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EDITORIAL
Year : 2016  |  Volume : 60  |  Issue : 4  |  Page : 231-233  

The transversus abdominis plane block: Case for optimal tap


Department of Anaesthesiology and Critical Care, VIMS, Ballari, Karnataka, India

Date of Web Publication31-Mar-2016

Correspondence Address:
S Bala Bhaskar
Department of Anaesthesiology and Critical Care, VIMS, Ballari, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.179444

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How to cite this article:
Bhaskar S B, Balasubramanya H. The transversus abdominis plane block: Case for optimal tap. Indian J Anaesth 2016;60:231-3

How to cite this URL:
Bhaskar S B, Balasubramanya H. The transversus abdominis plane block: Case for optimal tap. Indian J Anaesth [serial online] 2016 [cited 2019 Jun 20];60:231-3. Available from: http://www.ijaweb.org/text.asp?2016/60/4/231/179444

Among the various nerve blocks of the body that had been least glamorous for regional anaesthesiologists for a long period of time had been those related to the abdomen. The major reasons were the sparse, variable and less-reliable landmarks in this region for a routine 'blind' procedure and the need for multiple injections. Over the last decade, the advent of ultrasound (US) rekindled fresh interest followed by widespread use of the US-based techniques for abdominal blocks, especially for transversus abdominis plane (TAP) block. The anterior rami of the lower 6 thoracic (T7-T12) and the first lumbar (L1) nerves traversing and communicating widely as multiple mixed segmental nerves within the TAP produced perfect sono-landmarks for the US-guided TAP block. [1]

The TAP could be clearly defined in a cadaveric and volunteer study by McDonnell et al. [2] Real-time ultrasonography facilitates enhanced accuracy of placement of blocking needle as well as local anaesthetic (LA) deposition in TAP. Several clinical trials have demonstrated the analgesic utility of the technique. [3]

Hebbard et al. in 2007 described the US-guided posterior TAP block, where the LA was deposited posteriorly at the triangle of Petit. [4] A subsequent anatomical study on cadavers by Jankovic et al. [5] found that lumbar triangle of Petit was placed more posteriorly than the literature suggested. The nerves to be blocked had not entered the TAP in the specimens in that study at the point of the lumbar triangle of Petit posteriorly; but at the mid-axillary line, all the nerves were in the TAP.

A modified approach, the oblique subcostal approach, was later described for upper abdominal procedures. [6] In a study of open cholecystectomy under balanced general anaesthesia with multimodal analgesia with TAP block, Arghya and others [7] describe the administration of 15 ml of LA by multiple punctures by oblique subcostal approach along with single 5 ml injection at xiphoid process with satisfactory duration of post-operative analgesia.

Currently, majority of TAP blocks are performed at the mid-axillary line and are referred to as lateral TAP blocks. In a meta-analysis [3] covering 12 randomised controlled trials on human subjects, published between 2005 and 2012, Abdallah et al. found that the posterior approach to TAP block appeared to be associated with more prolonged analgesia compared to the lateral approach. They attributed this to retrograde LA spread to the paravertebral space in the posterior approach, potentially producing additional visceral block along the thoraco-lumbar sympathetic chain.

The lateral approach and oblique subcostal TAP block are more likely to produce reliable analgesia below the umbilicus and above the umbilicus, respectively. [3],[8]

A different approach, with four-point, single-shot technique [9] combining the posterior and oblique subcostal techniques, has been found to provide wider bilateral analgesic coverage in patients undergoing major open or laparoscopic abdominal surgery under general anaesthesia, with early mobilisation from the post-anaesthesia care unit.

TAP blocks can be performed either at the beginning or at the end of surgery. The single-shot TAP blocks provide analgesia with reduction pain scores and opioid consumption during the initial 24-48 h postoperatively. [3]

The relatively short duration of analgesia and limited extent of spread of block are real concerns with TAP, and catheter insertion techniques into TAP have been described. [10]

'Bilateral' TAP block performed for surgeries involving incisions across the midline or bilateral surgeries such as inguinal hernia repairs need careful dosing of the LAs. [11],[12]

There is insufficient evidence to support any particular LA agent or regimen for TAP block and volumes ranging from 8 ml to 30 ml have been used with mixed success. [13] Published in this issue of IJA is a study [14] comparing the relative analgesic efficacy of bupivacaine and ropivacaine for post-operative analgesia using US-guided TAP block in laparoscopic cholecystectomies; they conclude that though ropivacaine provided effective analgesia in the immediate post-operative period (up to 1 h) as compared to bupivacaine, both the drugs were similar in terms of 24 h cumulative analgesic requirement.

Additives to LAs have been tried (dexamethasone and dexmedetomidine) and they have been associated with prolongation of the duration of the block and decreased incidence of post-operative nausea and vomiting. [15],[16] Hyaluronidase added to lignocaine in a bilateral subcostal TAP block for laparoscopic cholecystectomy was found to be associated with excellent analgesia throughout the post-operative period. [17] However, addition of clonidine to a TAP block with bupivacaine in women undergoing elective caesarean delivery did not produce significant change in pain scores. [18]

Complications related to TAP blocks are rare. Theoretically, femoral nerve block can occur as the LA can seep along the transversalis fascia to the fascia iliaca and further, the femoral nerve. Poor technique can potentially result in liver, spleen, kidney and intestinal injury.

