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Fivi×o Puniisnrv

Mokini, Vitale,
Costantini, Fumagalli, et al.
Adult and Pediatric Surgery
Ultiasound Blocks
foi the Anteiioi
Abdominal Wall
Flying Publisher Guide to
Mokini – VitaIe – costantini – lumagaIIi
UItrasound ßIocks lor tle Anterior AbdominaI waII
lrincipIes and ImpIementation lor
AduIt and lediatric 8urgery
7lirajr Mokini
Ciovanni VitaIe
Amedeo costantini
koberto lumagaIIi
The Flying Publisher Guide to
Ultrasound Blocks for the
Anterior Abdominal Wall
Principles and Implementation
for Adult and Pediatric Surgery
!"" #dition
lIying lubIisler
AnestlesioIogy is an ever-clanging lieId. 1le pubIislers and autlor ol tlis
guide lave made every ellort to provide inlormation tlat is accurate and
compIete as ol tle date ol pubIication. lowever, in view ol tle rapid clanges
occurring in regionaI anestlesia, as weII as tle possibiIity ol luman error, tlis
Cuide may contain teclnicaI inaccuracies, typograplicaI or otler errors. It is
tle responsibiIity ol tle plysician wlo reIies on experience and knowIedge
about tle patient to determine tle most adequate treatment. 1le inlormation
contained lerein is provided ¨as is" and witlout warranty ol any kind. 1le
contributors to tlis book, incIuding lIying lubIisler & kamps discIaim
responsibiIity lor any errors or omissions or lor resuIts obtained lrom tle use ol
inlormation contained lerein.
1le presented ligures lave onIy an iIIustrative purpose. lovices slouId begin
tleir training loIIowed by an expert in regionaI anestlesia.
Centium ßasic and Centium ßook ßasic lont soltware by }. Victor
CauItney. 1le Centium project, and tle Centium ßasic and Centium
ßook ßasic lonts, are maintained by 8IL InternationaI. Centium lont
soltware is Iicensed under tle 8IL Open lont License, Version 1.1.
1lis Iicense is avaiIabIe at lttp:JJscripts.siI.orgJOlL.
1lis work is protected by copyriglt botl as a wloIe and in part.
C 2011 by lIying lubIisler & kamps
cover uesign: AttiIio ßaglino
I8ßl: 918-!-942õ81-0!-4
| S
8omatic post-surgicaI pain is invaIidating and distressing to
patients and carries tle risk ol important compIications. 1le
anterior abdominaI waII is invoIved in most surgicaI procedures
in generaI, gynecoIogic, obstetric, uroIogicaI, vascuIar and
pediatric surgery. combined muItimodaI strategies invoIving
nerve bIocks, opiates, and non-steroidaI anti-inlIammatory
drugs lor systemic anaIgesia are necessary lor optimaI pain
Anterior abdominaI waII bIocks, transverse abdominaI pIexus
bIock, iIiolypogastric and iIioinguinaI nervebIock, genitolemoraI
nerve bIock and rectus sleatl bIock lave an important roIe as
components ol muItimodaI anaIgesia lor somatic intraoperative
and postoperative pain controI. UItrasound visuaIization las
improved tle ellicacy and salety ol abdominaI bIocks and
impIemented tle appIication in tle cIinicaI setting.
lor tlis reason, tley are a very important tooI lor aII
anestlesioIogists wlo aim to treat ellectiveIy patients' pain. 1lis
guide provides an evidence based comprelensive and necessary
overview ol anatomicaI, anestlesioIogicaI and teclnicaI
inlormation needed to saleIy perlorm tlese bIocks.
7lirajr Mokini
Ciovanni VitaIe
Amedeo costantini
koberto lumagaIIi
1le Lditors
õ |
contributing Autlors
Gio$anni %itale
uepartment ol lerioperative
Medicine and Intensive care
8an Cerardo University lospitaI
ol Monza
Via lergoIesi, !!
20900, Monza, ItaIy
&oberto Fumagalli
uepartment ol lerioperative
Medicine and Intensive care
8an Cerardo University lospitaI
ol Monza, University ol MiIano
Via lergoIesi, !!
20900, Monza, ItaIy
Amedeo 'ostantini
lain 1lerapy and laIIiative care
Unit Annunziata University
lospitaI ol clieti, C. d'Annunzio
University ol clieti, campus
ßiomedico University ol kome
Via dei Vestini, 11
õõ100, clieti, ItaIy
(hira)r *okini
uepartment ol lerioperative
Medicine and Intensive care
8an Cerardo University lospitaI ol
Via lergoIesi, !!
20900, Monza, ItaIy
Tommaso *auri
uepartment ol LxperimentaI
Medicine, University ol MiIano
ßicocca, uepartment ol
lerioperative Medicine and
Intensive care
8an Cerardo University lospitaI ol
Via lergoIesi, !!
20900, Monza, ItaIy
Gabriele Aletti
uepartment ol lerioperative
Medicine and Intensive care
8an Cerardo University lospitaI ol
Via lergoIesi, !!
20900, Monza, ItaIy
Andrea Pradella
uepartment ol lerioperative
Medicine and Intensive care
8an Cerardo University lospitaI ol
Monza, University ol MiIano
Via lergoIesi, !!
