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Thoracolumbar Nerve Blocks - Transabdominis plane, Rectus sheath, and Ilioinguinal-Iliohypogastric Nerve blocks: A Review of the Anatomy and Techniques.? The Anatomy of the anterolateral abdominal wall. The borders of the anterolateral abdominal wall are the costal margin superiorly, the pubic crests inferiorly and the posterior abdominal wall laterally at the mid-axillary lines. The layers of the abdominal wall are: skin and fascia, muscles, fascia transversalis, extra peritoneal fat and the parietal peritoneum. Towards the midline, the abdominal wall musculature comprise the paired rectus abdominis muscles adjacent to the midline linea alba. The anterolateral abdominal wall contains three muscles, from superficial to deep: the external oblique, internal oblique and transversus abdominis; each covered within its own fascial sheath. Features such as the direction of muscle fibres, their origins and insertion points distinguish the abdominal wall muscles. The three lateral muscles are replaced by an aponeurosis (the linea semilunaris) at the lateral border of the rectus sheath. At this point the internal oblique aponeurosis splits into two layers ADDIN EN.CITE <EndNote><Cite><Author>McMin R. M. H.</Author><Year>1990</Year><RecNum>6</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="fp09s2d2ox5xv2e22spxwat7p20050a9e9e5">6</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>McMin R. M. H.,,</author></authors></contributors><titles><title>Last's Anatomy Regional & Applied</title></titles><edition>8th</edition><dates><year>1990</year></dates><publisher>Churchchill Livingstone</publisher><urls></urls></record></Cite></EndNote>1, ADDIN EN.CITE <EndNote><Cite><Author>Snell</Author><Year>2008</Year><RecNum>48</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">48</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Snell, R.S</author></authors></contributors><titles><title> Clinical Anatomy by Regions</title></titles><edition>8th</edition><dates><year>2008</year></dates><publisher>Lippincott Williams & Wilkins: Baltimore, Maryland.</publisher><urls></urls></record></Cite></EndNote>2 and is an important sono-anatomical landmark for performing transabdominis plane (TAP) and rectus sheath blocks. The linea semilunaris comprises the aponeurosis of both the internal and external oblique muscles and the transversus abdominis muscles and it continues medially to meet its contralateral counterparts via the linea alba in the midline. The linea semilunaris extends from the cartilage of rib 9 to the pubic tubercle. The superficial fascia of the abdominal wall comprises a single layer with variable amount of adipose tissue. Closer to the groin it is divisible into a superficial and deep layer. The deeper layer (Scarpa’s fascia) is thinner and more membranous than the superficial layer and blends with the fascia lata of the thigh below the inguinal ligament. ADDIN EN.CITE <EndNote><Cite><Author>Johnson</Author><Year>1996</Year><RecNum>96</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>96</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">96</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Johnson, D.</author><author>Dixon, A. K.</author><author>Abrahams, P. H.</author></authors></contributors><auth-address>Department of Radiology, Addenbrooke's Hospital, Cambridge, England, UK.</auth-address><titles><title>The abdominal subcutaneous tissue: computed tomographic, magnetic resonance, and anatomical observations</title><secondary-title>Clin Anat</secondary-title></titles><periodical><full-title>Clin Anat</full-title></periodical><pages>19-24</pages><volume>9</volume><number>1</number><edition>1996/01/01</edition><keywords><keyword>Abdominal Muscles/*anatomy & histology/radiography</keyword><keyword>Adipose Tissue/anatomy & histology/radiography</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Cadaver</keyword><keyword>Fascia/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging/*methods</keyword><keyword>Middle Aged</keyword><keyword>Tomography, X-Ray Computed/*methods</keyword></keywords><dates><year>1996</year></dates><isbn>0897-3806 (Print)
0897-3806 (Linking)</isbn><accession-num>8838275</accession-num><urls><related-urls><url>(SICI)1098-2353(1996)9:1<19::AID-CA4>3.0.CO;2-V [pii]
10.1002/(SICI)1098-2353(1996)9:1<19::AID-CA4>3.0.CO;2-V</electronic-resource-num><language>eng</language></record></Cite></EndNote>3The external oblique muscle is a broad quadrilateral muscle that runs from superolateral origins (external surface of ribs 5 -12) to inferomedial insertions (anterior half of the iliac crest). ADDIN EN.CITE <EndNote><Cite><Author>Snell</Author><Year>2008</Year><RecNum>48</RecNum><DisplayText><style face="superscript">2,4</style></DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">48</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Snell, R.S</author></authors></contributors><titles><title> Clinical Anatomy by Regions</title></titles><edition>8th</edition><dates><year>2008</year></dates><publisher>Lippincott Williams & Wilkins: Baltimore, Maryland.</publisher><urls></urls></record></Cite><Cite><Author>Gray</Author><Year>2000</Year><RecNum>49</RecNum><record><rec-number>49</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">49</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Gray, H</author></authors><secondary-authors><author>Lewis, W.H.</author></secondary-authors></contributors><titles><title>Gray's Anatomy of the Human Body</title></titles><dates><year>2000</year></dates><publisher>, New York</publisher><urls></urls></record></Cite></EndNote>2,4 Its fibres begin from the outer surface of ribs 5-12 and insert into the xiphoid process, the linea alba, the pubic crest, the pubic tubercle, and the anterior half of the iliac crest. It’s upper and lower four serrations run under the digitations of serratus anterior and latissimus dorsi respectively. The muscle’s insertions are by means of a broad aponeurosis that covers the centre of the abdominal wall. The inferior border of this aponeurosis thickens and forms the inguinal ligament between the anterior superior iliac spine (ASIS) and the pubic tubercle. The internal oblique muscle is immediately deep to the external oblique. It originates from the lumbar vertebrae (via thoracolumbar fascia), the anterior two thirds of the iliac crest and the lateral two thirds of the inguinal ligament and inserts into the lower borders of ribs 10, 11 and 12 and costal margin (upper margin – 10th costal cartilage), ADDIN EN.CITE <EndNote><Cite><Author>Sakamoto</Author><Year>1996</Year><RecNum>73</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>73</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">73</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sakamoto, H.</author><author>Akita, K.</author><author>Sato, T.</author></authors></contributors><auth-address>Department of Anatomy, School of Medicine, Tokyo Medical and Dental University, Japan.</auth-address><titles><title>An anatomical analysis of the relationships between the intercostal nerves and the thoracic and abdominal muscles in man. II. Detailed analysis of innervation of the three lateral abdominal muscles</title><secondary-title>Acta Anat (Basel)</secondary-title></titles><periodical><full-title>Acta Anat (Basel)</full-title></periodical><pages>143-50</pages><volume>156</volume><number>2</number><edition>1996/01/01</edition><keywords><keyword>Abdominal Muscles/*innervation</keyword><keyword>Humans</keyword><keyword>Intercostal Nerves/*anatomy & histology</keyword><keyword>Male</keyword><keyword>Muscles/*innervation</keyword><keyword>Thorax/*innervation</keyword></keywords><dates><year>1996</year></dates><isbn>0001-5180 (Print)
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ADDIN EN.CITE.DATA 2,4,5 The directions of its fibres are perpendicular to those of external oblique, except for the fibres originating from the inguinal ligament which are parallel to the external oblique. The transversus abdominis muscle is deep to the internal oblique muscle and is a thin muscle layer that runs horizontally across the abdominal wall. It has a broad origin from the inner surface of the lower six costal cartilages (interdigitating with the diaphragm), the lumbar vertebrae (via thoracolumbar fascia), the anterior two thirds of the iliac crest, and the lateral third of the inguinal ligament. ADDIN EN.CITE <EndNote><Cite><Author>Snell</Author><Year>2008</Year><RecNum>48</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">48</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Snell, R.S</author></authors></contributors><titles><title> Clinical Anatomy by Regions</title></titles><edition>8th</edition><dates><year>2008</year></dates><publisher>Lippincott Williams & Wilkins: Baltimore, Maryland.</publisher><urls></urls></record></Cite></EndNote>2 The fibres become aponeurotic anteriorly and insert into the xiphoid process and the pubic symphysis. The neurovascular plane between the internal oblique and transversus abdominis muscles is known as the TAP. It contains a fascial layer that is not adherent to the internal oblique, but binds the intercostals nerves on its deep surface to the transversus abdominis muscle. This layer is present throughout the TAP and extends medially to the linea semilunaris. ADDIN EN.CITE <EndNote><Cite><Author>Rozen</Author><Year>2009</Year><RecNum>4</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rozen, W. M.