TAP is also increasingly used in paediatric population. [19] A study of 10 neonates indicated low risk for toxicity when bupivacaine 0.125% at total volume of 1 ml/kg was used after TAP block. [20] Use of LA and neurolytic agents via TAP block is reported for a patient suffering from severe abdominal wall pain associated with carcinoma colon. [21]

The available evidence so far are in favour of US-guided TAP block as a simple and effective analgesic technique, especially for lower abdominal surgeries; the sono-anatomy makes the parietal pain more amenable for the block and the visceral pain has to be taken care of in a multimodal analgesia technique. The limitation in developing nations is the cost factor related to the US machine. The sheer numbers of submission of US-based TAP block research for publication to this journal in recent past, however, attests to its wider availability and use in India. The US-based TAP block has definitely opened new avenues for management of pain in abdominal surgeries.

Despite the immense literature available on TAP, the untapped components remain, concerning validation of the effects related to the LA agent of choice, the toxicity concerns and the analgesia benefit or lack of it in upper abdominal surgeries. Large-scale prospective controlled trials comparing the efficacy of different approaches of TAP block with other somatic blocks are required.

 
   References Top

1.
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.  Back to cited text no. 1
    
2.
McDonnell JG, O′Donnell BD, Farrell T, Gough N, Tuite D, Power C, et al. Transversus abdominis plane block: A cadaveric and radiological evaluation. Reg Anesth Pain Med 2007;32:399-404.  Back to cited text no. 2
    
3.
Abdallah FW, Laffey JG, Halpern SH, Brull R. Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: A meta-analysis. Br J Anaesth 2013;111:721-35.  Back to cited text no. 3
    
4.
Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care 2007;35:616-7.  Back to cited text no. 4
    
5.
Jankovic ZB, du Feu FM, McConnell P. An anatomical study of the transversus abdominis plane block: Location of the lumbar triangle of Petit and adjacent nerves. Anesth Analg 2009;109:981-5.  Back to cited text no. 5
    
6.
Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg 2008;106:674-5.  Back to cited text no. 6
    
7.
Mukherjee A, Guhabiswas R, Kshirsagar S, Rupert E. Ultrasound guided oblique subcostal transversus abdominis plane block: An observational study on a new and promising analgesic technique. Indian J Anaesth 2016;60:284-6.  Back to cited text no. 7
  Medknow Journal  
8.
Lee TH, Barrington MJ, Tran TM, Wong D, Hebbard PD. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesth Intensive Care 2010;38:452-60.  Back to cited text no. 8
    
9.
Børglum J, Maschmann C, Belhage B, Jensen K. Ultrasound-guided bilateral dual transversus abdominis plane block: A new four-point approach. Acta Anaesthesiol Scand 2011;55:658-63.  Back to cited text no. 9
    
10.
Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011;66:465-71.  Back to cited text no. 10
    
11.
Torup H, Mitchell AU, Breindahl T, Hansen EG, Rosenberg J, Møller AM. Potentially toxic concentrations in blood of total ropivacaine after bilateral transversus abdominis plane blocks; A pharmacokinetic study. Eur J Anaesthesiol 2012;29:235-8.  Back to cited text no. 11
    
12.
Hessian EC, Evans BE, Woods JA, Taylor DJ, Kinkel E, Bjorksten AR. Plasma ropivacaine concentrations during bilateral transversus abdominis plane infusions. Br J Anaesth 2013;111:488-95.  Back to cited text no. 12
    
13.
Young MJ, Gorlin AW, Modest VE, Quraishi SA. Clinical implications of the transversus abdominis plane block in adults. Anesthesiol Res Pract 2012;2012:731645.  Back to cited text no. 13
    
14.
Sinha S, Palta S, Saroa R, Prasad A. Comparison of ultrasound-guided transversus abdominis plane block with bupivacaine and ropivacaine as adjuncts for postoperative analgesia in laparoscopic cholecystectomies. Indian J Anaesth 2016;60:264-9.  Back to cited text no. 14
  Medknow Journal  
15.
Ammar AS, Mahmoud KM. Effect of adding dexamethasone to bupivacaine on transversus abdominis plane block for abdominal hysterectomy: A prospective randomized controlled trial. Saudi J Anaesth 2012;6:229-33.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
16.
Almarakbi WA, Kaki AM. Addition of dexmedetomidine to bupivacaine in transversus abdominis plane block potentiates post-operative pain relief among abdominal hysterectomy patients: A prospective randomized controlled trial. Saudi J Anaesth 2014;8:161-6.  Back to cited text no. 16
[PUBMED]  Medknow Journal  
17.
Johnson MZ, O′Connor TC. Excellent postoperative analgesia with the addition of hyaluronidase to lignocaine for subcostal TAP block used in conjunction with systemic analgesia for laparoscopic cholecystectomy. BMJ Case Rep 2014;2014. pii: Bcr2013202911.  Back to cited text no. 17
    
18.
Bollag L, Richebe P, Siaulys M, Ortner CM, Gofeld M, Landau R. Effect of transversus abdominis plane block with and without clonidine on post-cesarean delivery wound hyperalgesia and pain. Reg Anesth Pain Med 2012;37:508-14.  Back to cited text no. 18
    
19.
Sahin L, Sahin M, Gul R, Saricicek V, Isikay N. Ultrasound-guided transversus abdominis plane block in children: A randomised comparison with wound infiltration. Eur J Anaesthesiol 2013;30:409-14.  Back to cited text no. 19
    
20.
Suresh S, De Oliveira GS Jr. Blood bupivacaine concentrations after transversus abdominis plane block in neonates: A prospective observational study. Anesth Analg 2016;122:814-7.  Back to cited text no. 20
    
21.
Sakamoto B, Kuber S, Gwirtz K, Elsahy A, Stennis M. Neurolytic transversus abdominis plane block in the palliative treatment of intractable abdominal wall pain. J Clin Anesth 2012;24:58-61.  Back to cited text no. 21
    




 

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