20900, Monza, ItaIy
| 1
Sa$ino Spadaro
uepartment ol LxperimentaI
Medicine, University ol MiIano
8an Cerardo University lospitaI
ol Monza
Via lergoIesi, !!
20900, Monza, ItaIy
Giulio +apoletano
Anestlesia Unit
A.O. L. Maccli. loIo deI Verbano -
Via Marconi, 40
210!!, cittigIio, ItaIy
8 | UItrasound ßIocks lor tle Anterior AbdominaI waII
ASIS, anterior-superior iIiac spine
#-*, externaI obIique muscIe
gGF+, genitaI brancl ol
genitolemoraI nerve
gGFB, bIock ol tle genitaI brancl
ol genitolemoraI nerve
IFB, inguinaI lieId bIock
I.+, iIiolypogastric nerve
II+, iIioinguinaI nerve
I-*, internaI obIique muscIe
/IA, IocaI inliItration anestlesia
&A*, rectus abdominaI muscIe
&SB, rectus sleatl bIock
TA*, transverse abdominaI muscIe
TAPB, transverse abdominaI pIexus
TF+B, transient lemoraI nerve
| 9
1abIe ol contents
1. Anatomy lor AnestlesioIogists........................................ 1!
Anterior AbdominaI waII 8tructure.......................... 1!
ßIood 8uppIy to tle Anterior AbdominaI waII......... 1S
Anterior AbdominaI waII Innervation...................... 1õ
IIiolypogastric and IIioinguinaI lerves.................... 18
InguinaI canaI.............................................................. 20
CenitolemoraI lerve................................................... 20
kectus 8leatl.............................................................. 22
communication ßetween AnatomicaI lIanes........... 2!
2. UItrasound and kegionaI Anestlesia.............................. 24
8ound waves................................................................ 24
liezoeIectric Lllect...................................................... 2õ
Imaging........................................................................ 21
1ransducers................................................................. 29
locus............................................................................. !0
lresets.......................................................................... !0
1ime-gain compensation............................................ !0
8patiaI compound Imaging........................................ !0
UItrasound and tle leedIe......................................... !1
Lquipment.................................................................... !1
!. 1ransverse AbdominaI lIexus ßIock............................... !S
ßIind 1ransverse AbdominaI lIexus ßIock............... !õ
UItrasound-guided 1ransverse AbdominaI lIexus
ßIock............................................................................. !1
8pread........................................................................... 42
10 | UItrasound ßIocks lor tle Anterior AbdominaI waII
4. IIiolypogastric and IIioinguinaI lerve ßIock................ 44
ßIind IIiolypogastric and IIioinguinaI lerve ßIock. 44
UItrasonograplic VisuaIization 8tudies....................48
UItrasound-guided IIiolypogastric and IIioinguinaI
lerve ßIock.................................................................. 49
S. CenitolemoraI lerve ßIock.............................................. S!
õ. kectus 8leatl ßIock.......................................................... õ0
1. InguinaI lernia kepair..................................................... õS
InguinaI lieId ßIockJLocaI InliItration Anestlesia.. õS
IIiolypogastric and IIioinguinaI lerve ßIock........... õ9
8. InguinaI 8urgery in cliIdren........................................... 11
IIiolypogastric and IIioinguinaI lerve ßIock and
wound InliItration...................................................... 12
IIiolypogastric and IIioinguinaI lerve ßIock and
caudaI Anestlesia....................................................... 12
9. Obstetric and CynecoIogic 8urgery................................. 1S
Obstetric 8urgery........................................................ 1õ
CynecoIogic 8urgery................................................... 11
10. Otler AbdominaI 8urgery lrocedures.......................... 19
Lower AbdominaI 8urgery.......................................... 19
Upper AbdominaI 8urgery.......................................... 80
11. AbdominaI MidIine 8urgery........................................... 8!
12. LocaI Anestletics, llarmacokinetics and Adjuvants.. 84
uose, concentration and VoIume correIations........ 84
Long-Iasting IocaI anestletics.................................... 8õ
Absorption................................................................... 81
ßIood cIearance........................................................... 89
| 11
lediatric considerations.............................................89
Adjuvants..................................................................... 90
1!. compIications.................................................................. 91
1ransient lemoraI lerve ßIock................................. 91
leritoneaI and VisceraI luncture.............................. 9!
compIications ol kectus 8leatl ßIock..................... 9S
compIications ol CenitolemoraI lerve ßIock...........9õ
14. kelerences........................................................................ 91
1S. Index............................................................................... 111
12 | UItrasound ßIocks lor tle Anterior AbdominaI waII
1. Anatomy lor AnestlesioIogists | 1!
1. Anatomy lor AnestlesioIogists
Zhirajr Mokini
Anterior Abdominal Wall Structure
1le abdominaI waII and tle abdominaI organs are invoIved to
a variabIe extent in generaI, gynecoIogic, obstetric, vascuIar and
uroIogicaI surgery. 1le extent ol invoIvement ol tle abdominaI
waII, ol tle peritoneum and ol tle abdominaI organs determines
tle presence and tle severity ol tle somatic and visceraI
components ol post-surgicaI pain. lor tlis reason, operations
seIectiveIy invoIving tle abdominaI waII or tle groin and tle
spermatic cord are considered surlace procedures. 1ley cause
prevaIentIy somatic pain to tle abdominaI waII. lrocedures
requiring Iaparotomy and invoIving tle abdominaI organs may
cause severe somatic and visceraI pain. ßIocks ol tle anterior
abdominaI waII aim at eIiminating tle somatic component ol
surgicaI pain.
