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Transversus Abdominis Plane Block

  • Author: Michael T Wiisanen, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
 
Updated: Sep 23, 2015
 

Background

The transverse abdominis plane (TAP) block is a peripheral nerve block designed to anesthetize the nerves supplying the anterior abdominal wall (T6 to L1). It was first described in 2001 by Rafi as a traditional blind landmark technique using the lumbar triangle of Petit (see the image below).[1]

Anatomical depiction of the triangle of Petit from Anatomical depiction of the triangle of Petit from the lateral view.

Local anesthetic is then injected between the internal oblique and transverse abdominis muscles just deep the fascial plane between (the plane through which the sensory nerves pass; see the images below).

Cross-section of the abdominal wall layers. The TA Cross-section of the abdominal wall layers. The TAP block is performed by deposition of local anesthetic between the transversus abdominis muscle and the fascial layer superficial to it.
Illustration depicting the placement of the ultras Illustration depicting the placement of the ultrasound probe along the abdominal wall, and the ideal placement of local anesthetic.

In a recent meta-analysis, the TAP block was shown to reduce the need for postoperative opioid use, increase the time to first request for further analgesia, and provide more effective pain relief, while decreasing opioid related side effects such as sedation and postoperative nausea and vomiting.[2] Studies included a combination of both general abdominal and gynecologic procedures.[3, 4] The introduction of ultrasound has allowed providers to identify the appropriate tissue plane and perform this block with greater accuracy under direct visualization.[5]

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Indications

The TAP block is a simple procedure that can be used as an adjunct for postoperative pain control in abdominal, gynecologic[6] , or urologic surgery involving the T6 to L1 distribution.[1, 3, 4, 5] Surgical procedures investigated by randomized clinical trials include large bowel resection, caesarean delivery, abdominal hysterectomy, open appendectomy, and laparoscopic cholecystectomy.[1, 7]

However, the TAP block has also found clinical utility in procedures such as abdominal and inguinal hernia repair[8] , radical prostatectomy, nephrectomy[9] , and many different laparoscopic procedures in general.[10] Bilateral TAP blocks can be used for midline incisions. This technique is also useful for procedures in which epidural analgesia is contraindicated (ie, anticoagulated patients). In addition, if prolonged analgesia is desired, a continuous TAP block technique with placement of a catheter has been described.[11]

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Contraindications

Very few contraindications exist to performing a TAP block. Absolute contraindications include infection at the site of injection, patient refusal or inability to cooperate, and allergy to local anesthetics.

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Relevant Anatomy

The abdominal wall is composed of 5 paired muscles: 2 vertical muscles (the rectus abdominis and the pyramidalis) and 3 layered, flat muscles (the external abdominal oblique, the internal abdominal oblique, and the transversus abdominis muscles).

The internal abdominal oblique muscle is the intermediate layer of the 3 paired, flat abdominal muscles. It originates broadly from the anterior portion of the iliac crest, lateral half of the inguinal ligament, and thoracolumbar fascia. The internal abdominal oblique inserts on the inferior border of the 10th-12th ribs, the linea alba, and the pubic crest via the conjoint tendon. The muscle fibers of the internal abdominal oblique course upward in a superomedial orientation, perpendicular to the muscle fibers of the external abdominal oblique.

The transversus abdominis muscle is the deepest of the 3 paired, flat abdominal muscles. It originates on the internal surfaces of the 7th–12th costal cartilages, thoracolumbar fascia, anterior three fourths of the iliac crest, and lateral third of the inguinal ligament. As with the other flat muscles, the transversus abdominis forms a broad aponeurosis that helps make up the rectus sheath before it fuses in the midline to the linea alba. Above the arcuate line, the transversus abdominis aponeurosis contributes to the posterior rectus sheath. Below the arcuate line, it is fused with the other flat muscles as the anterior rectus sheath.

For more information about the relevant anatomy, see Regions and Planes of the Abdomen.

