TRANSVERSUS ABDOMINIS
PLANE (TAP) BLOCK
PRESENTED BY
D. Fathima
Msc AOTT
Key words
Fascia : it is a wide spread continuous sheet of tough collagenous
connective tissue that wraps , supports and separates every part of
body like muscle , organ , bone , nerve .
It is flexible , moves with body , provides structural support , facilitates
communication between body systems through rich nerve endings .
Peritoneum : it is a membrane that lines abdominopelvic cavity and
surrounds abdominal organs .
The costal margin, also known as the costal arch, is the lower, curved
boundary of the chest formed by the cartilages of the 7th through
10th ribs. It serves as a crucial anatomical landmark and provides
attachment points for the diaphragm and abdominal muscles,
protecting organs like the liver located just below the right side of the
arch .
Introduction
The transversus abdominis plane (TAP) block is a peripheral nerve
block designed to anesthetize the nerves supplying the anterior
abdominal wall (T6 to L1)
Anatomy of Abdomen
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 muscle).
Transversus Abdominis Plane (TAP) is a
fascial plane superficial to the Transversus
Abdominis muscle ( which is the innermost
layer of the anterolateral abdominal wall )
The Lateral Abdominal wall has three layers
of muscles and their associated fascia
From outside to inside they are
The MOST SUPERFICIAL muscle : External
oblique muscle
The NEXT MUSCLE : Internal oblique
muscle
The DEEPER MUSCLE : Transversus
Abdominis
The anterior rami of lower six thoracic and
first lumbar nerves provide sensation to skin
, muscles , parietal peritoneum of anterior
abdominal wall
Sensory Innervation of nerves
The innervation of the anterolateral 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 10th intercostal runs from under the costal margin diagonally
down and medially towards the umbilicus,
while the 12th intercostal (subcostal) nerve innervates the lower
antero - lateral part of the abdomen and the suprapubic area.
The first lumbar nerve originates from the 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).
The lower six Thoracic nerves (T7 to T 12 ) and first Lumbar (L1)
nerves after exiting vertebral columns foramina , these nerves pass
through Lateral Abdominal wall within the Fascial plane between
Internal Oblique and Transversus Abdominis
Injecting the local anesthetic into the Fascial plane between these
internal oblique and transversus abdominis muscles provides TAP
BLOCK .
INDICATIONS
Post operative analgesia in open and laparoscopic abdominal surgeries
like :
Cholecystectomy
Appendectomy
Umbilical or Ventral hernia repair
Cesarean section
Total abdominal hysterectomy
Nephrectomy / renal transplants
Prostatectomy and colorectal surgeries .
Equipments required for TAP block
20ml Syringes
Gauze
Antiseptic solution , sterile gloves
Short bevel (30° ) block needle (50 – 100 mm),
or 16-G Tuohy needle, with an extension set
Local anesthetic – 0.5 %Bupivacaine or a long acting local anesthetic
(Levobupivacaine, Ropivacaine) is used in majority of cases . 0.3-0.6
ml/kg per side can be used as a guide for volume calculation.
an ultrasound machine with high-frequency probe (10-5
MHz) , ultrasound gel , Sterile ultrasound probe cover sleeve
ULTRASOUND GUIDED TECHNIQUE
The ultrasound transducer is positioned horizontally across the
abdomen
The muscle layers in the antero-lateral part of the abdomen can be
traced by scanning from the midline towards the area between the
iliac crest and the costal margin, in the mid-axillary line.
The rectus abdominis muscle is identified, just off the midline, as an
oval / elliptical structure.
Scanning laterally ,the rectus abdominis abuts a fascial plane is
observed. This fascial plane then gives rise to 3 muscle layers: external
oblique, internal oblique and transversus abdominis
The ultrasound transducer is moved more posteriorly, aiming to
view the point where the transversus abdominis muscle begins to
tail off. With an adequate ultrasound image, the regional block
needle is inserted anterior to the transducer.
The local anesthetic is then slowly injected. If the needle is correctly
positioned, the fascial plane is seen to separate and form a well-
defined, hypoechoic, elliptical shape between the internal oblique
and transversus abdominis muscles.
It is essential to watch for the spread of local anesthetic. If a patchy
opacity appears within the muscle either superficial or deep to the
transversus abdominis plane, then the needle should be repositioned
until local is seen to spread within the plane, separating the fascia
between the muscles. Obviously if no local is seen to appear – stop;
the needle tip may not be where you think it is, or the local is being
injected into a vessel or the peritoneal cavity .
TRADITIONAL [ BLIND ] APPROACH
In this approach, the lumbar triangle of Petit is identified.
The triangle of Petit is formed by the iliac crest as the base (inferior
border), the external oblique muscle as the anterior border, and the
latissimus dorsi muscle as the posterior border. The floor of the
triangle is made up of the fascia from both the external and internal
oblique muscles .
A needle is inserted perpendicular to the skin just cephalad to the iliac
crest near the midaxillary line.
The TAP is identified using a 2-pop sensation (loss of resistance). The
first pop indicates penetration of the fascia of the external oblique
muscle, and the second indicates penetration of the fascia of the internal
oblique muscle. Local anesthetic is then injected with multiple
aspirations.
The other approaches for TAP block are
Subcostal TAP Block
Lateral TAP Block
Posterior TAP Block
Oblique Subcostal TAP Block
Other considerations are :
Dual TAP Block
Continuous TAP Block
CONTRAINDICATIONS
Absolute
Patient refusal
Allergy to local anesthetics
Localised infection over injection site
Relative
Coagulopathy
Surgery at injection site
COMPLICATIONS
Local anesthetic systemic toxicity { LAST }
Intra peritoneal injection
Bowel injury
Hepatic injury
Retroperitoneal hematoma if it is injected into the vascular system
REFERENCES
Transversus Abdominis Plane Block: An Updated Review of Anatomy
and Techniques
Hsiao-Chien Tsai 1, Takayuki Yoshida 2, Tai-Yuan Chuang 3,4, Sheng-Feng
Yang 5, Chuen-Chau Chang 1,6,7, Han-Yun Yao 5, Yu-Ting Tai 5,7, Jui-An
Lin 5,7,#, Kung-Yen Chen 5,✉,#
[Link]
[Link]
[Link]
Transabdominal Plane Block - StatPearls - NCBI Bookshelf
[Link] Ana C. Mavarez; Joseph
Maxwell Hendrix; Andaleeb A. Ahmed.
The Anesthesia Guide Text book
Chapter 152. Transversus Abdominis Plane (TAP) Block; Ilioinguinal and
Iliohypogastric Blocks
Arthur Atchabahian, Ruchir Gupta
Transversus Abdominis Plane Block: Background, Indications,
Contraindications [Link]
Atlas Of Regional Anesthesia Text book Fourth Edition
David l. brown ,MD