1le anterior abdominaI waII is lormed by skin and a
muscuIo-aponeurotic Iayer in wlicl aII muscIes are covered by a
posterior and an anterior lascia (ligure 1.1, 1.2, 1.!).
14 | UItrasound ßIocks lor tle Anterior AbdominaI waII
Figure "0" 1 The anterior abdominal 2all arteries0
Figure "0 1 Ultrasonographic $ie2 of anterior abdominal 2all0
1. Anatomy lor AnestlesioIogists | 1S
Figure "03 1 The musculo4aponeurotic layer0
AnteriorIy, tle rectus abdominaI muscIe (kAM) Iies on botl
sides ol tle verticaI midIine or Iinea aIba. On eitler side ol tle
kAM, tle muscuIo-aponeurotic pIane is made up respectiveIy,
lrom tle anterior to tle posterior surlace, ol tlree lIat muscuIar
sleets: tle externaI obIique muscIe (LOM), tle internaI obIique
muscIe (IOM) and tle transverse abdominaI muscIe (1AM). 1le
pattern ol reIative abdominaI muscIe tlickness is kAM - IOM -
LOM - 1AM (ligure 1.4) (kankin 200õ).
1le pIane between tle IOM and tle 1AM is tle target lor most
ol tle abdominaI bIocks (ligure !.4).
Blood Supply to the Anterior Abdominal Wall
knowIedge ol abdominaI waII vascuIarization is necessary lor a
sale perlormance ol bIocks. 1lree major arteriaI brancles
suppIy bIood to botl sides ol tle anterior abdominaI waII (ligure
1.1). 1le deep inlerior epigastric artery and vein originate lrom
1õ | UItrasound ßIocks lor tle Anterior AbdominaI waII
tle externaI iIiac vesseIs. A second brancl ol tle externaI iIiac
artery, tle deep circumlIex iIiac artery, runs paraIIeI to tle
inguinaI Iigament between tle 1AM and tle IOM (MiriIas 2010).
1le superior epigastric artery (tle terminaI brancl ol tle
internaI tloracic artery) and vein enter tle rectus sleatl
superiorIy and anastomose witl tle inlerior epigastric vesseIs
(MiriIas 2010).
Figure "05 1 TA' slice of the anterior abdominal 2all0
Anterior Abdominal Wall Inner$ation
1le anterior primary roots ol 1õ to L1 spinaI nerves suppIy tle
innervation ol tle anterior abdominaI waII. 1lese nerves are tle
target ol abdominaI bIocks (ligure 1.S).
1le intercostaI nerves, tle subcostaI nerves and tle lirst
Iumbar nerves tlat emerge lrom 1õ to L1 roots run witl tleir
accompanying bIood vesseIs in a neurovascuIar pIane known as
tle 1AM pIane (ligure !.S). 1lis is a virtuaI anatomicaI space
1. Anatomy lor AnestlesioIogists | 11
between tle IOM and tle 1AM (kozen 2008). 1AM pIane is
deIimitated superiorIy by tle costaI margin, inleriorIy by tle
iIiac crest, mediaIIy by tle IateraI border ol tle kAM, posteriorIy
by tle IumbodorsaI lascia, superliciaIIy by tle IOM and deepIy by
tle 1AM.
Figure "06 1 Inner$ation of the anterior abdominal 2all 7lines represent
T8 to T" and iliohypogastric and ilioinguinal ner$es90
Lvery segmentaI origin contributes to at Ieast two nerves tlat
divide into severaI brancles at tle IeveI ol tle anterior axiIIary
Iine (ßarrington 2009). Lacl nerve gives muscuIar brancles
innervating tle overIying IOM and LOM and tle kAM mediaIIy.
1lere is extensive and lree brancling and communication ol
nerves witlin tle 1AM pIane. As a consequence, tlere is a
considerabIe overIap in tle dermaI territories ol adjacent
cutaneous nerves.
1le intercostaI and subcostaI nerves communicate lreeIy in
tle 1AM pIane, and constitute a network corresponding to tle
18 | UItrasound ßIocks lor tle Anterior AbdominaI waII
intercostaI pIexus. 1le nerves lrom 19 to L1 contribute to a
IongitudinaI nerve pIexus, named tle transverse abdominaI
muscIe pIexus, tlat Iies aIongside and IateraI to tle ascending
brancl ol tle deep circumlIex iIiac artery (kozen 2008).
1le nerves lrom 1õ to L1 lorm a lurtler pIexus into tle rectus
sleatl named tle rectus sleatl pIexus. 1lis pIexus runs
craniaI-caudaIIy and IateraIIy to tle IateraI brancl ol tle deep
inlerior epigastric artery (kozen 2008). A brancl ol 110
innervates tle umbiIicus.