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Contributor Information and Disclosures
Author

Michael T Wiisanen, MD Assistant Professor of Anesthesiology, Loyola University, Chicago Stritch School of Medicine; Attending Anesthesiologist, Associate Program Director, Loyola University Medical Center

Michael T Wiisanen, MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey W Hartwig, DO Assistant Professor, Department of Anesthesiology, Loyola University, Chicago Stritch School of Medicine; Staff Anesthesiologist, Loyola University Medical Center

Jeffrey W Hartwig, DO is a member of the following medical societies: American Medical Association, American Society of Anesthesiologists

Disclosure: Nothing to disclose.

Chief Editor

Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center

Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

References
  1. Petersen PL, Mathiesen O, Torup H, Dahl JB. The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review. Acta Anaesthesiol Scand. 2010 May. 54(5):529-35. [Medline].

  2. Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth. 2011 Feb. 23(1):7-14. [Medline].

  3. McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg. 2008 Jan. 106(1):186-91, table of contents. [Medline].

  4. McDonnell JG, O'Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg. 2007 Jan. 104(1):193-7. [Medline].

  5. Aveline C, Le Hetet H, Le Roux A, Vautier P, Cognet F, Vinet E, et al. Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair. Br J Anaesth. 2011 Mar. 106(3):380-6. [Medline].

  6. Kawahara R, Tamai Y, Yamasaki K, Okuno S, Hanada R, Funato T. The analgesic efficacy of ultrasound-guided transversus abdominis plane block with mid-axillary approach after gynecologic laparoscopic surgery: A randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2015 Jan-Mar. 31 (1):67-71. [Medline].

  7. Ripollés J, Mezquita SM, Abad A, Calvo J. Analgesic efficacy of the ultrasound-guided blockade of the transversus abdominis plane - a systematic review. Braz J Anesthesiol. 2015 Jul-Aug. 65 (4):255-80. [Medline].

  8. Fields AC, Gonzalez DO, Chin EH, Nguyen SQ, Zhang LP, Divino CM. Laparoscopic-Assisted Transversus Abdominis Plane Block for Postoperative Pain Control in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial. J Am Coll Surg. 2015 Aug. 221 (2):462-9. [Medline].

  9. Güner Can M, Göz R, Berber İ, Kaspar Ç, Çakır Ü. Ultrasound/Laparoscopic Camera-Guided Transversus Abdominis Plane Block for Renal Transplant Donors: A Randomized Controlled Trial. Ann Transplant. 2015 Jul 23. 20:418-23. [Medline].

  10. Mukhtar K. Transversus Abdominis Plane (TAP) Block. The Journal of New York School of Regional Anesthesia. 2009. 28-33.

  11. Hebbard PD, Barrington MJ, Vasey C. Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique. Reg Anesth Pain Med. 2010 Sep-Oct. 35(5):436-41. [Medline].

  12. Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it?. Anesth Analg. 2008 Nov. 107(5):1758-9. [Medline].

  13. Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block. Reg Anesth Pain Med. 2008 May-Jun. 33(3):274-5. [Medline].

  14. Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia. 2001 Oct. 56(10):1024-6. [Medline].

 
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Anatomical depiction of the triangle of Petit from the lateral view.
Cross-section of the abdominal wall layers. The TAP block is performed by deposition of local anesthetic between the transversus abdominis muscle and the fascial layer superficial to it.
Illustration depicting the placement of the ultrasound probe along the abdominal wall, and the ideal placement of local anesthetic.
Equipment needed for TAP block (ultrasound probe not shown).
The abdominal wall layers under ultrasound. SC - subcutaneous tissue, EO - external oblique muscle, IO - internal oblique muscle, TA - transversus abdominis muscle
Ultrasound image of abdominal layers for subcostal approach. SC (subcutaneous tissue); RA (rectus abdominis); TA (transversus abdominis); L/M (lateral and medial)
TAP block (posterior approach) demonstrating deposition of local anesthetic between transversus abdominis muscle and its fascial plane. EO - external oblique muscle, IO - internal oblique muscle, TA - transversus abdominis muscle, P - peritoneum
Positioning of the patient and ultrasound probe for TAP block (posterior approach).
Ultrasound-guided TAP block (posterior approach).
 
 
 
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