Welcome to the US-guided nerve blocks training programme
Ultrasound-Guided
Transversus Abdominis Plane Blocks
Institute of Pain Medicine & Research Centre
Dept of Anaesthesia & Pain Medicine
Evercare Hospital Dhaka
Lt Col (Retd) Dr Md Rabiul Alam
Senior Consultant
Dept of Anaesthesia & Pain Medicine
Evercare Hospital Dhaka

Objectives
• Identifying the patients who would benefit from Transversus
Abdominis Plane (TAP) blocks
• Relevant anatomy associated with TAP blocks
• Several techniques to approach TAP blocks
• Importance of an interprofessional team

Importance
• A rise in opioid-related adverse effects and death has led to a surge in
utilizing alternative methods to treat pain

Opioid-related deaths
Ref: Kaplovitch E, Gomes T, Camacho X, Dhalla IA, Mamdani MM, Juurlink DN (2015) Sex Differences in
Dose Escalation and Overdose Death during Chronic Opioid Therapy: A Population-Based Cohort Study.
PLoS ONE 10(8): e0134550. doi:10.1371/ journal.pone.0134550

Opioid-related deaths…
Ref: Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The Burden of Opioid-Related Mortality
in the United States. JAMA Netw Open. 2018 Jun 1;1(2):e180217. doi:
10.1001/jamanetworkopen.2018.0217.

Introduction…
• US-guided RA parallels the rapid rise in availability of US machines
• Abdominal wall is a common source of pain after abdominal surgeries
• US-guided TAP blocks provide reliable relief of somatic incisional pain
• A great adjunct to a multimodal analgesic regimen
• Spares visceral pain relief(!), necessitate additional analgesic modes
• Creates a non-dermatomal field block

History
Ahmed Nadeem Rafi, MD
Institute of
Interventional Pain
Management
Russellville, Arkansas,
United States
Ref: Rafi A. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia
2001; 56: 1024- 26

History…
Ref: Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis
plane (TAP) block. Anaesth Intensive Care. 2007 Aug;35(4):616-7

Indications
• Major abdominal surgeries
• Colorectal surgeries - alternative to epidural anaesthesia(!)
• Hernia repairs
• Procedures involving the abdominal wall
• Cesarean section
• Appendectomy, abdominal hysterectomy, abdominoplasty, prostatectomy
• Laparoscopic surgeries

Contraindications
• Patient refusal
• Active infection over the site of injection
• Practice caution in patients
• Taking anticoagulation
• Pregnant patient
• Patients where anatomical landmarks are indistinguishable
• Avoid local anesthetics in those with known allergies

Anatomy
• The anterolateral abdominal wall is bound
• Laterally by the posterior axillary lines
• Superiorly:
• costal margin of the 7th to 10th ribs
• xiphoid process
• Inferiorly:
• Iliac crest
• Inguinal ligament
• Pubic crest
• Symphysis

Anatomy… muscles
• The muscles of the anterolateral
abdominal wall, from superficial to deep
• External oblique
• Internal oblique
• Transversus abdominis
• TAP is the fascial plane that separates the
TA from the IO muscle

Anatomy… nerves
• Innervation of the anterolateral
abdominal wall is composed of
• Thoracoabdominal nerves
• Ilioinguinal
• Iliohypogastric nerves which
communicate to form the upper and
lower TAP plexuses

Anatomy… nerves
• T6 entering just lateral to the linea alba
• T7-T9 enter the TAP medial to the
anterior axillary line
• T10-T12 nerves enter more laterally and
can be blocked in the midaxillary line
between the bottom of the thoracic
cage and the top of the iliac crest

Requirements
• US machine with a high frequency probe (10-5 MHz), linear, curvelinear
• US probe cover
• Antiseptic for skin disinfection
• Sterile ultrasound gel
• Needle: 50/80/100 mm needles
• 10/20ml syringes and injection tubing
• 40 to 60 ml local anaesthetic (this block relies on local anaesthetic spread rather than
concentration, i.e. is volume dependent)

Personnel
• Trained and skilled medical providers, including anesthesiologists, can
perform TAP blocks
• Typically a second healthcare provider or nurse is required for time-
out before starting the procedure, and to assist with the injection of
local anesthetic