Iliohypogastric and Ilioinguinal +er$es
1le Iumbar pIexus, lormed by tle ventraI brancles ol tle
spinaI nerves lrom L1 to L4, projects IateraIIy and caudaIIy lrom
tle intervertebraI loramina. Its roots innervate tle Iower part ol
tle anterior abdominaI waII, tle inguinaI lieId, tlrougl tle
iIiolypogastric nerve (Ill-greater abdominogenitaI nerve), tle
iIioinguinaI nerve (IIl-minor abdominogenitaI nerve) and tle
genitolemoraI nerve (Cll) (lorowitz 19!9).
A communication brancl lrom 112 tlat is caIIed tle subcostaI
nerve may join in S0 to õ0¼ ol cases tle anterior primary
division ol L1. More rareIy a brancl ol 111 may aIso join L1.
1le IIl and IIl pass obIiqueIy tlrougl or belind tle psoas
major muscIe and emerge lrom tle upper IateraI border ol tle
psoas major muscIe at tle L2 to L! IeveI (MiriIas 2010). 1le Ill
nerve, tle lirst ol tle Iumbar pIexus, and tle IIl may be lound as
a singIe or divided trunk in tle retroperitoneaI space. 1ley cross
obIiqueIy paraIIeI to tle intercostaI nerves and belind tle Iower
poIe ol tle kidney towards tle iIiac crest (wlicl expIains tle
relerred pain to genitaIia in kidney and ureter allections)
(AnIoague 2009).
Above tle iIiac crest, tle Ill and IIl pierce tle posterior
surlace ol tle 1AM and run between tlis muscIe and tle IOM
toward tle inguinaI region (}amieson 19S2, MiriIas 2010).
1. Anatomy lor AnestlesioIogists | 19
Figure "08 1 Abdominal 2all and iliohypogastric 7I.9 and ilioinguinal
7I+9 ner$es0
20 | UItrasound ßIocks lor tle Anterior AbdominaI waII
1le Ill and IIl lave a constant course in tle 1AM pIane in
reIation to tle mid-axiIIary Iine. At tlis point, tle nerves lave
not yet brancled extensiveIy (ligure 1.õ) (kozen 2008). ßeIow
tle anterior-superior iIiac spine (A8I8), tle Ill and IIl pierce
tle IOM and are lound between tlis muscIe and tle LOM.
1le Ill pierces tle aponeurosis ol tle LOM above tle
superliciaI inguinaI ring and continues towards tle Iower area ol
tle rectus sleatl. 1le IIl continues in most cases in tle inguinaI
canaI togetler witl tle gCll, generaIIy at tle posterior or at tle
anterior surlace ol tle spermatic cord (kab 2001).
1le Ill and IIl are aIso caIIed border nerves because tley
slare a sensitive lunction to tle skin over tle inguinaI canaI, tle
pubic area, tle base ol tle penis and tle mediaI upper tligl.
1ley slare a motor lunction lor tle anterior abdominaI muscIes.
1ley lave a liglIy variabIe origin, course, distribution,
communication between tleir brancles and asymmetry (MiriIas
2010). In some cases tley run as a singIe trunk.
Inguinal 'anal
1le inguinaI canaI is an obIique passage containing tle testis
and tle spermatic cord (tle round Iigament in lemaIes) at tle
Iowest border ol tle anterior abdominaI muscIes (ligure 1.1).
It extends lor about 4 cm downwards and mediaIIy lrom tle
internaI inguinaI ring, a deliciency in tle transversaIis lascia, to
tle externaI inguinaI ring, a deliciency in tle LOM aponeurosis
(MiriIas 2010). 1le waII ol tle inguinaI canaI is lormed by tle
LOM aponeurosis, tle IOM and tle 1AM (MiriIas 2010).
Genitofemoral +er$e
1le Cll emerges lrom L1 to L2 roots. It may pierce tle psoas
major muscIe and emerge lrom its anterior surlace near tle
mediaI border at tle IeveI ol L! to L4 vertebrae. It may emerge
botl as a singIe trunk or divided into a genitaI and a lemoraI
1. Anatomy lor AnestlesioIogists | 21
(caIIed aIso cruraI) brancl. It runs beneatl tle transversaIis
lascia and tle peritoneum (Liu 2002).
Figure "0: 1 Inguinal canal0
uescending tle surlace ol tle psoas muscIe underneatl tle
peritoneum, tle genitaI brancl crosses over anterior to tle
externaI iIiac vesseIs and enters tle inguinaI canaI tlrougl tle
deep ring. It accompanies tle cremasteric vesseIs at tle
posterior edge ol tle spermatic cord ensleatled by tle
cremasteric lascia (Liu 2002). 1lis nerve suppIies tle cremaster
muscIe and tle skin ol tle scrotum and tligl. In lemaIes, tle
genitaI brancl accompanies tle round Iigament ol tle uterus.
1le genitaI brancl ol tle genitolemoraI nerve (gCll) slares a
great variabiIity witl tle Ill and tle IIl (kab 2001).