</author><author>Tran, T. M.</author><author>Barrington, M. J.</author><author>Ashton, M. W.</author></authors></contributors><auth-address>Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia. warrenrozen@</auth-address><titles><title>Avoiding denervation of the rectus abdominis muscle in DIEP flap harvest III: a functional study of the nerves to the rectus using anesthetic blockade</title><secondary-title>Plast Reconstr Surg</secondary-title></titles><periodical><full-title>Plast Reconstr Surg</full-title></periodical><pages>519-22</pages><volume>124</volume><number>2</number><edition>2009/08/01</edition><keywords><keyword>Humans</keyword><keyword>Motor Neurons/physiology</keyword><keyword>Nerve Block</keyword><keyword>Rectus Abdominis/*innervation</keyword><keyword>Surgical Flaps/*innervation</keyword><keyword>Sympathectomy, Chemical</keyword><keyword>Tissue and Organ Harvesting</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1529-4242 (Electronic)</isbn><accession-num>19644268</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>6The rectus abdominis muscles arises by two tendinous heads from the pubic symphysis medially and the pubic crest laterally. ADDIN EN.CITE <EndNote><Cite><Author>Snell</Author><Year>2008</Year><RecNum>48</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">48</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Snell, R.S</author></authors></contributors><titles><title> Clinical Anatomy by Regions</title></titles><edition>8th</edition><dates><year>2008</year></dates><publisher>Lippincott Williams & Wilkins: Baltimore, Maryland.</publisher><urls></urls></record></Cite></EndNote>2 The two muscles lie edge to edge in the lower part ADDIN EN.CITE <EndNote><Cite><Author>McMin R. M. H.</Author><Year>1990</Year><RecNum>6</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="fp09s2d2ox5xv2e22spxwat7p20050a9e9e5">6</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>McMin R. M. H.,,</author></authors></contributors><titles><title>Last's Anatomy Regional & Applied</title></titles><edition>8th</edition><dates><year>1990</year></dates><publisher>Churchchill Livingstone</publisher><urls></urls></record></Cite></EndNote>1 but above the arcuate line they are separated by the linea alba due to the presence of the posterior layer of the internal oblique fascia. Above the arcuate line the rectus abdominis becomes broader but thinner. The rectus abdominis is divided by three tendinous intersections, ADDIN EN.CITE <EndNote><Cite><Author>Drake</Author><Year>2005</Year><RecNum>77</RecNum><DisplayText><style face="superscript">7,8</style></DisplayText><record><rec-number>77</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">77</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Drake, R. L., Vogl, W., Mitchell, A. W. M.</author></authors></contributors><titles><title> Gray's Anatomy for Students</title><secondary-title>Churchchill Living Stone</secondary-title></titles><periodical><full-title>Churchchill Living Stone</full-title></periodical><number>1st</number><dates><year>2005</year></dates><urls></urls></record></Cite><Cite><Author>McMinn</Author><Year>1990</Year><RecNum>78</RecNum><record><rec-number>78</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">78</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>McMinn, R. M. H.</author></authors></contributors><titles><title>Last's Anatomy Regional & Applied</title></titles><edition>8th</edition><dates><year>1990</year><pub-dates><date>1990</date></pub-dates></dates><publisher>Churchchill Livingstone</publisher><urls></urls></record></Cite></EndNote>7,8 strongly attached to the rectus sheath. The rectus sheath contains the rectus abdominis muscles, the anterior rami of the lower sixth thoracic nerves (T7-T12), the superior and inferior epigastric vessels and lymph vessels. It is formed by the fusion of the aponeuroses of external oblique, internal oblique and transversus abdominis. Above the costal margin, the rectus sheath attaches to the 5th – 7th costal cartilages and corresponding intercostal spaces. ADDIN EN.CITE <EndNote><Cite><Author>McMin R. M. H.</Author><Year>1990</Year><RecNum>6</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="fp09s2d2ox5xv2e22spxwat7p20050a9e9e5">6</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>McMin R. M. H.,,</author></authors></contributors><titles><title>Last's Anatomy Regional & Applied</title></titles><edition>8th</edition><dates><year>1990</year></dates><publisher>Churchchill Livingstone</publisher><urls></urls></record></Cite></EndNote>1 From the costal margin to the arcuate line, the external oblique aponeurosis fuses with the anterior layer of the internal oblique aponeurosis to become the anterior layer of the rectus sheath; whilst the posterior layer of the internal oblique aponeurosis together with the transversus abdominis aponeurosis form the posterior layer of the rectus sheath. ADDIN EN.CITE <EndNote><Cite><Author>April</Author><Year>1990</Year><RecNum>3</RecNum><DisplayText><style face="superscript">1,9</style></DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="fp09s2d2ox5xv2e22spxwat7p20050a9e9e5">3</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>April, E. W.</author></authors></contributors><titles><title>Anatomy</title><secondary-title>The National Medical Series for Independent Study</secondary-title></titles><edition>2nd</edition><dates><year>1990</year></dates><pub-location>Baltimore</pub-location><publisher>Williams & Wilkins</publisher><urls></urls></record></Cite><Cite><Author>McMin R. M. H.</Author><Year>1990</Year><RecNum>6</RecNum><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="fp09s2d2ox5xv2e22spxwat7p20050a9e9e5">6</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>McMin R. M. H.,,</author></authors></contributors><titles><title>Last's Anatomy Regional & Applied</title></titles><edition>8th</edition><dates><year>1990</year></dates><publisher>Churchchill Livingstone</publisher><urls></urls></record></Cite></EndNote>1,9 Below the arcuate line, the aponeuroses of all three lateral muscles pass anteriorly; thus the rectus muscle lies posterior to the rectus sheath against the transversalis fascia. The position of the arcuate line is variable and is rarely symmetrical. ADDIN EN.CITE <EndNote><Cite><Author>Monkhouse</Author><Year>1986</Year><RecNum>17</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="fp09s2d2ox5xv2e22spxwat7p20050a9e9e5">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Monkhouse, W. S.</author><author>Khalique, A.</author></authors></contributors><titles><title>Variations in the composition of the human rectus sheath: a study of the anterior abdominal wall</title><secondary-title>J Anat</secondary-title></titles><periodical><full-title>J Anat</full-title></periodical><pages>61-6</pages><volume>145</volume><dates><year>1986</year></dates><urls></urls></record></Cite></EndNote>10, ADDIN EN.CITE <EndNote><Cite><Author>Cunningham</Author><Year>2004</Year><RecNum>16</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="fp09s2d2ox5xv2e22spxwat7p20050a9e9e5">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cunningham, S. C.</author><author>Rosson, G. D.</author><author>Lee, R. H.</author><author>Williams, J. Z.</author><author>Lustman, C. A.</author><author>Slezak, S.</author><author>Goldberg, N. H.</author><author>Silverman, R. P.</author></authors></contributors><titles><title>Localization of the Arcuate Line From Surface Anatomic Landmarks:: A Cadaveric Study</title><secondary-title>Annals of Plastic Surgery</secondary-title></titles><periodical><full-title>Annals of Plastic Surgery</full-title></periodical><pages>129-131</pages><volume>53</volume><number>2</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>11 However some authors doubt the existence of the arcuate line and report that the posterior layer of the rectus sheath thins into transversalis fascia, while the anterior layer becomes thickened. ADDIN EN.CITE <EndNote><Cite><Author>Cousins</Author><Year>1998</Year><RecNum>80</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">80</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Cousins, M.J., Bridenbaugh, P.O.