Dr. Devaraj Acharya

Consultant in Anaesthesia & ICM

West Herts Hospitals NHS Trust

02/02/2015

• Introduction

• Anatomy – Abdominal wall

• TAP

• RSB

• Ilio-Inguinal/Ilio-Hypogastric

• Femoral/Saphenous

• Questions?

• Summary

• Abdominal surgeries – significant pain

from abdominal wall

• Simple blocks – good analgesia

• Do not relieve visceral pain

• Know your Anatomy

• Ultrasound guidance

ANTERIOR RAMI

• Pre-op assessment

• Correct patient/Site, Asepsis

• Ultrasound machine – ergonomics

• Appropriate needle

• IN PLANE, COMPLETE VISION

• Laparotomy

• Appendicectomy

• Laparoscopic surgery

• Abdominoplasty

• Caesarean section

• Operations on the abdominal wall

• Ant. Abdominal wall – ant primary rami

of T7-12 and L1

• Terminal branches – between Internal

Oblique and Transversus abdominis

• Transversus Abdominis Plane – TAP

• Unilateral analgesia – Skin, Muscles and

Parietal Peritoneum

EXTERNAL O

INTERNAL O

TRANSVERSUS A

TAP

• Supine position

• Patient asleep

• 13-6 MHz, Linear probe

• Transverse on the abdomen, at the

anterior axillary line, between the costal

margin and the iliac crest

• In Plane, TAP needle 80 mm

• Medial to lateral

• Initial 2 ml

• 20-30 ml Local anaesthetic

• Volume dependent spread

EO

IOTA

LA

• Few with USG

• Intra-peritoneal injection

• Bowel Haematoma

• Transient Femoral nerve palsy

• LA Toxicity

• Intravascular injection

• Failure

• In plane

• Complete vision – at all times

• Clear separation of fascial layers

• Frequent aspiration

• Slow Injection

• 1899 – Muscle relaxation

• Midline incisions

• Umbilical/Paraumbilical, Incisional

hernia repair

• Laparoscopic surgery

• Abdominoplasty

• Excision of urachal remnants

• The rectus sheath encloses the rectus

abdominis muscles

• Aponeuroses of the three flat abdominal

muscles; EO,IO,TA

Pubic Symphysis & Pubic Crest

Xiphisternum and 5-7 th costal

cartilages

Posterior sheath uninterrupted

Free spread

Arcuate ligament

Linea Alba – Medial

Linea semilunaris - lateral

• 13 - 6 MHz, Linear probe

• Transverse plane

• Optimum visualization of the posterior

rectus sheath

• In plane

• LA between the rectus abdominis muscle

and the posterior rectus sheath

Local anesthetic: 10 mL per side

• Peritoneal puncture

• Perforation of the bowel

• Visceral puncture

• Mesenteric vessel puncture

• Inferior epigastric vessel puncture

• Retroperitoneal haematoma

• Anaesthesia and postoperative analgesia for inguinal hernia repair

• Other inguinal surgery; analgesia following suprapubicincision

• Transducer position

Blind injections – Low success rates

•Weintraud et al Study

•62 Children land mark technique

•Observed by ultrasound

•86% IM injections

•45% Overall failure rate

Weintraud et al; II IH Blocks in children

Anesth Analg 2008;106: 89-93

• Supine

• High frequency linear probe

• Probe 5 cm cranial to the ASIS

• Iliac crest at the lateral view

• High probability 90% nerves betweein

IO and TA muscle

• In Plane

• LA between the Transversus abdominis

and internal oblique muscle planes, in

the vicinity of the two nerves

• Volume: 10 mL per side

• Indications: anterior thigh, femur, and knee surgery

• Goal: LA spread adjacent to the femoral N.

• Local anaesthetic: 10-20 mL

• Anaesthesia of the anterior and medial thigh down to the knee, variable strip of skin on the medial leg and foot

LARGEST NERVE OF LUMBAR PLEXUS - L2,3,4

• Transverse probe position

• Supine, Inguinal crease

• Lateral to the Femoral Artery

• Hyperechoic, roughly triangular or oval

• Sulcus in the iliopsoas muscle underneath

the fascia iliaca

• Depth of 2 - 4 cm

V A

COMPLICATIONS:

• Infection

• Haematoma formation

• Intravascular injection

• Nerve Injury

• LA Toxicity

• Failure

• In plane

• Patient- unable to bear weight

• Inject posterior first

• Visualise spread

• Frequent aspiration

• Slow injection

• LOW TECH block

• Anterior thigh, knee surgery, analgesia following hip and knee procedures

• Transverse, close to the femoral crease, lateral to the femoral artery

• Goal: medial-lateral spread of local anaesthetic underneath fascia iliaca

• LA: 30-40 mL of dilute local anesthetic

• Saphenous vein stripping or harvesting

• Supplementation for medial foot/ankle surgery in combination with a sciatic nerve block

• Transducer position: transverse on anteromedial mid thigh

• Goal: LA deep to the Sartorius muscle Local anesthetic: 5-10 mL

• Anaesthesia of a variable strip of skin on

the medial leg and foot

• Strictly sensory block

• Partial motor block of the vastus medialis

• Caution - unsupported ambulation after

proximal saphenous block

• Various blocks

• Multimodal analgesia

• Anatomy

• Ultra Sound advantages

• Complications