Ultrasound guided trasversus abdominis plane (TAP) block for abdominal wall surgeries in cases of difficult regional anaesthesia

1. Dr. Pranav Bansal
Associate Professor
Ultrasound guided Transversus
Abdominis Plane (TAP) Block for
excision of Inguinal Swelling in a case
of Severe Kypho-Scoliosis
Dept of Anaesthesiology and Critical Care, BPS Govt. Medical
College, Khanpur Kalan, Sonipat, Haryana

2. • A case of severe thoraco-lumbar
kyphoscoliosis presented with infected
inguinal swelling.
• Kyphoscoliosis was present since
childhood and deformity increased
progressively over years of
development.
• Inguinal swelling was present since
past 4 months.
• Resting respiratory rate: 30-34 breaths
per minute
• Pulmonary Function Tests revealed
FEV1: 42%, FVC: 52%, PEFR: 27%
and FEV25-75 : 45% of the predicted
values with a restrictive pattern on
flow-volume loop.
Case Study:

3. Anthropometric measurements
•Pectus Excavatum i.e. crowding of ribs
and markedly reduced lung fields (Baby
lung in X-ray AP view).
•Small Abdominal Cavity
•Hump on back (severe kyphosis)
•Mouth Opening and neck movements
within normal limits.
Deviated, stiff and immobile vertebral
column with no identifiable intervetebral
spaces on palpation. Cobb’s angle 120 °
in X-ray (Lateral view).
•Height: 4 feet (f) 8 inches
•Upper/ Lower seg. ratio: 2 Ft/2Ft & 8’
•Weight: 40 kg
Physical Examination Findings:

4. Anaesthetic Procedure
•Positioning of patient : Right Lateral Decubitus.
•The curve of vertebral column was immobile and
fixed with limited flexion.
•Attempts made to perform lumbar puncture using
23 G Quinke’s needle via midline, paramedian and
Taylor’s approach were not successful.
•The caudal space was obliterated and the
landmarks were unidentifiable, both radiologically
and clinically, so the approach for caudal epidural
block too failed.

5. Transversus Abdominis Plane (TAP) Block
•Position: Supine
•The curvilinear probe of portable ultrasound
machine placed in subcoastal region with an
oblique orientation on the small sized anterior
abdominal wall.
•Muscle planes were identified and 20 G, 1.5
inch needle introduced in transverses
abdominis plane.
•Local anaesthetics (Inj. Lignocaine 2% [with
adrenaline] 7 ml + Inj. Bupivacaine (0.5%) 8
ml + normal saline 10 ml [total volume 25 ml])
were administered.
•Satisfactory effect achieved and surgery
conduced uneventfully.

6. TAP Block-Technical Considerations
Ultrasound image during TAP Block. The
transversus abdominis muscle can be seen to
taper into a fascial line.The approximate needle
insertion angle is indicated.
Classical Posterior approach for
TAP block in Lumbar triangle of
Petit using in-plane needle
technique (T10-L1 blockade)
Diagram of transverse section
of abdominal wall during
landmark TAP block
performance (N, needle; ST,
subcutaneous tissue; EO,
external oblique muscle; IO,
internal oblique; TA,
transversus abdominis; LD
latissumis dorsi; QL, quadratus
lumborum)
The Oblique Subcostal approach to
TAP block for blocking T7-9 nerve
roots.

7. Uses of TAP Block:
Indicated for postoperative analgesia
in surgeries below the umbilicus
TAP block been successfully used as
sole anaesthetic technique for
inguinal hernia repair and
appendectomy.
Bilateral blocks are indicated for
postoperative analgesia in
surgeries with midline incision like
caesarean section, abdominal
hysterectomy, laparoscopic surgery
and prostatectomy.
TAP Block-Technical Considerations
Complications:
•Failure of block
•Intraperitoneal injection
•bowel hematoma
•liver laceration
•transient femoral nerve palsy

8. • Preoperative evaluation should focus on any cardiovascular, respiratory or
neurological impairment related to the deformity.
• Preoperative Pulmonary function tests (PFT) and ABG may guide
decisions regarding requirement of postoperative ventilatory support.
• Regional Anaesthetic techniques and peripheral nerve blocks are preferable
to General anaesthesia wherever possible owing to high risk of
postoperative pulmonary complications .
Conclusion
• Repeated attempts, inappropriate, inadequate, unpredictable or patchy
effect and complete failure are frequent complications associated with
neuroaxial anaesthesia in vertebral deformities.
• Ultrasound guidance is a promising aid in improving the accuracy &
efficacy of regional anaesthetic techniques in cases of altered anatomical
landmarks or bony deformities like severe kyphoscoliosis.
Anaesthetic Considerations in Severe
Kyphoscoliosis