anatomy of abdominal wall - nesranesra.co.uk/files/techniques/abdo wall inerve 09.pdf · anatomy of...
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Anatomy of Abdominal Wall
Nat HaslamConsultant Anaesthetist
City Hospitals Sunderland
Sunday, 1 November 2009
Sunday, 1 November 2009
Abdo Wall, Cross sectional anatomy
Sunday, 1 November 2009
Rectus Abdominus
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Internal Oblique
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Transversus Abdominis
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Lattissimus Dorsi
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Ultrasound Guided TAP
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Sunday, 1 November 2009
TAP Blocks
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TAP Blocks
Sunday, 1 November 2009
Skin / Sub-Q
External oblique
Internal oblique
Transversus ab.
Peritoneal cavity
Peritoneum
Skin / Subcut
External oblique
Internal oblique
Transversus ab.
Peritoneal cavity
Peritoneum
Sunday, 1 November 2009
Skin / Sub-Q
External oblique
Internal oblique
Transversus ab.
Peritoneal cavity
Peritoneum
Transversus Abdominis
Plane
Skin / Subcut
External oblique
Internal oblique
Transversus ab.
Peritoneal cavity
Peritoneum
Sunday, 1 November 2009
Skin / Sub-Q
External oblique
Internal oblique
Transversus ab.
Peritoneal cavity
Peritoneum
Transversus Abdominis
Plane
Skin / Subcut
External oblique
Internal oblique
Transversus ab.
Peritoneal cavity
Peritoneum
Transversus Abdominis
Plane
Sunday, 1 November 2009
Sunday, 1 November 2009
Too superficial Too deep
TAP-tastic !
TAP Blocks – correct plane?
Sunday, 1 November 2009
Discrepancies in height of block and duration of action of anterior US guided technique compared with Mc Donnell’s original “2-
pop technique”
Sunday, 1 November 2009
TAP Blocks
Sunday, 1 November 2009
External oblique m.Internal oblique m.
Transversus abdominis m.
Rectus m.
TAP Blocks
Original technique:
2 “pops” through triangle of Petit in mid-axillary line
Sunday, 1 November 2009
External oblique m.Internal oblique m.
Transversus abdominis m.
Rectus m.
TAP Blocks
Original technique:
2 “pops” through triangle of Petit in mid-axillary line
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Sunday, 1 November 2009
At T4
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At T4
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Sunday, 1 November 2009
Ilio-Inguinal - above ASIS
EO
IO
TA
PC
Lateral
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Ilio-Inguinal at ASIS
ASISEOA
IO
TA
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Sunday, 1 November 2009
Rectus Sheath Blocks
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Rectus Abdominus
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Sunday, 1 November 2009
Subcut
Rectus m.
Peritoneal cavity
Posterior fascia
Fascia transversalis
Peritoneum
Local inserted
•Deep to Muscle
•Superficial to fascia
Rectus Sheath Block
Sunday, 1 November 2009
Medial Lateral
SubQ
Rectus m.
Vessels
Peritoneal cavity
Posterior fascia PeritoneumFascia transversalis
Rectus Sheath Block Medial Lateral
Intraperitoneal Bowel contents
Peritoneum
Rectus muscle and sheath
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Sunday, 1 November 2009
Sunday, 1 November 2009
Intercostal Nerve Blocks
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Intercostal block anatomy
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Sunday, 1 November 2009
Intercostal blocks
Sunday, 1 November 2009
Intercostal blocks
Will need many levels of blocks, each with a risk of pneumothorax and local anaesthetic toxicity!
Sunday, 1 November 2009
Intercostal blocks
Will need many levels of blocks, each with a risk of pneumothorax and local anaesthetic toxicity!
Not practical as we would need to turn patient onto the side, wasting time and effort!
Sunday, 1 November 2009
Intercostal block sonoanatomy
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Summary
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Summary
Abdominal wall blocks play a useful role to deliver multi-modal analgesia
Sunday, 1 November 2009
Summary
Abdominal wall blocks play a useful role to deliver multi-modal analgesia
Many are old techniques, revived and modified
Sunday, 1 November 2009
Summary
Abdominal wall blocks play a useful role to deliver multi-modal analgesia
Many are old techniques, revived and modified The new TAP block (green) evolution.......!
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Sunday, 1 November 2009
Subcostal TAP Block
Peter Hebbard April 2007 on extending TAP Blocks
Page 3 Heartweb.com.au
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Is a Subcostal TAP Necessary?
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The “Emerald” TAP?
Sunday, 1 November 2009
The “Emerald” TAP?
Higher spread to T4 because performed more posterior in Petit’s triangle?
Sunday, 1 November 2009
The “Emerald” TAP?
Higher spread to T4 because performed more posterior in Petit’s triangle?
Longer duration of action because of sympathetic spread?
Sunday, 1 November 2009
The “Emerald” TAP?
Higher spread to T4 because performed more posterior in Petit’s triangle?
Longer duration of action because of sympathetic spread?
More predictable done with a “2-pop-technique”?
Sunday, 1 November 2009
The “Emerald” TAP?
Higher spread to T4 because performed more posterior in Petit’s triangle?
