Transversus Abdominis Plane Block

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Editor(s): Lee A. Fleisher, MD, FACC, FAHA Lee A. Fleisher, MD, FACC, FAHA

Robert Dunning Dripps
Professor and Chair
Department of Anesthesiology and Critical Care

Professor of Medicine
University of Pennsylvania School of Medicine
| Robert Gaiser, MD Robert Gaiser, MD

Professor of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine

Contributor(s): Moustafa M. Ahmed, MD Moustafa M. Ahmed, MD

Assistant Clinical Professor
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine
Philadelphia Veterans Administration Medical Center
Philadelphia, PA
| Acknowledgements Acknowledgements

Jeremy D. Kukafka, MD
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Infraclavicular Nerve Block: Ultrasound-Guided Technique
Intercostal Nerve Block: Ultrasound-Guided Technique
Intraoperative Transesophageal Echocardiography
Psoas Compartment Block: Ultrasound-Guided Technique
Supraclavicular Nerve Block: Ultrasound-Guided Technique

Gail A. Van Norman, MD
Clinical Associate Professor
Department of Anesthesiology
Univ of Washington
Seattle, WA

Elizabeth J. Watson, MD
Post-Doctoral Fellow
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Liang Xue, BS
Research Assistant
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

  • Supplementary anesthesia for lower abdominal surgery, especially inguinal hernia surgery
  • Postoperative analgesia for lower abdominal surgery, including cesarean section
  • Diagnosis of nerve entrapment syndromes following inguinal hernia surgery

Absolute Contraindications

  • Patient refusal
  • Local anesthetic allergy
  • Infection at the site of injection

Relative Contraindications

  • Coagulopathy or systemic anticoagulation
  • Systemic infection (sepsis)
  • Appropriate resuscitation equipment, including oxygen, suction, emergency airway equipment, and resuscitation medications
  • Local anesthetic, 20 mL × 2 syringes
    • 0.375% bupivacaine
  • Sterile gloves and mask
  • Sterile prep solution
  • 1- to 1.5-inch 22-gauge short-bevel needle
  • Small (3-5 mL) syringe with 25- or 30-gauge needle for skin infiltration
  • 4 × 4 inch sterile gauze pack

The abdominal wall consists of three muscle layers: the external oblique, the internal oblique, and the transversus abdominis, together with the transversalis fascia. The central abdominal wall also includes the rectus abdominis muscles and their associated fascial sheaths.

The skin, muscles, and parietal peritoneum of the anterior abdominal wall are innervated by the lower six thoracic nerves and the first lumbar nerve. The anterior primary rami of these nerves leave their respective intervertebral foramina and course over the vertebral transverse process. They then pierce the musculature of the lateral abdominal wall to course through a neurofascial plane between the internal oblique and transversus abdominis muscles. The sensory nerves branch first in the mid-axillary line, sending out a lateral cutaneous branch, and then continue within the plane to perforate anteriorly, supplying neural input to the skin as far as the midline.

The neurofascial plane is the plane between the transversus abdominis and internal oblique muscles that contain the nerve afferents before they pierce the internal oblique to the anterior abdominal wall. This plane can easily be accessed via the triangle of Petit (also known as the inferior lumbar triangle), which is bounded posteriorly by the latissimus dorsi muscle and anteriorly by the external oblique muscle. The iliac crest forms the base (inferior boundary) of the triangle.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • After surgery
    • Assess the pain level.
    • Assess for signs of hematoma.
  • Infection
  • Hematoma
  • Nerve injury
  • Local anesthetic toxicity (due to intravascular injection of anesthetic or delayed absorption of large volumes of local anesthetic)
  • Peritoneal perforation
  • Bowel perforation (rare)
  • Difficulty ambulating or fall and injury secondary to spread of local anesthetic to nerves of the buttock, lateral thigh, or leg in the distribution of the femoral nerve
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