Anatomy of Abdominal Wall - NESRAnesra.co.uk/files/techniques/Abdo Wall iNerve 09.pdf · Anatomy of Abdominal Wall Nat Haslam Consultant Anaesthetist City Hospitals Sunderland Sunday,

Anatomy of Abdominal Wall

Nat HaslamConsultant Anaesthetist

City Hospitals Sunderland

Sunday, 1 November 2009


Abdo Wall, Cross sectional anatomy


Rectus Abdominus


Internal Oblique


Transversus Abdominis


Lattissimus Dorsi


Ultrasound Guided TAP



TAP Blocks


TAP Blocks


Skin / Sub-Q

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum

Skin / Subcut

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum


Skin / Sub-Q

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum


Plane

Skin / Subcut

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum


Skin / Sub-Q

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum


Plane

Skin / Subcut

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum


Plane



Too superficial Too deep

TAP-tastic !

TAP Blocks – correct plane?


Discrepancies in height of block and duration of action of anterior US guided technique compared with Mc Donnell’s original “2-

pop technique”


TAP Blocks


External oblique m.Internal oblique m.

Transversus abdominis m.

Rectus m.

TAP Blocks

Original technique:

2 “pops” through triangle of Petit in mid-axillary line


External oblique m.Internal oblique m.

Transversus abdominis m.

Rectus m.

TAP Blocks

Original technique:

2 “pops” through triangle of Petit in mid-axillary line



At T4


At T4



Ilio-Inguinal - above ASIS

EO

IO

TA

PC

Lateral


Ilio-Inguinal at ASIS

ASISEOA

IO

TA



Rectus Sheath Blocks


Rectus Abdominus



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Subcut

Rectus m.

Peritoneal cavity

Posterior fascia

Fascia transversalis

Peritoneum

Local inserted

•Deep to Muscle

•Superficial to fascia

Rectus Sheath Block


Medial Lateral

SubQ

Rectus m.

Vessels

Peritoneal cavity

Posterior fascia PeritoneumFascia transversalis

Rectus Sheath Block Medial Lateral

Intraperitoneal Bowel contents

Peritoneum

Rectus muscle and sheath




Intercostal Nerve Blocks


Intercostal block anatomy



Intercostal blocks


Intercostal blocks

Will need many levels of blocks, each with a risk of pneumothorax and local anaesthetic toxicity!


Intercostal blocks

Will need many levels of blocks, each with a risk of pneumothorax and local anaesthetic toxicity!

Not practical as we would need to turn patient onto the side, wasting time and effort!


Intercostal block sonoanatomy


Summary


Summary

Abdominal wall blocks play a useful role to deliver multi-modal analgesia


Summary


Many are old techniques, revived and modified


Summary


Many are old techniques, revived and modified The new TAP block (green) evolution.......!



Subcostal TAP Block

Peter Hebbard April 2007 on extending TAP Blocks

Page 3 Heartweb.com.au


Is a Subcostal TAP Necessary?


The “Emerald” TAP?



Higher spread to T4 because performed more posterior in Petit’s triangle?




Longer duration of action because of sympathetic spread?





More predictable done with a “2-pop-technique”?





More predictable done with a “2-pop-technique”?

A type of “paravertebral block”?




Abdominal Pain

Cutaneous – well defined, superficial skin injury, short duration

Somatic – dull, poorly localised of longer duration

Visceral – from body organs, aching and difficult to localise, long duration, may be a “referred” pain

Aim for a comfortable patient as part of Multi-modal Analgesia strategy




Topics to be covered

1. Advantages of U/Sd2. How do these blocks differ?3. Overview of abdominal anatomy 4. Ultrasound visualisation of anatomy



?