Preparations
• Discuss risks, benefits, alternatives with the patient & obtain informed consent
• Monitoring: ECG, SpO2, and BP every 5 minutes
• IV access
• Position the patient supine and uncover the abdomen
• Be sure to thoroughly clean the skin over the anterolateral abdomen, from the
costal margin to iliac crest, followed by placement of sterile towels
surrounding the border of the procedural field
• A procedural time-out should take place prior to starting the procedure

Types of TAP blocks
• Subcostal
• Lateral
• Posterior
• Anterior (iliohypogastric & ilioinguinal nerves block)
Plus
• Rectus Sheath nerve blocks

Subcostal

Lateral

Posterior

Anterior (IH & II nerves)
Distribution of block: hypogastric region, inguinal crease, upper medial thigh,
mons pubis, part of labia, root of the penis, & anterior part of the scrotum

Rectus sheath nerve block
Distribution of block: periumbilical area (spinal dermatomes 9, 10, & 11)

Complications
• Field blocks are safer, neurological injury is rare
• Nerve trauma, hematoma
• Intraperitoneal injection, visceral trauma, vascular injury, and liver trauma
• Transient femoral nerve palsy
• Essential to well visualizing the LA injection within TAP
• Be cautious to avoid vascular puncture and intravascular injection
• LA systemic toxicity is a rare but known complication

Team approach…
• A team-based, interprofessional methodology
• Communication with the surgeon
• Location of the incision, timing of the block, and other unique considerations
• Time-out to promote patient safety
• Verbal contact with the patient throughout the procedure
• Extreme caution when handling sharps as accidental needle sticks may occur
• Sharps require disposal using appropriately marked bins
• Documentations

Organizational initiatives
• An interprofessional team: clinicians (both general & specialists), nurses, surgical
assistants, and pharmacists
• Clinicians should send the patient to the specialists, who will prepare the patient for the
procedure in conjunction with the nursing staffs
• The pharmacy will prepare the anesthetic and can act as a resource for any medication-
related questions by the team
• Nursing will assist during the procedure, and additional nursing duties
• Interprofessional team will optimize the results from a TAP block leading to better
patient outcomes

Nursing assistance
• Nurse is in charge of setting up the instrument tray for the block
• Nurse may position and prep the patient for the procedure
• Nurse is also responsible for making sure that the patient has signed
consent
• And that the procedure is taking place on the correct side of the
abdominal pathology

Nursing assistance…
• Before starting the procedure, the nurse must make sure that
resuscitative equipment is in the room
• One nurse should be dedicated to the monitoring of the patient
during and after the procedure
• In the recovery room, the nurse should assess the patient's
hemodynamic status and evaluated the site of the block for bleeding

Take-home messages
• Selection of appropriate candidates
• Preparations of patients, OR/procedural room & ancilliaries
• Skills & perfections for good outcomes
• Development of an organized team & patients’ safety net
• Obtaining adequate peers’ & administrative supports
• Rational projections & marketing for viability

Conclusion
• TAP blocks have become an important addition to multimodal pain
management for abdominal wall surgery
• The safety, ease, and effectiveness of the block make it an excellent
adjunct to perioperative pain management

References
1. Kaplovitch E, Gomes T, Camacho X, Dhalla IA, Mamdani MM, Juurlink DN (2015) Sex Differences in Dose Escalation and Overdose Death
during Chronic Opioid Therapy: A Population-Based Cohort Study. PLoS ONE 10(8): e0134550
2. Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. The Burden of Opioid-Related Mortality in the United States. JAMA Netw
Open. 2018 Jun 1;1(2):e180217
3. Rafi A. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001; 56: 1024- 26
4. Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care. 2007
Aug;35(4):616-7
5. Hammi C, Ahn K. Transversus Abdominis Plane Block. [Updated 2022 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547730/
6. Mukhtar K. Transversus Abdominis Plane (TAP) block. The Journal of NYSORA 2009; 12: 28-33
7. Elsharkawy H, Bendtsen TF. Ultrasound-Guided Transversus Abdominis Plane and Quadratus Lumborum Nerve Blocks.
https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/abdomen/ultrasound-guided-transversus-
abdominis-plane-quadratus-lumborum-blocks/ (Accessed on 12 June 2022)