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Involvement of umbilical region by transversus abdominis plane block
- Akemi Shido, Katsushi Doi, Shinichi Sakura, Yoji Saito (11 May 2009)
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Limitations of ultrasound-guided transversus abdominis plane block
- Phillip James Cowlishaw, David Belavy (10 January 2009)
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Akemi Shido Department of anesthesiology, Shimane University Faculty of Medicine, Katsushi Doi, Shinichi Sakura, Yoji Saito
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We read with interest the article by Tran and colleagues(1). Transversus abdominis plane (TAP) block has been getting popularity as a method for pain relief after abdominal surgery. While some(2,3) have reported its effectiveness, some(1,4) have indicated the limitation of its indication to lower abdominal surgery. Having performed ultrasound guided TAP blocks on patients undergoing laparoscopic gynecologic surgery for several months, we have an impression that TAP block, even under ultrasound guidance, dose not always cover whole lower abdominal wall pain. We would like to show that the results of our retrograde study agree with authors’ anatomical report that ultrasound guided TAP injection involved T10-L1 nerves and the rate of T10 involvement was 50%. We reviewed the anesthetic and postoperative care unit records to clarify the postoperative pain of patients undergoing laparoscopic gynecologic surgery with ultrasound-guided TAP block ( n=9, age= 36±11 ( yr, mean±SD)). In each case, TAP block was performed bilaterally immediately after induction of general anesthesia with propofol, remifentanil and fentanyl. Linear probe (11-3MHz) was positioned on the lateral abdominal wall between costal margin and iliac crest. With in- plane technique, a 100 mm, 21 gauge needle (Type CCR, Hakko, Japan) was advanced from anterolateral abdominal surface to the posterolateral direction until the needle tip reached the plane between internal oblique and transversus abdominis muscles. Local anesthetic (ropivacaine) was injected into TAP under ultrasound confirmation. No analgesic was given unless requested after surgery. Concentration and total volume of local anesthetic used for the block were 0.31±0.07 % and 28±4 ml, respectively. Within one hour after operation (171±22 min after TAP block), two patients requested analgesics because of the abdominal pain on unrestricted area and four requested because of umbilical region’s pain. Records on postoperative sensory blockade area were not obtained. We considered the abdominal pain that two patients complained about may have been visceral pain which TAP block cannot remove. The umbilical region’s pain (4 out of 9, 44.4%) must have been somatic pain which TAP block failed to remove. Our results are compatible to those of Tran et al. that the rate of T10 involvement was 50%, although the authors' results were obtained on cadaver and the substance injected and the volume injected were not the same as ours. We believe that further studies to obtain wider analgesic area will make TAP block more useful and effective to relieve postoperative lower abdominal pain. References 1. Tran KMN, Ivanusic JJ, Hebbard P and Barrington MJ. Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric study. Br J Anaesth 2009; 102: 123-7 2. McDonnell JG, O'Donnel B, Curley G, Heffernan A, Power C and Laffey JG. An analgesic efficacy of Transversus abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth Analg 2007; 104: 193-7 3. Mukhtar K, Singh S. Tranversus abdominis plane block for laparoscopic surgery. Br J Anaesth 2009; 102: 143-4 4. Shibata Y, Sato Y, Fujiwara Y, Komatsu T. Transversus abdominis plane block. Anesth Analg 2007; 105: 883 Conflict of Interest:None declared |
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Phillip James Cowlishaw, Consultant Anaesthetist Mater Health Services, Brisbane, David Belavy
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Editor - We congratulate Tran et al[1] on their cadaveric study to determine the spread of injectate after ultrasound guided transversus abdominis plane block (TAPB). Like Shibata et al[2] and Hebbard[3], we have assessed a series of 19 ultrasound guided TAPB by using loss of sensation to ice. We demonstrated no extension of the block above T10. Similarly to Tran et al1 we also found inguinal sparing in 20% of cases. This is in keeping with Rozen et al[4] and Jamieson et al[5] anatomical dissections which show that the L1 branch or iliohypogastric nerve often pierces transversus abdominis in front of the anterior axillary line. Unlike the rectus sheath block, the TAPB anaesthetises the abdominal wall lateral to linea semilunaris by blocking the lateral branches of the thoracoabdominal nerves. We found no extension of block beyond the lateral border of rectus muscle (lateral sparing) in 10% of cases and concluded that local anaesthetic had not spread to these lateral segmental nerves. Rozen et al[4] and Tran et al[1] make no mention of these branches in their anatomical dissections. Could the authors please comment on their existence and their location in relationship to the injected dye? The authors also noted the absence of evidence supporting the use of ultrasound guided TAPB. We have recently completed recruitment for a randomised, double blind, placebo controlled trial to assess the analgesic efficacy of ultrasound guided TAPB after caesarean section. We hope that despite these anatomical limitations we can replicate the impressive results of McDonnell et al[6] with their landmark guided technique. P. Cowlishaw D. Belavy Brisbane, Australia Email: phillip.cowlishaw@mater.org.au 1. Tran TMN, Ivanusic JJ, Hebbard P, and Barrington MJ. Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric study. Br J Anaesth 2009; 102:123-127 2 Shibata Y, Sato Y, Fujiwara Y, Komatsu T. Transversus abdominis plane block. Anesth Analg 2007; 105:883 3 Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008; 106:674–5 4 Rozen WM, Tran TM, Ashton MW, Barrington MJ, Ivanusic JJ, Taylor GI. Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat 2008; 21:325–33 5 Jamieson RW, Swigart LL, Anson BJ. Points of parietal perforation of the ilioinguinal and iliohypogastric nerves in relation to optimal sites for local anaesthesia. Q Bull Northwest Univ Med Sch 1952; 26:22–6 6 McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg 2008; 106:186–91 Conflict of Interest:None declared |
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