</author></authors></contributors><titles><title>Neural Blockade in Clinical Anesthesia and Mangement of Pain</title></titles><edition> 3rd edition</edition><dates><year>1998</year><pub-dates><date>1998</date></pub-dates></dates><publisher> Philadelphia, New York, Lippincott-Raven</publisher><urls></urls></record></Cite></EndNote>12 In contrast, close to the xiphoid process, is the presence of the transversus abdominis muscle posterior to the rectus sheath and rectus abdominis muscles providing a potential site of injection of local anesthetic to cover T6 –T7.The extraperitoneal connective tissue between the parietal peritoneum and the transversalis fascia comprises an adipose layer and a fibrous or membranous layer in contact with the transversalis fascia. The extraperitoneal layer adjacent to the peritoneum can be a very distinct, transparent and fairly tough layer. ADDIN EN.CITE <EndNote><Cite><Author>Colborn GL</Author><Year>1998</Year><RecNum>83</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>83</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">83</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Colborn GL, Skandalakis JE</author></authors></contributors><titles><title>Laparoscopic inguinal anatomy</title><secondary-title>Hernea</secondary-title></titles><periodical><full-title>Hernea</full-title></periodical><pages>179-191</pages><volume>2</volume><number>4</number><dates><year>1998</year></dates><urls></urls></record></Cite></EndNote>13 Course of the thoracolumbar nerves (T6 – L1) innervating the anterolateral abdominal wall. The posterior branches of the spinal nerves supply the skin of the back and the back musculature. The intercostal nerves are the anterior primary rami of T1 – T11, T12 is termed a subcostal nerve because it does not run between two ribs. The intercostal nerves exit the intervertebral foramen. enter the paravertebral region and become related to the intercostal muscles posteriorly. The nerves then run posterolaterally within the grooves of their corresponding ribs between the innermost and internal intercostal muscles. T12 has a similar relationship except it is a subcostal nerve. Segmental nerves T6 – T9 emerge from the costal margin to enter the TAP, between the midline and the anterior axillary line. T6 enters the TAP just lateral to the linea alba and T7, T8 and T9 emerge from the costal margins at increasingly lateral positions respectively. ADDIN EN.CITE <EndNote><Cite><Author>Rozen</Author><Year>2009</Year><RecNum>4</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rozen, W. M.</author><author>Tran, T. M.</author><author>Barrington, M. J.</author><author>Ashton, M. W.</author></authors></contributors><auth-address>Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia. warrenrozen@</auth-address><titles><title>Avoiding denervation of the rectus abdominis muscle in DIEP flap harvest III: a functional study of the nerves to the rectus using anesthetic blockade</title><secondary-title>Plast Reconstr Surg</secondary-title></titles><periodical><full-title>Plast Reconstr Surg</full-title></periodical><pages>519-22</pages><volume>124</volume><number>2</number><edition>2009/08/01</edition><keywords><keyword>Humans</keyword><keyword>Motor Neurons/physiology</keyword><keyword>Nerve Block</keyword><keyword>Rectus Abdominis/*innervation</keyword><keyword>Surgical Flaps/*innervation</keyword><keyword>Sympathectomy, Chemical</keyword><keyword>Tissue and Organ Harvesting</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1529-4242 (Electronic)</isbn><accession-num>19644268</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>6 The T10 segmental nerve is located caudal to the costal margin (rib 10) and T11, T12, and L1 are located in a caudal direction, to the level of the iliac crest. The intercostal, subcostal and first lumbar nerves are located in the TAP as are the blood vessels (deep circumflex iliac, inferior epigastric, superior epigastric). Proximal to the angle of the ribs T6 – T12 nerves send lateral cutaneous branches to the dermis, which in turn bifurcate into anterior and posterior cutaneous branches that supply the skin of the lateral torso. Note that the origins of the lateral cutaneous nerves are at or proximal to the costal angle. However, the point at which it pierces the muscle layers is at the angle of rib or mid-axillary line. ADDIN EN.CITE <EndNote><Cite><Author>Sakamoto</Author><Year>1996</Year><RecNum>73</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>73</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">73</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sakamoto, H.</author><author>Akita, K.</author><author>Sato, T.</author></authors></contributors><auth-address>Department of Anatomy, School of Medicine, Tokyo Medical and Dental University, Japan.</auth-address><titles><title>An anatomical analysis of the relationships between the intercostal nerves and the thoracic and abdominal muscles in man. II. Detailed analysis of innervation of the three lateral abdominal muscles</title><secondary-title>Acta Anat (Basel)</secondary-title></titles><periodical><full-title>Acta Anat (Basel)</full-title></periodical><pages>143-50</pages><volume>156</volume><number>2</number><edition>1996/01/01</edition><keywords><keyword>Abdominal Muscles/*innervation</keyword><keyword>Humans</keyword><keyword>Intercostal Nerves/*anatomy & histology</keyword><keyword>Male</keyword><keyword>Muscles/*innervation</keyword><keyword>Thorax/*innervation</keyword></keywords><dates><year>1996</year></dates><isbn>0001-5180 (Print)
0001-5180 (Linking)</isbn><accession-num>8993634</accession-num><urls><related-urls><url> The lateral cutaneous branches are significant because they send fibres that supply much of the abdominal wall (T6 – T12) and thorax (T1 – T5). The anterior cutaneous nerve sends twigs to the external oblique muscle as well as skin to the lateral margin of the rectus abdominis. The posterior cutaneous branch runs backwards supplying the skin to the lateral border of paravertebral region. The main intercostal nerve throughout its course supplies adjacent muscle (e.g. innermost intercostal) in addition to parietal pleura and peritoneum. There is also a collateral branch formed before the angle of the rib that runs in the intercostal space before entering the posterior rectus sheath. The collateral branch may join the main intercostal nerve for a distance and then separate to form an additional anterior cutaneous branch. ADDIN EN.CITE <EndNote><Cite><Author>Pallie</Author><Year>1982</Year><RecNum>84</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>84</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">84</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pallie, W., Thoma, A</author></authors></contributors><titles><title>Abdominoplasty and Abdominal Wall Innervation</title><secondary-title>Anat Clin</secondary-title></titles><periodical><full-title>Anat Clin</full-title></periodical><pages>323 - 328</pages><volume>4</volume><dates><year>1982</year></dates><urls></urls></record></Cite></EndNote>14 The iliohypogastric and ilioinguinal nerves pass laterally through the psoas muscle and then course anterior to quadratus lumborum and then caudally towards the iliac crest. The nerves continue their course on the inner surface of the transversus abdominis muscle and then pierce the transversus abdominis muscle at a variable location and run for a short distance in the TAP. Most of the literature considers these nerves to be variable in their origin, course and distribution.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LbGFhc3NlbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA 15-17 While most texts describe them as originating from L1, there is some contention about their origin. ADDIN EN.CITE <EndNote><Cite><Author>Klaassen</Author><Year>2011</Year><RecNum>93</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>93</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">93</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Klaassen, Z.</author><author>Marshall, E.</author><author>Tubbs, R. S.</author><author>Louis, R. G., Jr.</author><author>Wartmann, C. T.</author><author>Loukas, M.</author></authors></contributors><auth-address>Department of Anatomical Sciences, School of Medicine, St George's University, Grenada, West Indies.</auth-address><titles><title>Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions</title><secondary-title>Clin Anat</secondary-title></titles><periodical><full-title>Clin Anat</full-title></periodical><pages>454-61</pages><volume>24</volume><number>4</number><edition>2011/04/22</edition><keywords><keyword>Abdominal Wall/innervation</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Cadaver</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hypogastric Plexus/*anatomy & histology</keyword><keyword>Ilium/*innervation</keyword><keyword>Inguinal Canal/*innervation</keyword><keyword>Intraoperative Complications/prevention & control</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Peripheral Nerves/*anatomy & histology</keyword><keyword>Spinal Nerves/*anatomy & histology</keyword></keywords><dates><year>2011</year><pub-dates><date>May</date></pub-dates></dates><isbn>1098-2353 (Electronic)
0897-3806 (Linking)</isbn><accession-num>21509811</accession-num><urls><related-urls><url> In one cadaver study, both the nerves were located in the TAP 5 cm cranial and posterior to the ASIS. ADDIN EN.CITE <EndNote><Cite><Author>Eichenberger</Author><Year>2006</Year><RecNum>102</RecNum><DisplayText><style face="superscript">18</style></DisplayText><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">102</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eichenberger, U.</author><author>Greher, M.</author><author>Kirchmair, L.</author><author>Curatolo, M.</author><author>Moriggl, B.</author></authors></contributors><auth-address>Department of Anaesthesia and General Intensive Care (B), Medical University of Vienna, A-1090 Vienna, Austria. urs.eichenberger@insel.ch</auth-address><titles><title>Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection</title><secondary-title>Br J Anaesth</secondary-title></titles><periodical><full-title>Br J Anaesth</full-title></periodical><pages>238-43</pages><volume>97</volume><number>2</number><edition>2006/05/16</edition><keywords><keyword>Abdomen/innervation</keyword><keyword>Abdominal Muscles</keyword><keyword>Abdominal Wall</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Cadaver</keyword><keyword>Coloring Agents/diagnostic use</keyword><keyword>Dissection/methods</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block/*methods</keyword><keyword>Peripheral Nerves/anatomy & histology/*ultrasonography</keyword><keyword>Transducers</keyword></keywords><dates><year>2006</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0007-0912 (Print)
