Anatomy of Abdominal Wall - NESRAnesra.co.uk/files/techniques/Abdo Wall iNerve 09.pdf · Anatomy of...

Anatomy of Abdominal Wall

Nat HaslamConsultant Anaesthetist

City Hospitals Sunderland

Sunday, 1 November 2009

Abdo Wall, Cross sectional anatomy

Rectus Abdominus

Internal Oblique

Transversus Abdominis

Lattissimus Dorsi

Ultrasound Guided TAP

TAP Blocks

Skin / Sub-Q

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum

Skin / Subcut

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum

Skin / Sub-Q

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum

Skin / Subcut

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum

Skin / Sub-Q

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum

Skin / Subcut

External oblique

Internal oblique

Transversus ab.

Peritoneal cavity

Peritoneum

Too superficial Too deep

TAP-tastic !

TAP Blocks – correct plane?

Discrepancies in height of block and duration of action of anterior US guided technique compared with Mc Donnell’s original “2-

pop technique”

TAP Blocks

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

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

Ilio-Inguinal - above ASIS

Lateral

Ilio-Inguinal at ASIS

ASISEOA

Rectus Sheath Blocks

Rectus Abdominus

Subcut

Rectus m.

Peritoneal cavity

Posterior fascia

Fascia transversalis

Peritoneum

Local inserted

•Deep to Muscle

•Superficial to fascia

Rectus Sheath Block

Medial Lateral

Rectus m.

Vessels

Peritoneal cavity

Posterior fascia PeritoneumFascia transversalis

Rectus Sheath Block Medial Lateral

Intraperitoneal Bowel contents

Peritoneum

Rectus muscle and sheath

Intercostal Nerve Blocks

Intercostal block anatomy

Intercostal blocks

Will need many levels of blocks, each with a risk of pneumothorax and local anaesthetic toxicity!

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!

Intercostal block sonoanatomy

Summary

Abdominal wall blocks play a useful role to deliver multi-modal analgesia

Summary

Many are old techniques, revived and modified

Summary

Many are old techniques, revived and modified The new TAP block (green) evolution.......!

Subcostal TAP Block

Peter Hebbard April 2007 on extending TAP Blocks

Heartweb.com.au

Is a Subcostal TAP Necessary?

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”?

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

Topics to be covered

1. Advantages of U/Sd2. How do these blocks differ?3. Overview of abdominal anatomy 4. Ultrasound visualisation of anatomy

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

Intercostal nerve anatomy

Intercostal nerve block performance

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

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”

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

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)

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

Professor Adrian Bösenberg

“It is not often that a new block is described”!

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

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

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

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?

Applications

Both uni- and bilateral lower abdominal surgery Appendicectomies Hernia repairs (inguinal & umbilical) Lower abdominal laparoscopic surgery Open urological procedures Hysterectomies & caesarean sections

The use of Ultrasound for Abdominal Wall

Blocks By

Stef Oosthuysen NNUH Sonosite Course

November 2008

“In the land of the blind, the man with one-eye is

king”Desiderius Erasmus

(1466 -1536)

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

Abdominal blocks

Thoracic intercostal nerve blocks Rectus sheath blocks Ilioinguinal nerve blocks Transversus Abdominus Plane blocks (TAP)

TAP Blocks

Based on sound Anatomical and Scientific evidence

as follows:

Anatomy of Abdominal Wall - NESRAnesra.co.uk/files/techniques/Abdo Wall iNerve 09.pdf · Anatomy of...

Documents

Transcript of Anatomy of Abdominal Wall - NESRAnesra.co.uk/files/techniques/Abdo Wall iNerve 09.pdf · Anatomy of...

Anatomy of the Abdominal Wall

Abdominal Wall and Cavity Surface Anatomy Muscular Wall and Hernias Peritoneum and Mesenteries.

Clinical anatomy of the abdominal wall: hernia surgery...Knowledge of the anatomy and func tion of the abdominal wall is the cornerstone for successful hernia re-pairs based on restoring

823946 abdominal-anatomy

ANATOMY: Posterior Abdominal Wall

Abdominal Wall anatomy

Antero-Lateral Abdominal Wall (Anatomy of the Abdomen)

Surgical Anatomy of anterior abdominal wall

Surface anatomy and structure of anterior abdominal wall

Abdominal Wall and Abdominal Wall Hernias

ABDOMINAL WALL ANATOMY & FASCIA CLOSURE_.pdf

Abdominal wall defects diagnosis and managementtmftp.org/webkontrol/uploads/files/Abdominal wall defects_Istanbul.pdf · Abdominal wall defects – diagnosis and management ... Amniotic

templateforlearning.files.wordpress.com · Web viewLesson: 2 Health Assessment Question Sheet I . Post-Test. Abdominal . Anatomy . Abdominal . Anatomy . Abdominal Quadrants

Clinical Anatomy of the Anterior Abdominal Wall in its ... · Clinical Anatomy of the Anterior Abdominal Wall in its Relation to Hernia Lawrence M. Witmer, PhD Professor of Anatomy

Abdominal anatomy

Anatomy, Lecture 10, Abdominal Wall (1) (Lecture Notes)

2.1 Surface anatomy 2.2 Anterior abdominal wall Albert van Schoor GNK 288 (SA4 Anatomy dissection) Abdomen 1.

Anatomy, Lecture 9, Abdominal Wall (2)

ACUTE ABDOMINAL EMERGENCIES. Abdominal Anatomy and Physiology Abdominal pain and distress Abdominal conditions.

Posterior Abdominal Wall - Anatomy Resources · Posterior Abdominal Wall Dr. Morton ANAT 6010 Page 26. ... Anterior fem. cut. n. (L2-L4) L5 L3 L1 L2 L4 Dermatomes vs. Cutaneous Fields.