1le lemoraI brancl passes belind tle inguinaI Iigament or tle
IOM aIongside tle externaI iIiac artery. It enters tle lemoraI
sleatl superliciaIIy and IateraIIy to tle lemoraI artery. 1le
lemoraI brancl pierces tle anterior lemoraI sleatl and lascia
22 | UItrasound ßIocks lor tle Anterior AbdominaI waII
Iata to suppIy tle proximaI-mediaI area ol tle tligl and over tle
triangIe ol 8carpa. It may slare brancles witl tle genitaI brancl
in some cases (kab 2001).
&ectus Sheath
1le rectus sleatl is a biIaminar librous extension ol tle
aponeurotic Iayer ol tle LOM, IOM and 1AM (ligure 1.!, 1.8, õ.!).
It encases tle kAM on botl sides lrom tle costaI margin down
to tle IeveI ol tle anterior-superior iIiac spine, lusing in tle
midIine as tle Iinea aIba. 1le superior and inlerior epigastric
vesseIs run IongitudinaIIy tlrougl tle mediaI portion ol tle
Figure "0; 1 &ectus sheath 7line90
A virtuaI space exists between tle posterior rectus sleatl and
tle kAM. LocaI anestletic can spread lreeIy in tlis space in a
caudaI and ceplaIic direction.
1. Anatomy lor AnestlesioIogists | 2!
'ommunication Bet2een Anatomical Planes
As conlirmed by severaI, aItlougl conlIicting, anatomicaI and
cIinicaI studies, a virtuaIIy communicating pIane may exist
between tle quadratus Iumborum muscIe, tle psoas major
muscIe and tle 1AM, tle transversaIis lascia and tle iIiac lascia.
1lis communication occurs especiaIIy at tle inguinaI IeveI
wlere tle Iumbar pIexus roots run (larny 1994, kosario 1991).
Moreover tlere may be a communication between tle
tloracoIumbar or IumbodorsaI lascia, tle paravertebraI space,
tle lascia transversaIis and iIiac lascia (MiriIas 2010, 8aito 1999).
1le presented data are important lor tle perlormance ol sale
and ellective bIocks and to avoid tle possibIe compIications ol
abdominaI bIocks.
24 | UItrasound ßIocks lor tle Anterior AbdominaI waII
2. UItrasound and kegionaI Anestlesia
Gabriele Aletti
Sound Wa$es
1le appIication ol pressure to a medium lor a given period ol
time causes tle compression ol its moIecuIes tlat wiII become
cIoser to tle subsequent moIecuIes. 1le pressure energy wiII be
propagated deeper between adjacent moIecuIes in tle direction
ol tle compression. 1le movement ol tle moIecuIes wiII
propagate in tle lorm ol a pressure wave. A wave is a
disturbance in a medium traveIing tlrougl it at a constant
speed. 1le periodic appIication ol pressure wiII generate more
waves tlat wiII traveI tlrougl tle medium.
8ound waves are subsequent and periodic ligl pressure and
Iow pressure waves ol moIecuIar vibration. 1ley traveI
IongitudinaIIy tlrougl a plysicaI medium determining ligl
pressure areas (compression) and Iow pressure areas (rarelac-
tion) aIong tle direction ol propagation. Lacl wave las a lre-
quency (l) ol propagation measured as cycIes per unit ol time.
1le waveIengtl ( ) is delined as tle geometric distance at an in λ -
stant between two successive ligl pressure puIses or two
successive Iow pressure puIses. 1le waveIengtl ol sound
decreases as lrequency increases. 1le speed ol propagation ol
2. UItrasound and kegionaI Anestlesia | 2S
tle wave (c) depends on tle plysicaI properties ol tle medium
(ligure 2.1).
Figure 0" 1 From left to right, Pressure 2a$e and returning echoes0
Speed< 2a$elength and fre=uency correlations0 Scattering effect0
Spatial compound imaging0
UItrasounds are cycIic sound pressures witl a lrequency above
tlose wlicl lumans can lear. 1le luman learing Iimit is 20
klz. UItrasounds used in tle medicaI setting lave a lrequency ol
1 to 2S mlz. 8ound waves are not ionising and are not larmluI at
tle energy IeveIs used lor diagnostic purposes. 1lere is to date
no epidemioIogicaI evidence ol larmluI ellects (Moore 2011).
UItrasounds traveI laster in dense bodies and sIower in
compressibIe bodies. In solt tissue tle speed ol sound is 1S40
mJs, in bone about !400 mJs, and in air !!0 mJs. In tissues wlere
tle sound traveIs more sIowIy, tle waveIengtl decreases.
2õ | UItrasound ßIocks lor tle Anterior AbdominaI waII
Pie>oelectric #ffect
8ome materiaIs can produce eIectric energy in response to a
meclanicaI stress and converseIy, produce e meclanicaI
response wlen an eIectric current traveIs tlrougl tlem. 1lis is
tle so-caIIed piezoeIectric ellect. MedicaI uItrasound waves are
produced by a piezoeIectric crystaI as a consequence ol tle
meclanicaI response to an eIectric lieId. 1le transducer aIso
picks up tle relIected waves or ¨ecloes" lrom tle tissues and
converts tlem into eIectricaI signaIs tlat are used to lorm
reaI-time images on a computer. 1le crystaI tlus botl transmits
and receives tle sound (ligure 2.1).