0007-0912 (Linking)</isbn><accession-num>16698865</accession-num><urls><related-urls><url> [pii]
10.1093/bja/ael103</electronic-resource-num><language>eng</language></record></Cite></EndNote>18 This is consistent with recommendations made by Jamieson, that the initial point of injection for both nerves be 4 – 6 cm posterior to the ASIS (along the external lip of the ilium) where the nerves perforate the transversus abdominis muscle. ADDIN EN.CITE <EndNote><Cite><Author>Jamieson</Author><Year>1952</Year><RecNum>161</RecNum><DisplayText><style face="superscript">19</style></DisplayText><record><rec-number>161</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">161</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jamieson, R. W.</author><author>Swigart, L. L.</author><author>Anson, B. J.</author></authors></contributors><titles><title>Points of parietal perforation of the ilioinguinal and iliohypogastric nerves in relation to optimal sites for local anaesthesia</title><secondary-title>Q Bull Northwest Univ Med Sch</secondary-title></titles><periodical><full-title>Q Bull Northwest Univ Med Sch</full-title></periodical><pages>22-6</pages><volume>26</volume><number>1</number><edition>1952/01/01</edition><keywords><keyword>*Anesthesia, Conduction</keyword><keyword>Hernia, Inguinal/*surgery</keyword></keywords><dates><year>1952</year></dates><accession-num>14912259</accession-num><urls><related-urls><url> Medial to the anterior superior iliac spine the ilioinguinal nerve (IIN) pierces the internal oblique close to the inguinal ligamentPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZGlheWU8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 16,20 and it is at this location that landmark techniques usually aim to locate the IIN. The iliohypogastric nerve (IHN) and the IIN supply the skin and muscles of the pubic and inguinal region and genitalia. In summary, the IHN and IIN are located in the TAP close to the iliac crest and anterior superior iliac spine. ADDIN EN.CITE <EndNote><Cite><Author>Eichenberger</Author><Year>2006</Year><RecNum>102</RecNum><DisplayText><style face="superscript">18</style></DisplayText><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">102</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eichenberger, U.</author><author>Greher, M.</author><author>Kirchmair, L.</author><author>Curatolo, M.</author><author>Moriggl, B.</author></authors></contributors><auth-address>Department of Anaesthesia and General Intensive Care (B), Medical University of Vienna, A-1090 Vienna, Austria. urs.eichenberger@insel.ch</auth-address><titles><title>Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection</title><secondary-title>Br J Anaesth</secondary-title></titles><periodical><full-title>Br J Anaesth</full-title></periodical><pages>238-43</pages><volume>97</volume><number>2</number><edition>2006/05/16</edition><keywords><keyword>Abdomen/innervation</keyword><keyword>Abdominal Muscles</keyword><keyword>Abdominal Wall</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Cadaver</keyword><keyword>Coloring Agents/diagnostic use</keyword><keyword>Dissection/methods</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block/*methods</keyword><keyword>Peripheral Nerves/anatomy & histology/*ultrasonography</keyword><keyword>Transducers</keyword></keywords><dates><year>2006</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0007-0912 (Print)
0007-0912 (Linking)</isbn><accession-num>16698865</accession-num><urls><related-urls><url> [pii]
10.1093/bja/ael103</electronic-resource-num><language>eng</language></record></Cite></EndNote>18 Medial and inferior to the anterior superior iliac spine the nerves are located between the internal and external oblique muscles. ADDIN EN.CITE <EndNote><Cite><Author>Klaassen</Author><Year>2011</Year><RecNum>93</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>93</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">93</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Klaassen, Z.</author><author>Marshall, E.</author><author>Tubbs, R. S.</author><author>Louis, R. G., Jr.</author><author>Wartmann, C. T.</author><author>Loukas, M.</author></authors></contributors><auth-address>Department of Anatomical Sciences, School of Medicine, St George's University, Grenada, West Indies.</auth-address><titles><title>Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions</title><secondary-title>Clin Anat</secondary-title></titles><periodical><full-title>Clin Anat</full-title></periodical><pages>454-61</pages><volume>24</volume><number>4</number><edition>2011/04/22</edition><keywords><keyword>Abdominal Wall/innervation</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Cadaver</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hypogastric Plexus/*anatomy & histology</keyword><keyword>Ilium/*innervation</keyword><keyword>Inguinal Canal/*innervation</keyword><keyword>Intraoperative Complications/prevention & control</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Peripheral Nerves/*anatomy & histology</keyword><keyword>Spinal Nerves/*anatomy & histology</keyword></keywords><dates><year>2011</year><pub-dates><date>May</date></pub-dates></dates><isbn>1098-2353 (Electronic)
0897-3806 (Linking)</isbn><accession-num>21509811</accession-num><urls><related-urls><url> Rozen et. al. ADDIN EN.CITE <EndNote><Cite><Author>Rozen</Author><Year>2009</Year><RecNum>4</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rozen, W. M.</author><author>Tran, T. M.</author><author>Barrington, M. J.</author><author>Ashton, M. W.</author></authors></contributors><auth-address>Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia. warrenrozen@</auth-address><titles><title>Avoiding denervation of the rectus abdominis muscle in DIEP flap harvest III: a functional study of the nerves to the rectus using anesthetic blockade</title><secondary-title>Plast Reconstr Surg</secondary-title></titles><periodical><full-title>Plast Reconstr Surg</full-title></periodical><pages>519-22</pages><volume>124</volume><number>2</number><edition>2009/08/01</edition><keywords><keyword>Humans</keyword><keyword>Motor Neurons/physiology</keyword><keyword>Nerve Block</keyword><keyword>Rectus Abdominis/*innervation</keyword><keyword>Surgical Flaps/*innervation</keyword><keyword>Sympathectomy, Chemical</keyword><keyword>Tissue and Organ Harvesting</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1529-4242 (Electronic)</isbn><accession-num>19644268</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>6 documented extensive communication between T9 – L1 in the TAP. For example in one cadaver study both T11 and T12 nerves had communicating branches to the nerves of segmental origins above and below. Similarly Sakamoto documented complex distal communications between all thoracolumbar nerves. ADDIN EN.CITE <EndNote><Cite><Author>Sakamoto</Author><Year>1996</Year><RecNum>73</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>73</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">73</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sakamoto, H.</author><author>Akita, K.</author><author>Sato, T.</author></authors></contributors><auth-address>Department of Anatomy, School of Medicine, Tokyo Medical and Dental University, Japan.</auth-address><titles><title>An anatomical analysis of the relationships between the intercostal nerves and the thoracic and abdominal muscles in man. II. Detailed analysis of innervation of the three lateral abdominal muscles</title><secondary-title>Acta Anat (Basel)</secondary-title></titles><periodical><full-title>Acta Anat (Basel)</full-title></periodical><pages>143-50</pages><volume>156</volume><number>2</number><edition>1996/01/01</edition><keywords><keyword>Abdominal Muscles/*innervation</keyword><keyword>Humans</keyword><keyword>Intercostal Nerves/*anatomy & histology</keyword><keyword>Male</keyword><keyword>Muscles/*innervation</keyword><keyword>Thorax/*innervation</keyword></keywords><dates><year>1996</year></dates><isbn>0001-5180 (Print)
0001-5180 (Linking)</isbn><accession-num>8993634</accession-num><urls><related-urls><url> Because of the proximal communications the nerves in a given rectus sheath ‘segment’ correspond to multiple spinal origins.The intercostal nerves (lower five) pierce the lateral margin of the linea semilunaris to enter the rectus sheath posterolaterally. The intercostal (T6 – T9), subcostal and L1 nerves terminate in the rectus abdominis muscle with three patterns: 1. Terminate simply within the muscle, 2. Supply the muscle and then terminate as a cutaneous branch, and 3. Pass through the muscle and terminate as a cutaneous branch. ADDIN EN.CITE <EndNote><Cite><Author>Sakamoto</Author><Year>1996</Year><RecNum>73</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>73</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">73</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sakamoto, H.</author><author>Akita, K.</author><author>Sato, T.</author></authors></contributors><auth-address>Department of Anatomy, School of Medicine, Tokyo Medical and Dental University, Japan.</auth-address><titles><title>An anatomical analysis of the relationships between the intercostal nerves and the thoracic and abdominal muscles in man. II. Detailed analysis of innervation of the three lateral abdominal muscles</title><secondary-title>Acta Anat (Basel)</secondary-title></titles><periodical><full-title>Acta Anat (Basel)</full-title></periodical><pages>143-50</pages><volume>156</volume><number>2</number><edition>1996/01/01</edition><keywords><keyword>Abdominal Muscles/*innervation</keyword><keyword>Humans</keyword><keyword>Intercostal Nerves/*anatomy & histology</keyword><keyword>Male</keyword><keyword>Muscles/*innervation</keyword><keyword>Thorax/*innervation</keyword></keywords><dates><year>1996</year></dates><isbn>0001-5180 (Print)