Longer duration of action because of sympathetic spread?
More predictable done with a “2-pop-technique”?
A type of “paravertebral block”?
Sunday, 1 November 2009
Sunday, 1 November 2009
Sunday, 1 November 2009
Abdominal Pain
Cutaneous – well defined, superficial skin injury, short duration
Somatic – dull, poorly localised of longer duration
Visceral – from body organs, aching and difficult to localise, long duration, may be a “referred” pain
Aim for a comfortable patient as part of Multi-modal Analgesia strategy
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Sunday, 1 November 2009
Sunday, 1 November 2009
Topics to be covered
1. Advantages of U/Sd2. How do these blocks differ?3. Overview of abdominal anatomy 4. Ultrasound visualisation of anatomy
Sunday, 1 November 2009
Sunday, 1 November 2009
?
Sunday, 1 November 2009
Intercostal nerve blocks
Nerve supply to most of the abdomen Easy visualisation of neurovascular bundle Approach may need a short axis approach Reduced local anaesthetic volumes definitely
possible with ultrasound
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Intercostal nerve anatomy
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Intercostal nerve block performance
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How do abdominal blocks differ from other areas of USGPRA
No fear of damaging a nerve plexus Blocks often done with patient asleep Blocks done for pain relief not for perfoming
surgery per se Pain relief not absolute and part of a Multi-
Modal Analgesia regime
Sunday, 1 November 2009
Rectus Sheath Blocks
Problems with blind (“pops and clicks”) techniques
Advantages of ultrasound visualisation Increased popularity of laparoscopic surgery Relieves cutan/somatic pain, may still have the
“visceral component”
Sunday, 1 November 2009
Sunday, 1 November 2009
Rectus Sheath Block
• Poor correlation between depth and weight/height/BSA– Short distance between skin & peritoneum
• Median 8mm (5-13.8mm)
• Small volumes (0.1ml/kg 2.5mg/ml LevoB)– Early discharge, so limited effect duration details– No problems reported post-discharge at follow-up
• Spread NOT limited by anterior tendinous intersections
Sunday, 1 November 2009
Ilio-Inguinal Block
• Reduced dose with US technique– 0.2 vs 0.3ml/kg 2.5mg/ml Levo-bupivacaine.
• Reduced intra-op analgesia requirement– 4% vs 26% (Fentanyl)
• Reduced post-op analgesia requirement– 6% vs 40% (Paracetamol)
Sunday, 1 November 2009
Top Tips
Medial to lateral approach possibly safer At 0,2mls/Kg Levo-bupivacaine - reduced
volumes spares you a femoral nerve block Aim to “miss” the neurovascular bundle
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Professor Adrian Bösenberg
“It is not often that a new block is described”!
Sunday, 1 November 2009
Transversus Abdominus Plane Blocks (TAP)
Described by John Mc Donnell & Co - 05 Need to understand the Anatomy Advantages of TAP ultrasound guided The approach using Ultrasound
Sunday, 1 November 2009
TAP Blocks
New approach to blockade of the anterior abdominal wall
Blocks the anterior & lateral branches of intercostal nerves (height reached T9)
Still use “Pops” as markers, now adapted for ultrasound guided blockade
Local Anaesthetic spreads in a posterior direction with time
Sunday, 1 November 2009
TAP Blocks
• 32 bowel resections• 2 “pop” technique (landmark)• Reduction in VAS at all time points throughout
24hr period• ¼ 24hr morphine requirements
– 21.9mg vs 80.4mg
The Analgesic Efficacy of Tranversus Abdominis Plane Block After Abdominal Surgery
McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG
Anesth Analg 2007; 104(1): 193-7
Sunday, 1 November 2009
Technique for TAP Block
Transversely orientated probe Between iliac crest & inferior costal margin Identify the 3 Muscle planes Site block in Mid-axillary line Insert needle anterior to probe Pass needle obliquely to correct plane Local spreads “oval shaped”, saline 1st?
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Sunday, 1 November 2009
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Sunday, 1 November 2009
Sunday, 1 November 2009
Applications
Both uni- and bilateral lower abdominal surgery Appendicectomies Hernia repairs (inguinal & umbilical) Lower abdominal laparoscopic surgery Open urological procedures Hysterectomies & caesarean sections
Sunday, 1 November 2009
The use of Ultrasound for Abdominal Wall
Blocks By
Stef Oosthuysen NNUH Sonosite Course
November 2008
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“In the land of the blind, the man with one-eye is
king”Desiderius Erasmus
(1466 -1536)
Sunday, 1 November 2009
Advantages of U/Sd
See the needle tip See the spread and accurately deliver LA See the anatomy causing complications Able to reduce local anaesthetic dosage
Sunday, 1 November 2009
Abdominal blocks
Sunday, 1 November 2009
Abdominal blocks
Thoracic intercostal nerve blocks Rectus sheath blocks Ilioinguinal nerve blocks Transversus Abdominus Plane blocks (TAP)
Sunday, 1 November 2009
TAP Blocks
Sunday, 1 November 2009
Based on sound Anatomical and Scientific evidence
as follows:
Sunday, 1 November 2009