Figure 0 1 Ultrasound system0 From top to bottom, linear "! and ";
and con$e? 6 m.> transducers0
Lacl eIectric signaI is registered, ampIilied, and liItered to
reduce noise, and tle deptl ol tle tissue tlat las generated tle
eclo is caIcuIated. 1le signaIs are tlen digitaIized and processed
in order to produce an image.
2. UItrasound and kegionaI Anestlesia | 21
LarIy uItrasound devices used a singIe crystaI to create a one
dimension image, caIIed a-mode image. Modern maclines
generate a b-mode or two-dimensionaI or gray-scaIe image
created by 128 or more crystaIs. Lacl crystaI receives a puIse
tlat produces a scan Iine used to create an image on tle screen.
1lis image is renewed severaI times eacl second to produce a
reaI-time image. AdditionaI modes, incIuding ligl resoIution
reaI time gray scaIe imaging, uoppIer mode, coIor-lIow uoppIer
mode, coIor-veIocity uoppIer and tissue larmonic modes are
now commonIy avaiIabIe.
uepending on tle medium's plysicaI properties and tle
contact witl dillerent interlaces into tle medium, tle energy ol
tle wave is dissipated, attenuated and relIected. At tle interlace
wlere one tissue borders anotler tissue, tle wave is relracted
and relIected back as an eclo. 1le relIection depends on tle
tissue density and tlus on tle speed ol tle wave. 8o, as tle
waves penetrate tissues, tley detect wlere solt tissue meets air,
or solt tissue meets bone, or wlere bone meets air. Instead, some
structures wiII compIeteIy absorb tle sound waves. 1lus, ecloic
tissues are tlose tissues tlat relIect tle wave wlereas anecloic
tissues do not relIect tle wave.
UItrasounds penetrate weII tlrougl lIuids tlat are anecloic
and appear as bIack on tle monitor. lIuids aIIow uItrasounds to
pass tlrougl more or Iess attenuated untiI tley encounter tle
surlace ol denser structures. ßone or air are poorIy penetrated
by uItrasounds and generate a kind ol ¨sound-sladow".
1le transverse appearance ol nerves is round or ovaI and
lypo-ecloic (ligure 2.!). 1ley may appear as loneycomb
structures containing lyper-ecloic points or septa inside tlem.
lerves are surrounded by a lyper-ecloic border tlat
corresponds to connective tissue. 1endons lave a simiIar
appearance. On tle IongitudinaI scan, tendons disappear wliIe
28 | UItrasound ßIocks lor tle Anterior AbdominaI waII
tracking tlem lor some distances wlereas nerves do not
Figure 03 1 Ultrasound appearance of median ner$e and of radial
ner$e 2ith the needle 7in4plane approach90
ßIood vesseIs appear as round lypo-ecloic structures witl a
weII delined lyper-ecloic border corresponding to tle vesseI
waII. 1le arteries are not compressibIe and are puIsating, veins
lave a tlinner border and are compressibIe (ligure S.!, 1!.!).
MuscIes appear as leterogeneous or lomogeneous
lypo-ecloic structures witl lyper-ecloic septa and a
librous-IameIIar texture (ligure !.2). 1le periostium appears as
lyper-ecloic as it relIects entireIy tle ecloes. As a consequence,
tle bone underIying tle periostium appears as bIack (uItrasound
sladow) (ligure 4.1). 1le knowIedge ol normaI anatomy is
essentiaI lor tle identilication ol dillerent tissues witl
2. UItrasound and kegionaI Anestlesia | 29
8ince tle speed ol tle wave in dillerent tissues is known, tle
time lor tle relIected wave to return back indicates tle deptl ol
tle tissue.
AII tlis inlormation is converted into a two-dimensionaI image
on tle screen. 1lis sIice may be directed in any anatomicaI
pIane: sagittaI (or IongitudinaI), transverse (or axiaI), coronaI (or
lrontaI), or some combination (obIique).
uuring an uItrasound-guided nerve bIock, tle Ielt side ol tle
screen slouId correspond to tle Ielt side ol tle transducer. An
indicator on tle transducer is used to orient tle user to tle
orientation on tle screen. ßy convention tle indicator
corresponds to tle Ielt side ol tle screen as it is viewed lrontaIIy.
1le transducer slouId be pIaced aIso in order to lave tle
indicator on tle Ielt side ol tle transducer.
8ince uItrasound examinations are best suited lor
investigations ol solt tissues, tley are indicated lor tle
visuaIization ol tle abdominaI waII.
Lower-lrequency uItrasounds lave better penetration and are
used lor deeper organs, but lave a Iower resoIution. 1le deeper
tle structure, tle Iower tle needed lrequency.
ligler-lrequency uItrasounds provide better resoIution, but
witl a Iow penetration. 8o ligl-lrequency uItrasounds are useluI
in tle case ol superliciaI tissues. uepending on tle abdominaI
waII tlickness, typicaI transducersJprobes used to visuaIize tle
abdominaI waII are Iinear ones lrom 10 to 20 mlz (ligure 2.2).
Linear compound array transducers aIIow better visuaIization
ol structures poorIy visuaIized by uItrasounds sucl as nerves.
lor 0 to ! cm ol deptl, Iinear -10 mlz transducers are necessary.
lor 4 to õ cm ol deptl, õ to 10 mlz Iinear transducers are used.