0001-5180 (Linking)</isbn><accession-num>8993634</accession-num><urls><related-urls><url> Rozen et. al. ADDIN EN.CITE <EndNote><Cite><Author>Rozen</Author><Year>2009</Year><RecNum>4</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rozen, W. M.</author><author>Tran, T. M.</author><author>Barrington, M. J.</author><author>Ashton, M. W.</author></authors></contributors><auth-address>Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia. warrenrozen@</auth-address><titles><title>Avoiding denervation of the rectus abdominis muscle in DIEP flap harvest III: a functional study of the nerves to the rectus using anesthetic blockade</title><secondary-title>Plast Reconstr Surg</secondary-title></titles><periodical><full-title>Plast Reconstr Surg</full-title></periodical><pages>519-22</pages><volume>124</volume><number>2</number><edition>2009/08/01</edition><keywords><keyword>Humans</keyword><keyword>Motor Neurons/physiology</keyword><keyword>Nerve Block</keyword><keyword>Rectus Abdominis/*innervation</keyword><keyword>Surgical Flaps/*innervation</keyword><keyword>Sympathectomy, Chemical</keyword><keyword>Tissue and Organ Harvesting</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1529-4242 (Electronic)</isbn><accession-num>19644268</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>6 also noted that as the nerves approach the posterior surface of the rectus abdominis, a longitudinal branch of fibres run craniocaudally with the deep inferior epigastric artery (DIEA). In addition, the cutaneous branches were closely related to the perforating musculocutaneous vessels. Together T7 – L1 supply the skin from the xiphoid sternum (T7 nerve root) to the pubic symphysis (L1 nerve root), with T10 nerve supplying the umbilical segment. The IHN nerve supplies the lowermost segment of the rectus abdominis muscle and overlying skin.Transabdominis plane block.The TAP block is a relatively new regional analgesic technique suitable for use in abdominal surgery. TAP block involves injection of local anesthetic into the neurovascular plane (TAP) between the internal oblique and transversus abdominis muscles. The TAP block was first described by Rafi HYPERLINK \l "_ENREF_21" \o "Rafi, 2001 #1" ADDIN EN.CITE <EndNote><Cite><Author>Rafi</Author><Year>2001</Year><RecNum>1</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rafi, A. N.</author></authors></contributors><titles><title>Abdominal field block: a new approach via the lumbar triangle</title><secondary-title>Anaesthesia</secondary-title></titles><periodical><full-title>Anaesthesia</full-title></periodical><pages>1024-6</pages><volume>56</volume><number>10</number><edition>2001/09/29</edition><keywords><keyword>Abdomen/*surgery</keyword><keyword>Abdominal Muscles</keyword><keyword>Anesthetics, Local/administration & dosage</keyword><keyword>Humans</keyword><keyword>Injections, Intramuscular/methods</keyword><keyword>Nerve Block/*methods</keyword></keywords><dates><year>2001</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-2409 (Print)
0003-2409 (Linking)</isbn><accession-num>11576144</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>21 and then subject to randomized controlled trials by McDonnell.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Rvbm5lbGw8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFy
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ADDIN EN.CITE.DATA 24,25 TAP block has been combined with multimodal analgesia for postoperative analgesia following colonic surgery ADDIN EN.CITE <EndNote><Cite><Author>McDonnell</Author><Year>2007</Year><RecNum>22</RecNum><DisplayText><style face="superscript">23</style></DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McDonnell, J. G.</author><author>O'Donnell, B.</author><author>Curley, G.</author><author>Heffernan, A.</author><author>Power, C.</author><author>Laffey, J. G.</author></authors></contributors><auth-address>Department of Anaesthesia and Intensive Care Medicine, University College Hospital, Galway, Ireland.</auth-address><titles><title>The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial</title><secondary-title>Anesth Analg</secondary-title></titles><periodical><full-title>Anesth Analg</full-title></periodical><pages>193-7</pages><volume>104</volume><number>1</number><edition>2006/12/21</edition><keywords><keyword>*Abdomen</keyword><keyword>*Analgesia</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Intestine, Large/*surgery</keyword><keyword>Intestines/surgery</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neuromuscular Depolarizing Agents/*therapeutic use</keyword><keyword>Pain, Postoperative/*prevention & control</keyword><keyword>*Surgical Procedures, Operative</keyword></keywords><dates><year>2007</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1526-7598 (Electronic)
0003-2999 (Linking)</isbn><accession-num>17179269</accession-num><urls><related-urls><url> [pii]
10.1213/01.ane.0000250223.49963.0f</electronic-resource-num><language>eng</language></record></Cite></EndNote>23, appendicectomy HYPERLINK \l "_ENREF_26" \o "Carney, 2010 #26" ADDIN EN.CITE <EndNote><Cite><Author>Carney</Author><Year>2010</Year><RecNum>26</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carney, J.</author><author>Finnerty, O.</author><author>Rauf, J.</author><author>Curley, G.</author><author>McDonnell, J. G.</author><author>Laffey, J. G.</author></authors></contributors><auth-address>Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland, Galway, Ireland. john.laffey@nuigalway.ie</auth-address><titles><title>Ipsilateral transversus abdominis plane block provides effective analgesia after appendectomy in children: a randomized controlled trial</title><secondary-title>Anesth Analg</secondary-title></titles><periodical><full-title>Anesth Analg</full-title></periodical><pages>998-1003</pages><volume>111</volume><number>4</number><edition>2010/08/31</edition><keywords><keyword>Abdominal Muscles/drug effects/*surgery</keyword><keyword>Adolescent</keyword><keyword>Amides/*administration & dosage</keyword><keyword>Analgesia, Patient-Controlled/*methods</keyword><keyword>Appendectomy/*adverse effects/methods</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Double-Blind Method</keyword><keyword>Humans</keyword><keyword>Nerve Block/*methods</keyword><keyword>Pain, Postoperative/*prevention & control</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1526-7598 (Electronic)
0003-2999 (Linking)</isbn><accession-num>20802056</accession-num><urls><related-urls><url> [pii]
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ADDIN EN.CITE.DATA 28, hernia repair and other types of abdominal surgery. The TAP block is well described following paediatric surgeryPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW5kZW1hbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA 31 A systematic review of studies has demonstrated clinically significant reductions of post-operative opioid requirements and pain ADDIN EN.CITE <EndNote><Cite><Author>Siddiqui</Author><Year>2011</Year><RecNum>32</RecNum><DisplayText><style face="superscript">32</style></DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Siddiqui, M. R.</author><author>Sajid, M. S.</author><author>Uncles, D. R.</author><author>Cheek, L.</author><author>Baig, M. K.</author></authors></contributors><auth-address>Department of Colorectal Surgery, Worthing Hospital, West Sussex BN112DH, UK. md0u812a@</auth-address><titles><title>A meta-analysis on the clinical effectiveness of transversus abdominis plane block</title><secondary-title>J Clin Anesth</secondary-title></titles><periodical><full-title>J Clin Anesth</full-title></periodical><pages>7-14</pages><volume>23</volume><number>1</number><edition>2011/02/08</edition><keywords><keyword>*Abdomen/surgery</keyword><keyword>Analgesia</keyword><keyword>Analgesics, Opioid/adverse effects/therapeutic use</keyword><keyword>Anesthetics, Local</keyword><keyword>Humans</keyword><keyword>Intensive Care</keyword><keyword>Laparoscopy</keyword><keyword>Laparotomy</keyword><keyword>Morphine/adverse effects/therapeutic use</keyword><keyword>*Nerve Block</keyword><keyword>Pain Measurement/drug effects</keyword><keyword>Pain, Postoperative/diagnosis/drug therapy/*epidemiology</keyword><keyword>Postoperative Nausea and Vomiting/epidemiology</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2011</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1873-4529 (Electronic)
0952-8180 (Linking)</isbn><accession-num>21296242</accession-num><urls><related-urls><url>(10)00372-7 [pii]
