Transverse abdominis plane
block (TAP)
Dr. S. Parthasarathy
MD, DA, DNB, Dip Diab.MD ,DCA, Dip
software based statistics,
PhD (physiology) FICA
Definition
• Transversus abdominis plane (TAP) blocks involve
injecting local anesthetic into the neurovascular
plane between the internal oblique and transversus
abdominis muscles.
• The neurovascular plane between the internal
oblique and transversus abdominis muscles is known
as the TAP plane, hence the term TAP block.
History
• Rafi first described the TAP
block in 2001
• A 24-gauge, blunt-tipped, 2inch needle was then advanced
perpendicular to the skin until
a single confirmatory “pop”
was appreciated.
• RAFI – xiphoid to pubis
• 2007 – Mcdonnel published
TAP
Anatomy
The External Oblique Muscle
• Largest , most superficial
• Origin - Lower 8 ribs – runs down – iliac crest,
inguinal ligament and linea alba
What is internal oblique
• Origin – iliac crest , inguinal ligament
• Its’ fibres cover the anterolateral part of the
abdomen inserting anteriorly into the linea
alba, above the transversus abdominis muscle,
and superiorly into the cartilages of the lower
6 ribs.
Internal oblique
The transversus abdominis muscle
• most internal of the 3 muscle layers,
• Its’ fibres arise from the inguinal ligament, the
iliac crest, the lumbodorsal fascia and the inner
surfaces of the cartilages from the lower 6 ribs.
• Its’ fibres run transversely across the abdomen
ending in a broad aponeurosis.
• This aponeurosis is formed more laterally than
the aponeuroses of the external and internal
oblique muscles. It continues medially and inserts
into the linea alba.
So four muscles
• T7 to L1 nerves from
the spinal cord traverse
this plane TAP to supply
the anterior abdominal
wall
• Basis of block
• Includes ILIH
• T6 – T9 more anterior
entry
• These nerves travel within the TAP and
undergo multiple divisions before providing
sensory innervation to the skin, muscles, and
parietal peritoneum of the anterolateral
abdominal wall
No to visceral pain
Indications
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Hernia repair
Open appendicectomy
Caesarian section
Total abdominal hysterectomy
Radical prostatectomy
Midline laparotomy , cholecystectomy ,
umbilical hernia repair also !!
Rare – surgical, pain
• TAP blocks have provided surgical anesthesia in
high-risk patients for abdominal wall hernia
repair, emergency laparotomy, elective Cesarean
delivery.
• Continuous TAP blockade has been used for
treatment of chronic pain , for complex traumatic
pelvic fractures and for rescue analgesia
Absolute contraindications
• Patient refusal,
• soft tissue infection of the abdominal wall and
skin,
• abnormality at the needle insertion site.
• Coagulation status is an area of uncertainty
with the TAP block and will require further
investigation.
General precautions
• Asepsis
• Needles – blunted
• Local anesthetics – ligno + adrenaline , bupi
ropi etc. ( usually 20 ml – 0.25 % bupi each
side )
• Diluents
• Gloves
• USG – steridrapes
Technique
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Subcostal
Mid axillary
Ilioinguinal
Posterior
• PETIT
• Landmark guided
• Palpate iliac crest ant to
post – dip felt – go
posterior and above
• Go cranially – double
pop
• Go close to the bone –
single pop
Mid axillary – classical
Anatomy
Go posterior – TA will wane off
EO
IO
Needle
TAP
TA
Plane exact
Subcostal approach
Subcostal
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T6 to T9
Aponeurosis and plane
Drug
Go posterior to deposit more
Bilateral can be used
Subcostal TAP
Subcostal
Ilioinguinal TAP
Which type of block ??
Indications – depend upon area
of nociception
Rectus sheath block
• The rectus sheath nerves are the terminal branches of the
myocutaneous nerves (T8–L1) supplying the lower twothirds of the anterior abdominal wall, including the muscle
layers and the parietal peritoneum.
• They enter the rectus sheath through its lateral border
(linea semilunaris) and pass towards the linea alba.
• Within the rectus sheath the nerves lie between the rectus
abdominis muscle and the posterior wall of the sheath,
and supply the central abdominal wall.
Rectus sheath block
Clinical usage
• Reduced VAS
• Reduced opioid requirements
• Reduced side effects
• epidura;l – VAS less but side effects
Complications
Rectus Sheath Block
TAP Block
ILH Block
•Injury to bowel &
Peritoneum
•Deep inferior gastric
vascular injection
•LA toxicity
SC-TAP
•Hepatic injury
Injury to bowel
and Peritoneum
Mid Axillary
•Injury to peritoneum
and bowel
Posterior Approach
•Injury to kidney
•LA toxicity
Quadratus lumborum block
Transversalis fascia plane block
• Local anesthetic injected between the
transversus abdominis muscle and its deep
investing transversalis fascia will spread over
the inner surface of the quadratus lumborum
muscle and block the proximal portions of the
T12 and L1 nerves
• Iliac crest bone graft and hernia
Transversalis fascia plane block
Transversalis fascia plane block
Summary
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Definition
Where
Indications
Contraindications
Landmark
USG types
Complications
Transversalis plane
Thank you all