8tructures wlicl are deeper tlan õ cm need 2 to õ convex
transducers. 1le transducer slouId be positioned perpendicuIar
!0 | UItrasound ßIocks lor tle Anterior AbdominaI waII
to tle anatomicaI target. 1le transmission geI is an essentiaI tooI
lor tle transmission ol ecloes.
1le transducer and tle cabIe must be covered witl a steriIe
cover. 1le geI in contact witl tle skin must be steriIe. 1le skin
must be disinlected prior to any contact witl tle transducer and
tle needIe.
1le locus ol tle image is usuaIIy marked witl a point or an
arrow at tle riglt side ol tle screen ol tle uItrasound device.
1lis arrow slouId be pIaced at tle same deptl ol tle targeted
structure or a bit deeper. It ensures ligl delinition ol tissue at
tlat deptl.
8ome uItrasound maclines oller tle possibiIity to cloose
between dillerent presets (lor muscIes, tendons, vesseIs, solt
tissues). Lacl preset las tle best setting ol lrequency, deptl,
locus and compound in order to view tlat tissue.
Time4gain 'ompensation
8ince ecloes relIected lrom deeper tissues are progressiveIy
attenuated, time gain compensation is used to ampIily ecloes
lrom increasing deptls to compensate lor tleir progressive
Spatial 'ompound Imaging
Modern piezoeIectric crystaIs can produce ecloes tlat traveI
in many directions and tlus return witl more inlormation. 1le
contrast resoIution is tlus enlanced to provide better tissue
dillerentiation, cIearer organ borders, and structure margin
2. UItrasound and kegionaI Anestlesia | !1
visuaIization. 1issue Iayers, nerves and vesseIs are more cIearIy
dillerentiated (ligure 2.1).
Ultrasound and the +eedle
wlen inserted to perlorm a bIock, tle needIe may be
visuaIized dynamicaIIy witl tle use ol eitler an ¨in-pIane" or
¨out-ol-pIane" approacl. An in-pIane approacl is perlormed
wlen tle needIe is paraIIeI to tle Iong axis ol tle transducer
(LOX) (ligure 2.4). An out-ol-pIane approacl is perlormed wlen
tle needIe is perpendicuIar to tle Iong axis ol tle transducer or
paraIIeI to tle slort axis (8OX). An out-ol-pIane approacl may
over- or underestimate tle deptl ol tle needIe (Marloler 2010).
1le needIe axis must be paraIIeI and aIso aIigned witl tle axis ol
tle probe.
wlen injecting, IocaI anestletic spread must be monitored. Il
anestletic spread is not seen, intravascuIar injection or poor
visuaIization must be excIuded. leedIe eIectrostimuIators may
conlirm tle presence ol tle nerve because ol tle twitcling ol
tle muscIes caused by tle current. lowever, in abdominaI
bIocks tlis ellect may not occur.
One ol tle probIems witl needIe visuaIization is tlat
depending on tle angIe ol insertion, some ecloes are relIected
out ol tle pIane ol tle transducer and tlus Iost (ligure 2.1). 1le
more tle needIe is paraIIeI to tle transducer, tle more tle
ecloes wiII be captured lrom tle transducer and tle needIe
UItrasonograply is a sale and ellective lorm ol imaging. Over
tle past two decades, uItrasound equipment las become more
compact, ol ligler quaIity and Iess expensive (ligure 2.2). 1lis
improvement las laciIitated tle growtl ol point-ol-care
uItrasonograply, tlat is, uItrasonograply perlormed and
!2 | UItrasound ßIocks lor tle Anterior AbdominaI waII
interpreted by tle cIinician at tle bedside. UItrasounds lave
been used to guide needIe insertion, and a number ol approacles
to nerves and pIexuses (groups ol nerves) lave been reported.
A cIear advantage ol tle teclnique is tlat uItrasound produces
"Iiving pictures" or ¨reaI-time" images. 1le identilication ol
neuronaI and adjacent anatomicaI structures (bIood vesseIs,
peritoneum, bone, organs) aIong witl tle needIe is anotler
Figure 05 1 +eedle parallel to short and long a?is of the transducer,
out4of4plane and in4plane approaches0
UItrasounds use las been rated as one ol tle salest practices
lor patients. 1le prevention ol intravascuIar injection during
regionaI anestlesia bIocks is best accompIisled witl a
combination ol uItrasound teclnique and epineplrine test
dosing (leaI 2010).
Moreover, anatomicaI variabiIity may be responsibIe lor bIock
laiIures, and uItrasound teclnoIogy enabIing direct visuaIization
may overcome tlis probIem. Many studies slow tlat compIex
nerve pIexus bIock as weII as singIe nerve bIock teclniques can
be successluIIy perlormed witl Iower voIumes ol IocaI
anestletics. 8onograplic visuaIization aIIows lor tle
2. UItrasound and kegionaI Anestlesia | !!
perlormance ol extraepineuriaI needIe tip positioning and
administration ol IocaI anestletic, avoiding intraepineuriaI
injection. linaIIy, tlere may be a reduced need lor generaI
anestlesia and reduced inpatient stay.