10.1016/j.jclinane.2010.05.008</electronic-resource-num><language>eng</language></record></Cite></EndNote>32, in addition to reduced opioid-related side effects. ADDIN EN.CITE <EndNote><Cite><Author>Petersen</Author><Year>2010</Year><RecNum>29</RecNum><DisplayText><style face="superscript">33</style></DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">29</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Petersen, P. L.</author><author>Mathiesen, O.</author><author>Torup, H.</author><author>Dahl, J. B.</author></authors></contributors><auth-address>Department of Anaesthesia, Copenhagen University Hospital, Ndr. Ringvej, DK-2600 Glostrup, Denmark. pernille.lykke.petersen@dadlnet.dk</auth-address><titles><title>The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review</title><secondary-title>Acta Anaesthesiol Scand</secondary-title></titles><periodical><full-title>Acta Anaesthesiol Scand</full-title></periodical><pages>529-35</pages><volume>54</volume><number>5</number><edition>2010/02/24</edition><keywords><keyword>Abdominal Muscles/*innervation/surgery</keyword><keyword>Analgesics, Opioid/therapeutic use</keyword><keyword>Humans</keyword><keyword>Morphine/therapeutic use</keyword><keyword>Nerve Block/instrumentation/*methods</keyword><keyword>Pain, Postoperative/*prevention & control</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2010</year><pub-dates><date>May</date></pub-dates></dates><isbn>1399-6576 (Electronic)
0001-5172 (Linking)</isbn><accession-num>20175754</accession-num><urls><related-urls><url> [pii]
10.1111/j.1399-6576.2010.02215.x</electronic-resource-num><language>eng</language></record></Cite></EndNote>33 Recently, TAP block has been combined with sedation and utilized for surgical anesthesia for caesarean section. ADDIN EN.CITE <EndNote><Cite><Author>Mei</Author><Year>2011</Year><RecNum>162</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>162</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">162</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mei, W.</author><author>Jin, C.</author><author>Feng, L.</author><author>Zhang, Y.</author><author>Luo, A.</author><author>Zhang, C.</author><author>Tian, Y.</author></authors></contributors><auth-address>Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Ave. 1095#, 430030 Wuhan, China.</auth-address><titles><title>Bilateral ultrasound-guided transversus abdominis plane block combined with ilioinguinal-iliohypogastric nerve block for cesarean delivery anesthesia</title><secondary-title>Anesth Analg</secondary-title></titles><periodical><full-title>Anesth Analg</full-title></periodical><pages>134-7</pages><volume>113</volume><number>1</number><edition>2011/04/07</edition><keywords><keyword>Abdominal Muscles/*innervation/*ultrasonography</keyword><keyword>Adult</keyword><keyword>Autonomic Nerve Block/*methods</keyword><keyword>Cesarean Section/adverse effects/*methods</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Pain, Postoperative/etiology/prevention & control</keyword><keyword>Pregnancy</keyword><keyword>Ultrasonography, Interventional/*methods</keyword></keywords><dates><year>2011</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1526-7598 (Electronic)
0003-2999 (Linking)</isbn><accession-num>21467562</accession-num><urls><related-urls><url> [pii]
10.1213/ANE.0b013e31821891e2</electronic-resource-num><language>eng</language></record></Cite></EndNote>34 Knowledge of the location of the thoracolumbar nerves in the transversus abdominis plane is the basis for this procedure.Techniques and approachesTriangle of Petit (Landmark technique)The triangle of Petit is formed by the iliac crest as the base, the external oblique muscle as the anterior border and the latissimus dorsi muscle as the posterior border. The floor of the triangle is formed by the fascia of the external and internal oblique muscles. This is the only location in the abdominal wall where the internal oblique muscle is readily accessible. The space can be located by palpating from the anterior superior iliac spine posteriorly along the iliac crest till the finger slips over the edge of a muscle. ADDIN EN.CITE <EndNote><Cite><Author>Rafi</Author><Year>2001</Year><RecNum>1</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rafi, A. N.</author></authors></contributors><titles><title>Abdominal field block: a new approach via the lumbar triangle</title><secondary-title>Anaesthesia</secondary-title></titles><periodical><full-title>Anaesthesia</full-title></periodical><pages>1024-6</pages><volume>56</volume><number>10</number><edition>2001/09/29</edition><keywords><keyword>Abdomen/*surgery</keyword><keyword>Abdominal Muscles</keyword><keyword>Anesthetics, Local/administration & dosage</keyword><keyword>Humans</keyword><keyword>Injections, Intramuscular/methods</keyword><keyword>Nerve Block/*methods</keyword></keywords><dates><year>2001</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-2409 (Print)
0003-2409 (Linking)</isbn><accession-num>11576144</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>21 Using this technique, a short-bevel or blunt needle is inserted immediately cephalad to the iliac crest through the skin perpendicular into the triangle with two pops indicating entry into the TAP. Further detail can be found in the initial description by Rafi HYPERLINK \l "_ENREF_21" \o "Rafi, 2001 #1" ADDIN EN.CITE <EndNote><Cite><Author>Rafi</Author><Year>2001</Year><RecNum>1</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rafi, A. N.</author></authors></contributors><titles><title>Abdominal field block: a new approach via the lumbar triangle</title><secondary-title>Anaesthesia</secondary-title></titles><periodical><full-title>Anaesthesia</full-title></periodical><pages>1024-6</pages><volume>56</volume><number>10</number><edition>2001/09/29</edition><keywords><keyword>Abdomen/*surgery</keyword><keyword>Abdominal Muscles</keyword><keyword>Anesthetics, Local/administration & dosage</keyword><keyword>Humans</keyword><keyword>Injections, Intramuscular/methods</keyword><keyword>Nerve Block/*methods</keyword></keywords><dates><year>2001</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-2409 (Print)
0003-2409 (Linking)</isbn><accession-num>11576144</accession-num><urls><related-urls><url> [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>21 and also in subsequent work by McDonnell. ADDIN EN.CITE <EndNote><Cite><Author>McDonnell</Author><Year>2007</Year><RecNum>10</RecNum><DisplayText><style face="superscript">35</style></DisplayText><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McDonnell, J. G.</author><author>Laffey, J. G.</author></authors></contributors><titles><title>Transversus abdominis plane block</title><secondary-title>Anesth Analg</secondary-title></titles><periodical><full-title>Anesth Analg</full-title></periodical><pages>883</pages><volume>105</volume><number>3</number><edition>2007/08/25</edition><keywords><keyword>Abdominal Muscles/*surgery</keyword><keyword>Anesthetics, Local/*administration & dosage</keyword><keyword>Female</keyword><keyword>*Gynecologic Surgical Procedures</keyword><keyword>Humans</keyword><keyword>Nerve Block/*methods</keyword><keyword>Time Factors</keyword></keywords><dates><year>2007</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1526-7598 (Electronic)
0003-2999 (Linking)</isbn><accession-num>17717264</accession-num><urls><related-urls><url> [pii]
10.1213/01.ane.0000268542.45107.79</electronic-resource-num><language>eng</language></record></Cite></EndNote>35Ultrasound guided techniquesRegardless of side of TAP block, the ultrasound machine can be placed on the opposite side of the patient to where the proceduralist stands, so that he/she directly faces the screen. An intermediate frequency probe (with a wide field of view) and a 100 – 150 mm needle are suitable. Although the abdominal wall sonogram is straightforward, identification of the exact muscular layer in obese patients can be challenging. Therefore, a useful starting point for both the subcostal and posterior approaches is the linea semilunaris. This aponeurosis is readily identified with sonography, separating the rectus abdominis from the three muscles of the lateral abdominal wall and dynamic scanning from medial to lateral or vice-versa helps with correct identification of muscle layers. In many patients, the rectus abdominis muscle may be displaced further away from the midline than expected. The presenter’s preferred needle trajectory is from medial to posterolateral using an in-plane technique with the probe initially located medially. Needle imaging can be improved by separating the initial needle entry point through the skin from the probe by 2 – 5 cm and heel-toe the probe. Oblique Subcostal TAP blockIt is useful to locate the tranversus abdominis muscle posterior to the rectus abdominis muscle close to the xyphoid process. ADDIN EN.CITE <EndNote><Cite><Author>Hebbard</Author><Year>2010</Year><RecNum>46</RecNum><DisplayText><style face="superscript">25</style></DisplayText><record><rec-number>46</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">46</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hebbard, P. D.</author><author>Barrington, M. J.</author><author>Vasey, C.</author></authors></contributors><auth-address>Northeast Health Wangaratta, 134 Templeton St, Wangaratta, Victoria 3677, Australia. p.hebbard@</auth-address><titles><title>Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique</title><secondary-title>Reg Anesth Pain Med</secondary-title></titles><periodical><full-title>Reg Anesth Pain Med</full-title></periodical><pages>436-41</pages><volume>35</volume><number>5</number><edition>2010/09/14</edition><keywords><keyword>Abdominal Muscles/*anatomy & histology</keyword><keyword>Abdominal Wall/*innervation/ultrasonography</keyword><keyword>Catheters</keyword><keyword>Humans</keyword><keyword>Nerve Block/*methods</keyword><keyword>Pain, Postoperative/*prevention & control</keyword><keyword>Ultrasonography, Interventional</keyword></keywords><dates><year>2010</year><pub-dates><date>Sep-Oct</date></pub-dates></dates><isbn>1532-8651 (Electronic)