Intercostal nerve blocks

Nerve supply to most of the abdomen Easy visualisation of neurovascular bundle Approach may need a short axis approach Reduced local anaesthetic volumes definitely

possible with ultrasound


Intercostal nerve anatomy


Intercostal nerve block performance


How do abdominal blocks differ from other areas of USGPRA

No fear of damaging a nerve plexus Blocks often done with patient asleep Blocks done for pain relief not for perfoming

surgery per se Pain relief not absolute and part of a Multi-

Modal Analgesia regime


Rectus Sheath Blocks

Problems with blind (“pops and clicks”) techniques

Advantages of ultrasound visualisation Increased popularity of laparoscopic surgery Relieves cutan/somatic pain, may still have the

“visceral component”



Rectus Sheath Block

• Poor correlation between depth and weight/height/BSA– Short distance between skin & peritoneum

• Median 8mm (5-13.8mm)

• Small volumes (0.1ml/kg 2.5mg/ml LevoB)– Early discharge, so limited effect duration details– No problems reported post-discharge at follow-up

• Spread NOT limited by anterior tendinous intersections


Ilio-Inguinal Block

• Reduced dose with US technique– 0.2 vs 0.3ml/kg 2.5mg/ml Levo-bupivacaine.

• Reduced intra-op analgesia requirement– 4% vs 26% (Fentanyl)

• Reduced post-op analgesia requirement– 6% vs 40% (Paracetamol)


Top Tips

Medial to lateral approach possibly safer At 0,2mls/Kg Levo-bupivacaine - reduced

volumes spares you a femoral nerve block Aim to “miss” the neurovascular bundle


Professor Adrian Bösenberg

“It is not often that a new block is described”!


Transversus Abdominus Plane Blocks (TAP)

Described by John Mc Donnell & Co - 05 Need to understand the Anatomy Advantages of TAP ultrasound guided The approach using Ultrasound


TAP Blocks

New approach to blockade of the anterior abdominal wall

Blocks the anterior & lateral branches of intercostal nerves (height reached T9)

Still use “Pops” as markers, now adapted for ultrasound guided blockade

Local Anaesthetic spreads in a posterior direction with time


TAP Blocks

• 32 bowel resections• 2 “pop” technique (landmark)• Reduction in VAS at all time points throughout

24hr period• ¼ 24hr morphine requirements

– 21.9mg vs 80.4mg

The Analgesic Efficacy of Tranversus Abdominis Plane Block After Abdominal Surgery

McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG

Anesth Analg 2007; 104(1): 193-7


Technique for TAP Block

Transversely orientated probe Between iliac crest & inferior costal margin Identify the 3 Muscle planes Site block in Mid-axillary line Insert needle anterior to probe Pass needle obliquely to correct plane Local spreads “oval shaped”, saline 1st?






Applications

Both uni- and bilateral lower abdominal surgery Appendicectomies Hernia repairs (inguinal & umbilical) Lower abdominal laparoscopic surgery Open urological procedures Hysterectomies & caesarean sections


The use of Ultrasound for Abdominal Wall

Blocks By

Stef Oosthuysen NNUH Sonosite Course

November 2008


“In the land of the blind, the man with one-eye is

king”Desiderius Erasmus

(1466 -1536)


http://upload.wikimedia.org/wikipedia/commons/b/bd/Rotterdam_standbeeld_Erasmus.jpg

http://upload.wikimedia.org/wikipedia/commons/b/bd/Rotterdam_standbeeld_Erasmus.jpg

Advantages of U/Sd

See the needle tip See the spread and accurately deliver LA See the anatomy causing complications Able to reduce local anaesthetic dosage


Abdominal blocks


Abdominal blocks

Thoracic intercostal nerve blocks Rectus sheath blocks Ilioinguinal nerve blocks Transversus Abdominus Plane blocks (TAP)


TAP Blocks


Based on sound Anatomical and Scientific evidence

as follows:


Documents

Anatomy of Abdominal Wall - NESRAnesra.co.uk/files/techniques/Abdo Wall iNerve 09.pdf · Anatomy of Abdominal Wall Nat Haslam Consultant Anaesthetist City Hospitals Sunderland Sunday,