CHAPTER 9: TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK
Main characteristics…………………………………………………………………… 189
Techniques and indications……………………………………………………………. 190
TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK
The innervation of the antero lateral abdominal wall is provided by the lower six thoracic
(intercostal) nerves and the first lumbar nerve. The 7th intercostal nerve swings up and terminates
around the xiphoid of the sternum at the highest point in the abdominal wall. The 10 th intercostal
runs from under the costal margin diagonally down and medially toward the umbilicus, while the
12th intercostal (subcostal) nerve innervates the lower antero lateral part of the abdomen and the
suprapubic area. The first lum bar nerve originates th e iliohypogastric and il ioinguinal nerves,
which run in proximity to the antero superior iliac spine before providing some innervation to the
suprapubic area (iliohypogastric) and some of the inguinal and genital areas (ilioinguinal).
Main characteristics
This block was first descri bed in 2001 by Dr Rafi, who at the tim e was working in
Ireland. His technique involved the identification of the triangle of Petit, an anatomical formation
first described by Jean Louis Petit (1674-1750), a Fr ench surgeon and anatom ist in his “Traite
des maladies chirurgicales et des operations qui leur conviennent”, published posthum ously in
1774. The triangle is form ed anteriorly by the fr ee posterior border of the external oblique
muscle, posteriorly by the anterior border of latissimus dorsi and inferiorly by the iliac crest. The
area of the triangle is occupi ed by the internal oblique superficially and th e transversus
abdominis underneath. The triangle can have d ifferent dimensions, although according to one
study involving 80 cadavers it is us ually small and it could be absent in up to 17.5% of the cases
(Loukas et al 2007). Its absence is due to a latissimus dorsi overlapping the external oblique.
The original technique was a “blind” techni que performed through the triangle of Petit,
which was identified by palpation. The technique re lies on the operator’s ab ility to feel a “pop”
or loss of resistance as the needle is driven into the correct fascial plane. Controversy exists as to
how many “pops” are supposed to be felt. Th e most accepted version involves two pops, but
even among the people that accept this version there is no agreement as to the reason for them. In
my opinion the first pop is due to the needle cr ossing through the fascia lining the superf icial
aspect of the internal oblique muscle, and the second pop is th e result of the n eedle crossing the
combined internal oblique deep f ascia and the fascia covering the supe rficial aspect of the
transversus abdominis muscle, under which the desired neurovascular plane is found. It is
important to notice that a need le inserted though th e triangle of Petit doe s not traverse the
external oblique since this muscle does not insert on the thoracolumbar fascia and instead it has a
free border that becom es the anteri or boundary of the triangle. No part of the external oblique
extends into the area of the tr iangle. The internal oblique and transversus abdominis muscles on
the other hand do continue m edially to insert on the thoracolumbar fascia and fill the area of the
triangle. The use of ultrasound greatly facilitates the performance of this block and eliminates the
need to feel subjective “pops”.
Another point of controversy is the extent of analgesia. Some authors believe that
analgesia after a TAP block can extend through the enti re abdominal wall (T7-T10), but this is
neither backed by the clinical ev idence nor by the anatomy. It is m ore likely that a TAP block
performed either using landm arks or ultrasound can provide analgesia and/or anesthesia from
about T10 level (um bilical region) to L1 (sup rapubic region). If a h igher spread is desired a
subcostal injection into the transversus abdominis plane is needed.
It is im portant to keep in m ind that becau se the thoraco lumbar nerves originate their
important lateral perforating branch between the anterior and midaxillary lines the block needs to
be performed not anterior (proximal) than the midaxillary line.
TAP Block Technique
Indications
To produce anesthesia or analg esia of th e abdominal wall, below the um bilicus. For
analgesia of the upper abdomen a subcostal injection is needed.
Point of contact with the nerves
The needle approaches the thoraco abdom inal nerves as they trav el between the
transversus abdominis (deep) and the internal obli que (superficial) m uscles at the level of the
mid axillary line.
Patient position
The patient can be supine or in lateral position with the arm on the side to b e blocked
elevated and turned to the opposite side.
Type of needle
A 5 or 10cm, 21G, insulated needle can be use d. Using an 18-G epidural needle provides
a better visualization of this larger needle an d its curved rounded tip c ould lower the risk of
accidental penetration of the peritoneum and abdominal cavity.