1098-7339 (Linking)</isbn><accession-num>20830871</accession-num><urls><related-urls><url> The segmental nerves are located in this plane but T6 – T 8 may only have a short course between the transversus abdominis and the rectus abdominis muscles. The nerves may, after a short distance beyond the costal margin penetrate the posterior rectus sheath and rectus muscle, therefore the injection close to the costal margin may improve anesthesia. ADDIN EN.CITE <EndNote><Cite><Author>Barrington</Author><Year>2009</Year><RecNum>5</RecNum><DisplayText><style face="superscript">36</style></DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barrington, M. J.</author><author>Ivanusic, J. J.</author><author>Rozen, W. M.</author><author>Hebbard, P.</author></authors></contributors><auth-address>Department of Anaesthesia, St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia. michael.barrington@.au</auth-address><titles><title>Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: a cadaveric study</title><secondary-title>Anaesthesia</secondary-title></titles><periodical><full-title>Anaesthesia</full-title></periodical><pages>745-50</pages><volume>64</volume><number>7</number><edition>2009/07/25</edition><keywords><keyword>Abdominal Muscles/innervation/metabolism/ultrasonography</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Anesthetics, Local/*administration & dosage/pharmacokinetics</keyword><keyword>Coloring Agents/administration & dosage/pharmacokinetics</keyword><keyword>Drug Administration Schedule</keyword><keyword>Humans</keyword><keyword>Nerve Block/*methods</keyword><keyword>Ultrasonography, Interventional/*methods</keyword></keywords><dates><year>2009</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1365-2044 (Electronic)
0003-2409 (Linking)</isbn><accession-num>19624629</accession-num><urls><related-urls><url> [pii]
10.1111/j.1365-2044.2009.05933.x</electronic-resource-num><language>eng</language></record></Cite></EndNote>36 Beginning at the transversus-rectus abdominis interface medially, an incremental injection of 3 – 5 mls of local anesthetic can then be extend the hydrodissection laterally along a line parallel to the costal margin (oblique subcostal line) so that the number of nerves involved in local anesthetic is maximized. ADDIN EN.CITE <EndNote><Cite><Author>Barrington</Author><Year>2009</Year><RecNum>5</RecNum><DisplayText><style face="superscript">36</style></DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barrington, M. J.</author><author>Ivanusic, J. J.</author><author>Rozen, W. M.</author><author>Hebbard, P.</author></authors></contributors><auth-address>Department of Anaesthesia, St Vincent's Hospital, Melbourne, Fitzroy, Victoria, Australia. michael.barrington@.au</auth-address><titles><title>Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: a cadaveric study</title><secondary-title>Anaesthesia</secondary-title></titles><periodical><full-title>Anaesthesia</full-title></periodical><pages>745-50</pages><volume>64</volume><number>7</number><edition>2009/07/25</edition><keywords><keyword>Abdominal Muscles/innervation/metabolism/ultrasonography</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Anesthetics, Local/*administration & dosage/pharmacokinetics</keyword><keyword>Coloring Agents/administration & dosage/pharmacokinetics</keyword><keyword>Drug Administration Schedule</keyword><keyword>Humans</keyword><keyword>Nerve Block/*methods</keyword><keyword>Ultrasonography, Interventional/*methods</keyword></keywords><dates><year>2009</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1365-2044 (Electronic)
0003-2409 (Linking)</isbn><accession-num>19624629</accession-num><urls><related-urls><url> [pii]
10.1111/j.1365-2044.2009.05933.x</electronic-resource-num><language>eng</language></record></Cite></EndNote>36Posterior TAP blockThe ultrasound probe is positioned in the mid to anterior axillary line between the iliac crest and the costal margin. In many patients the distance between these two landmarks is small, so the exact position (e.g. halfway between the iliac crest and costal margin) probably does not matter. An in-plane technique with the needle directed anterior to posterior (towards the midaxillary line) is straightforward. Incremental injections, hydrodissection then needle advancement is similar to the subcostal technique. Local anesthetic dosage, volume and spreadThere have been inconsistent descriptions of the extent of sensory blockade achieved with TAP. In one cadaver study a mock ultrasound-guided posterior TAP block demonstrated that segmental nerves T10, T11, T12, and L1 were involved in dye in 50%, 100%, 100%, and 93% of the hemi-abdomens respectively. ADDIN EN.CITE <EndNote><Cite><Author>Tran</Author><Year>2009</Year><RecNum>6</RecNum><DisplayText><style face="superscript">37</style></DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tran, T. M.</author><author>Ivanusic, J. J.</author><author>Hebbard, P.</author><author>Barrington, M. J.</author></authors></contributors><auth-address>Department of Anaesthesia, St Vincent's Hospital, Melbourne, PO Box 2900, Fitzroy, VIC 3065, Australia.</auth-address><titles><title>Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: a cadaveric study</title><secondary-title>Br J Anaesth</secondary-title></titles><periodical><full-title>Br J Anaesth</full-title></periodical><pages>123-7</pages><volume>102</volume><number>1</number><edition>2008/12/09</edition><keywords><keyword>Abdominal Wall/innervation/*ultrasonography</keyword><keyword>Anesthetics, Local/*administration & dosage/pharmacokinetics</keyword><keyword>Aniline Compounds/administration & dosage/pharmacokinetics</keyword><keyword>Coloring Agents/administration & dosage/pharmacokinetics</keyword><keyword>Humans</keyword><keyword>Nerve Block/*methods</keyword><keyword>Spinal Nerve Roots/metabolism</keyword><keyword>Ultrasonography, Interventional/*methods</keyword></keywords><dates><year>2009</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1471-6771 (Electronic)
0007-0912 (Linking)</isbn><accession-num>19059922</accession-num><urls><related-urls><url> [pii]
10.1093/bja/aen344</electronic-resource-num><language>eng</language></record></Cite></EndNote>37 This is consistent with a clinical study where the posterior approach consistently produced sensory block of three dermatomal segments using a 20 ml injectate, the most cephalad being T10. ADDIN EN.CITE <EndNote><Cite><Author>Lee</Author><Year>2010</Year><RecNum>13</RecNum><DisplayText><style face="superscript">38</style></DisplayText><record><rec-number>13</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">13</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lee, T. H.</author><author>Barrington, M. J.</author><author>Tran, T. M.</author><author>Wong, D.</author><author>Hebbard, P. D.</author></authors></contributors><auth-address>Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia.</auth-address><titles><title>Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block</title><secondary-title>Anaesth Intensive Care</secondary-title></titles><periodical><full-title>Anaesth Intensive Care</full-title></periodical><pages>452-60</pages><volume>38</volume><number>3</number><edition>2010/06/03</edition><keywords><keyword>Abdomen/*surgery</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block/*methods</keyword><keyword>Pain, Postoperative/*therapy</keyword><keyword>Prospective Studies</keyword><keyword>Ultrasonics</keyword></keywords><dates><year>2010</year><pub-dates><date>May</date></pub-dates></dates><isbn>0310-057X (Print)
0310-057X (Linking)</isbn><accession-num>20514952</accession-num><urls><related-urls><url> Confinement of sensory blockade to the lower abdomen following posterior TAP block is consistent with correspondence from Shibata et. al. ADDIN EN.CITE <EndNote><Cite><Author>Shibata</Author><Year>2007</Year><RecNum>115</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shibata, Y.</author><author>Sato, Y.</author><author>Fujiwara, Y.</author><author>Komatsu, T.</author></authors></contributors><titles><title>Transversus abdominis plane block</title><secondary-title>Anesth Analg</secondary-title></titles><periodical><full-title>Anesth Analg</full-title></periodical><pages>883; author reply 883</pages><volume>105</volume><number>3</number><edition>2007/08/25</edition><keywords><keyword>Abdominal Muscles/*surgery/ultrasonography</keyword><keyword>Anesthetics, Local/*administration & dosage</keyword><keyword>Female</keyword><keyword>*Gynecologic Surgical Procedures</keyword><keyword>Humans</keyword><keyword>Nerve Block/*methods</keyword><keyword>Sensory Thresholds</keyword></keywords><dates><year>2007</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1526-7598 (Electronic)
