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    Note that TAP blocks only provide analgesia of the abdominal wall and no visceral analgesia, so some opiate administration perioperatively is still required.


    Indications: Paraumbilical hernia repair, midline abdominal surgery


    Anatomy


    Source: AAGBI

    The anterior abdominal wall is innervated by thoracolumbar segmental nerves T6-L1. These nerves travel in the neurofascial (TAP) plane, until the mid-axillary line when a cutaneous branch pierces the internal and external oblique muscles to supply the skin of the anterior abdominal wall. The rest of the nerve continues down to pierce the posterior rectus sheath to supply the skin midline of abdomen.


    Source: Wikipedia

    Above the arcuate line, the anterior rectus sheath is the fusion of the external oblique aponeurosis and the anterior half of the internal oblique aponeurosis. The posterior rectus sheath is the fusion of the posterior half of the internal oblique aponeurosis and the transversus abdominus aponeurosis.


    Source: Wikipedia

    Below the arcuate line, the aponeuroses of all three muscles form the anterior rectus sheath. There is no posterior rectus sheath.


    Technique

    • Position patient supine

    • Identify lateral border of rectus sheath (linea semilunaris)

    • Insert needle above or below the umbilicus roughly 0.5cm medial to the linea semilunaris

    • Advance needle until the anterior rectus sheath is encountered, when there is a loss of resistance felt as the needle passes through the fascial layer. Advance further through the belly of the rectus muscle until resistance is felt at the posterior rectus sheath.

    • After careful aspiration, administer 0.15-0.2ml/kg of 0.25% bupivacaine on each side

      • Tip: Resistance to injection may mean needle tip is still within muscle body


    • A single site of injection on each side should be sufficient as the LA should spread freely all along the posterior rectus sheath



    References

    Warman P, Conn D, Nicholls B, Wilkinson D. Regional Anaesthesia, Stimulation, and Ultrasound Techniques. Oxford Specialist Handbooks in Anaesthesia.



Author: Ms Yanyu Tan  | Speciality: Anaesthetics/ICU  | Date Added: 09/11/2018

 
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