internal oblique and transversus abdominis near the anterior part of the iliac crest. It supplies the upper and medial part of the thigh and part of the skin covering the genitalia. The transversus abdominis is the deepest layer, and below is the peritoneum. The skin, muscles, and peritoneum of the anterior abdominal wall are innervated by the lower 6 thoracic nerves and the first intercostals nerve.

7. TAP us view

8. Technique Patient Position: Supine. Probe : Ultrasound machine with a linear transducer. (Sometimes a curvilinear transducer might be needed, if the patient is obese or if performing a posterior approach) Probe Position: Transverse or transverse oblique between the margin of the 12th rib and superior iliac spine. Needle : 22-gauge blunt needle (5-10 cm) for single injection. 18-gauge Tuohy needle (5-10 cm) for continuous infusions. Local Anesthetic: Bupivaciane 0.25% (20-30 mL), ropivacaine 0.2% (20-30 mL).

9. Technique: This block may be performed before or following induction of general or spinal anesthesia. The patient needs to be lying supine. An aseptic technique is advocated using a no- touch technique, an appropriate cleaning solution, and a sterile cover for the ultrasound probe .  The ultrasound probe is positioned horizontally on the skin just above the iliac crest in the midaxillary line. The muscle layers are identified. We prefer to use a peripheral nerve block needle because it allows "distant" injection by your assistant while you remain in control of ultrasound probe and needle. A 50-mm needle is usually sufficient . We use an in-plane approach inserting the needle posteriorly and directing anteriorly. The needle is followed under direct vision as it passes through the muscle layers. Tip lies between the internal oblique and transversus abdomenus muscles.

10. Ultrasound- guided TAP The ultrasound probe is placed in a transverse plane to the lateral abdominal wall in the midaxillary line, between the lower costal margin and iliac crest . 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. Upon reaching the plane, 2 ml of saline is injected to confirm correct needle position after which 20 ml of local anaesthetic solution is injected. The transversus abdominis plane is visualized expanding with the injection ( appears as a hypoechoic space).

11.  Injection of the local anesthetic must be seen to ensure correct placement. It is very characteristic to see the layer expanding in an ellipsoid way. We use of 20 mL of 0.5% ropivacaine resulting in a block from T8 to the symphysis pubis.

12. If prolonged analgesia is required beyond the duration of a single shot of local anaesthetic , a catheter can be introduced into the transversus abdominis plane through a touhy needle. After opening up the plane with 2 ml of saline, the catheter is introduced around 3 cm beyond the needle tip. . Position is verified by injecting the local anaesthetic bolus (20ml). An infusion of a dilute local anaesthetic is started at a rate of 7 to 10 ml per hour.

13. TAP needling

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