0003-2999 (Linking)</isbn><accession-num>17717265</accession-num><urls><related-urls><url> [pii]
10.1213/01.ane.0000268541.83265.7d</electronic-resource-num><language>eng</language></record></Cite></EndNote>39 who assessed sensory block in 26 patients having laparoscopic gynaecological surgery and reported sensory block over the T10–L1 dermatomes. In contrast, a study by McDonnell and colleagues reported a sensory block from T7 to L1 in three volunteers when a landmark technique was used to access the TAP through the lumbar triangle. ADDIN EN.CITE <EndNote><Cite><Author>McDonnell</Author><Year>2007</Year><RecNum>8</RecNum><DisplayText><style face="superscript">40</style></DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">8</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McDonnell, J. G.</author><author>O'Donnell, B. D.</author><author>Farrell, T.</author><author>Gough, N.</author><author>Tuite, D.</author><author>Power, C.</author><author>Laffey, J. G.</author></authors></contributors><auth-address>Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Tallaght, Dublin, Ireland.</auth-address><titles><title>Transversus abdominis plane block: a cadaveric and radiological evaluation</title><secondary-title>Reg Anesth Pain Med</secondary-title></titles><periodical><full-title>Reg Anesth Pain Med</full-title></periodical><pages>399-404</pages><volume>32</volume><number>5</number><edition>2007/10/27</edition><keywords><keyword>*Abdominal Wall/anatomy & histology</keyword><keyword>Adult</keyword><keyword>Anesthetics, Local/administration & dosage/pharmacokinetics/pharmacology</keyword><keyword>Cadaver</keyword><keyword>Humans</keyword><keyword>Lidocaine/administration & dosage/pharmacokinetics/pharmacology</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Methylene Blue</keyword><keyword>*Nerve Block/methods</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>2007</year><pub-dates><date>Sep-Oct</date></pub-dates></dates><isbn>1098-7339 (Print)
1098-7339 (Linking)</isbn><accession-num>17961838</accession-num><urls><related-urls><url>(07)00573-1 [pii]
10.1016/j.rapm.2007.03.011</electronic-resource-num><language>eng</language></record></Cite></EndNote>40 Sensory blockade following the subcostal approach results in of four segments blocked, the most cephalad being T8. ADDIN EN.CITE <EndNote><Cite><Author>Lee</Author><Year>2010</Year><RecNum>13</RecNum><DisplayText><style face="superscript">38</style></DisplayText><record><rec-number>13</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">13</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lee, T. H.</author><author>Barrington, M. J.</author><author>Tran, T. M.</author><author>Wong, D.</author><author>Hebbard, P. D.</author></authors></contributors><auth-address>Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia.</auth-address><titles><title>Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block</title><secondary-title>Anaesth Intensive Care</secondary-title></titles><periodical><full-title>Anaesth Intensive Care</full-title></periodical><pages>452-60</pages><volume>38</volume><number>3</number><edition>2010/06/03</edition><keywords><keyword>Abdomen/*surgery</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block/*methods</keyword><keyword>Pain, Postoperative/*therapy</keyword><keyword>Prospective Studies</keyword><keyword>Ultrasonics</keyword></keywords><dates><year>2010</year><pub-dates><date>May</date></pub-dates></dates><isbn>0310-057X (Print)
0310-057X (Linking)</isbn><accession-num>20514952</accession-num><urls><related-urls><url> Ninety-eight percent of patients had some degree of demonstrable sensory block and the dermatomal spread differed between posterior and subcostal approaches (P <0.001). ADDIN EN.CITE <EndNote><Cite><Author>Lee</Author><Year>2010</Year><RecNum>13</RecNum><DisplayText><style face="superscript">38</style></DisplayText><record><rec-number>13</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">13</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lee, T. H.</author><author>Barrington, M. J.</author><author>Tran, T. M.</author><author>Wong, D.</author><author>Hebbard, P. D.</author></authors></contributors><auth-address>Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia.</auth-address><titles><title>Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block</title><secondary-title>Anaesth Intensive Care</secondary-title></titles><periodical><full-title>Anaesth Intensive Care</full-title></periodical><pages>452-60</pages><volume>38</volume><number>3</number><edition>2010/06/03</edition><keywords><keyword>Abdomen/*surgery</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block/*methods</keyword><keyword>Pain, Postoperative/*therapy</keyword><keyword>Prospective Studies</keyword><keyword>Ultrasonics</keyword></keywords><dates><year>2010</year><pub-dates><date>May</date></pub-dates></dates><isbn>0310-057X (Print)
0310-057X (Linking)</isbn><accession-num>20514952</accession-num><urls><related-urls><url> The posterior approach appears to be appropriate for lower abdominal surgery and the subcostal approach better suited to upper abdominal surgery. The spread of injectate following TAP block is limited by the linear semilunaris and tendinous intersections of rectus abdominis. The posterior rectus sheath, together with the tendinous intersections, can limit spread of and contain local anaesthetic within the injected rectus sheath segment. Optimal volumes and concentrations of local anesthetics for use in TAP block have yet to be determined. It is the presenter’s practice is to use approximately ropivacaine 3 – 3.5 mg/kg as the total dose received by the patient diluted to 20 - 30 ml for each side. 4. Rectus sheath block.The rectus sheath block can provide postoperative analgesia for abdominal surgery requiring midline incisions around the umbilicus and has been used effectively following incisional and umbilical hernea repair, caesarian section (when midline incision used) and laparoscopy. The rectus sheath block aims to block the terminal branches of segmental nerves, T6 – L1. Anteriorly, the rectus sheath is tough and fibrous from the xiphoid to the pubis. Posteriorly, it is well defined and identifiable till the level of the umbilicus and then inferiorly fades into the transversalis fascia. The posterior rectus sheath is substantial and has been described as a “backboard” for injecting local anesthetics. ADDIN EN.CITE <EndNote><Cite><Author>Cousins</Author><Year>1998</Year><RecNum>80</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">80</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Cousins, M.J., Bridenbaugh, P.O.</author></authors></contributors><titles><title>Neural Blockade in Clinical Anesthesia and Mangement of Pain</title></titles><edition> 3rd edition</edition><dates><year>1998</year><pub-dates><date>1998</date></pub-dates></dates><publisher> Philadelphia, New York, Lippincott-Raven</publisher><urls></urls></record></Cite></EndNote>12 Techniques and approachesLoss-of-resistance (LOR) techniqueThis technique relies on the LOR indicating entry of a block needle through the anterior layer of the rectus sheath into the rectus sheath. Probably, this technique has been underutilized because of perceived accuracy in needle tip location and underlying peritoneum. If ultrasound equipment and appropriate skills were available, then the LOR technique is probably not justified.Ultrasound-guided techniquesIdentifying the linea semilunaris on the lateral border of the rectus abdominis muscle as for the subcostal approach is very useful, then slide the transducer medially to locate the rectus abdominis. The layers of the rectus sheath are readily identified with ultrasound with transverse scanning of the rectus abdominis and either out-of-plane or in-plane needle imaging techniques. In a training study, ultrasound techniques significantly improved the accuracy of needle placement compared with a LOR technique.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb2xhbjwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 41 Ultrasound-guided rectus sheath catheters have been recently described using an in-plane technique. ADDIN EN.CITE <EndNote><Cite><Author>Shido</Author><Year>2010</Year><RecNum>144</RecNum><DisplayText><style face="superscript">42</style></DisplayText><record><rec-number>144</rec-number><foreign-keys><key app="EN" db-id="e9vwerrfl5fp9gew5p3x5xasxwvps2vrs5a2">144</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shido, A.</author><author>Imamachi, N.</author><author>Doi, K.</author><author>Sakura, S.</author><author>Saito, Y.</author></authors></contributors><titles><title>Continuous local anesthetic infusion through ultrasound-guided rectus sheath catheters</title><secondary-title>Can J Anaesth</secondary-title></titles><periodical><full-title>Can J Anaesth</full-title></periodical><pages>1046-7</pages><volume>57</volume><number>11</number><edition>2010/08/31</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Anesthetics, Local/*administration & dosage</keyword><keyword>Catheters</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block/*methods</keyword><keyword>Pain, Postoperative/*drug therapy</keyword><keyword>Rectus Abdominis/innervation/*ultrasonography</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1496-8975 (Electronic)
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