Type of transducer
A linear high frequency (8-15 MHz) probe is usually sufficient. In larger patients a
curved, low frequency (3-7 MHz) probe may be necessary.
Scanning
The probe is placed diagonally over the latera l abdominal wall at the level of the m id
axillary line.
Needle insertion
The needle can be inserted in plane or out of plane. W e prefer to insert the needle in
plane from anterior to posterior, as shown in figure 9-1.
Fig 9-1. Needle insertion, in
plane. The needle is in serted in
plane, from anterior to posterior.
(On a model with permission).
The characteristic ultrasound im age obtained at around the m idaxillary line level is
shown in figure 9-2.
Fig 9-2. TAP block. With the probe
placed diagonally over t he lateral
abdominal wall, th e external oblique
(EXT), internal oblique INT) and
transversus abdominis (TRA) are easily
distinguished. The arrows sh ow the
fascial plane between the in ternal
oblique and transversus muscles where
the injection is p erformed. Author’s
collection.
In bigger patients a reasonable good image can be obtained by applying pressure to the
transducer in order to com press the subcutaneous layer and adi pose tissue. Figures 9-3, and 9-4
show the needle advancing toward the TAP in an obese patient.
Fig 9-3. Needle insertion. Compared
to figure 9-2 a thick layer o f adipose
tissue (significantly compressed by
probe pressure) can be observed under
the skin. The needle (white arrow) is
seen traversing the external oblique
(ext). Also shown are i nternal oblique
(int) and transversus (tra). Author’s
collection.
Fig 9-4. Needle reaching the
subfascial TAP. The needle, shown
with white arrows, h as reached the
TAP. The injected local anesthetic,
shown with black arrows, is seen
forming a sm all pool on top of the
transversus abdominis muscle but
under its superficial fascia (right TAP
plane). Author’s collection.
To produce a block abo ve the umbilicus it is ne cessary to make a subcostal injection, as
shown by Hebbard et al (Anesth Analg, 2008). At this location the injection is made in the plane
between rectus abdominis and transversus muscle, shown in figure 9-5.
Fig 9-5. TAP subcostal. At the
subcostal level the upper
thoracoabdominal nerves (T7-T9) run
in the plane between the rectu s
abdominis (rectus abd) anteriorly and
transversus abdominis muscle (transv)
posteriorly. Also shown is th e costal
margin (rib) and part of the peritoneal
cavity. Author’s collection.
Local anesthetic and volume
Usually we inject 15-20 mL of local anesthetic solution for unilateral blocks or 30-40 mL
total for bilateral blocks. 1% mepivacaine can be used but preferably either ropivacaine 0.5% or
0.375 bupivacaine is used to obtain a longer effect. We always add epineph rine as an
intravascular indicator.
References
1. Snell RS: Clinical anatomy for medical students, 5th edition. Boston, MA : Little, Brown
and Company; 1986, pp 133-182
2. Rafi A. Abdom inal field bloc k: A new approach via the lumbar triangle. Anaesthesia
2001; 56: 1024-1026
3. Loukas M, Tubbs RS, El-Sedfi A, Jester A, Po lepalli S, Kinsela C, Wu S. The clinical
anatomy of the triangle of Petit. Hernia 2007; 11: 441-444
4. McDonnell J, O’Donnell B, Cu rley G, Heffernan A, Power C, Laffey J. The analgesic
efficacy of transversus abdom inis plane b lock after abdom inal surgery: A prospective
randomized controlled trial. Anesth Analg 2007; 104: 193-197
5. Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided tr ansversus abdominis
plane (TP) block. Anaesthesia and Int Care 2007; 35: 616-617
6. McDonnell J, Curley G , Carney J, Benton A, Costello J, Maharaj C, Laffey J. The
analgesic efficacy of transversus abdominis plane blo ck after cesare an delivery: A
randomized controlled trial. Anesth Analg 2008; 106:186-191
7. Carney J, McDonnell J, Ochana A, Bhinder R, Laffey J. The transversus abdominis plane
block provides effective postoperative analge sia in patients under going total abdom inal
hysterectomy. Anesth Analg 2008; 107: 2056-2060
8. Hebbard P. Subcostal transversus abdom inis plane block under ultrasound guidance.
Anesth Analg 2008; 106: 674-675
9. Griffiths J, Middle J, Barron F, Grant S, Popham P, Royse C. Transversus abdom inis
plane block does not provide additional benefit to multimodal analgesia in gynecological
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