1le perlormance ol peripleraI nerve bIocks is cIearIy
dependent on teclnique, and expertise and tle use ol
uItrasounds requires additionaI skiIIs. 8ome ol tle prerequisites
lor tle impIementation ol uItrasounds in regionaI anestlesia
incIude exceIIent understanding and knowIedge ol luman
anatomy, understanding ol tle principIes reIated to
uItrasound-guided bIocks, laving good land skiIIs and land–eye
coordination (Conano 2009).
Most uItrasound novices lave probIems witl exact
coordination between uItrasound transducer position and needIe
tip visuaIization during advancement. 1le American and
Luropean 8ocieties ol kegionaI Anestlesia (A8kA and L8kA) lave
recentIy pubIisled guideIines lor training in uItrasound-guided
regionaI anestlesia, liglIiglting tle encouragement ol
individuaI institutions to support a quaIity-improvement process
(8ites 2001, 8ites 2009).
kecentIy a coclrane review reported tlat in experienced
lands, uItrasound guidance lor peripleraI nerve bIocks las
success rates at Ieast as peripleraI nerve stimuIation. 1le
incidence ol vascuIar puncture or lematoma lormation was
reduced in some studies. UItrasounds may improve tle quaIity ol
sensory and motor bIock. Many studies assessed bIock
perlormance time and lound a signilicant reduction witl
uItrasounds use. lo study las assessed trunk bIocks and
statisticaI anaIysis was not possibIe due to tle leterogeneity ol
tle studies. lowever, tle lindings are IikeIy to relIect tle use ol
uItrasounds in experienced lands and may not be reproducibIe
by Iess skiIIed practitioners (waIker 2009).
In concIusion, tle use ol uItrasounds may provide a potentiaI
standard in regionaI anestlesia il a responsibIe, scientilic,
!4 | UItrasound ßIocks lor tle Anterior AbdominaI waII
structured and careluI impIementation ol sucl teclniques is
perlormed (Marloler 2010).
!. 1ransverse AbdominaI lIexus ßIock | !S
!. 1ransverse AbdominaI lIexus ßIock
Zhirajr Mokini
1le bIock ol transverse abdominaI pIexus (1Alß) provides
ellective anaIgesia wlen used as a part ol muItimodaI anaIgesic
strategies lor abdominaI surgery and in clronic pain. lrom tle
lirst description, severaI cIinicaI triaIs lave evaIuated tle 1Alß
lor postoperative anaIgesia in a variety ol procedures (kali 2001)
conceptuaIIy tle 1Alß is a compartmentaI bIock because tle
IocaI anestletic is deposited into tle lasciaI pIane between tle
internaI obIique muscIe and tle transverse abdominaI muscIe.
cadaveric and radioIogicaI studies lave demonstrated tle
deposition ol tle IocaI anestletic in tle 1AM pIane (McuonneII
UnIike tle rectus sleatl bIock (k8ß), wlicl targets onIy tle
midIine, tle 1Alß targets tle entire anterior-IateraI abdominaI
waII (kozen 2008). 1le extent ol tle bIock wiII depend on tle
puncture site and tle voIume ol IocaI anestletic. 1le typicaI
voIume used lor tle 1Alß is 20 to !0 mI eacl side. 1le maximum
bIock extent is observed alter !0 to õ0 minutes and residuaI
bIock may persist alter 24 lours (Lee 2008). 1le bIock can be
aclieved botl bIindIy and witl tle use ol uItrasounds. 1eclnicaI
aspects ol tle 1Alß and otler bIocks are slowed in 1abIe õ.1.
!õ | UItrasound ßIocks lor tle Anterior AbdominaI waII
1le indications lor tle 1Alß are evoIving and tle teclnique
las been used lor postoperative anaIgesia alter generaI,
uroIogicaI, obstetric, pIastic and gynecoIogic surgery procedures.
Blind Trans$erse Abdominal Ple?us Block
MuItipIe Iandmarks lor accessing tle 1AM pIane lave been
1- percutaneous Ioss-ol-resistance teclnique injection tlrougl
tle Iower Iumbar triangIe ol }ean-Louis letit (kali 2001),
2- tle injection between costaI margin and tle iIiac crest at tle
mid-axiIIary Iine,
!- subcostaI injection under tle costaI margin.
1le Iandmark-based teclniques reIy on a two pop leeIing. 1le
lirst ¨pop",¨cIick", ¨ping" or ¨ting" occurs wlen tle needIe
pierces tle lascia between tle LOM and tle IOM. 1le second
occurs wlen tle needIe pierces tle lascia between tle IOM and
tle 1AM.
1le inlerior Iumbar triangIe is a trianguIar area ol tle dorsaI
abdominaI waII bordered inleriorIy by tle iIiac crest, posteriorIy
by tle anterior edge ol tle Iatissimus dorsaI muscIe and
anteriorIy by tle posterior edge ol tle LOM (ligure !.1) (Loukas
2001). 1le lIoor ol tle triangIe lrom superliciaI to deep is lormed
by tle IOM and tle 1AM. wlen tle triangIe ol }ean-Louis letit is
used as a Iandmark, onIy tle lascia between tle IOM and tle
1AM wiII be leIt in most cases.
At tlis IeveI, tle 1õ to L1 allerent nerves are lound in tle
compartment between tle IOM and tle 1AM. caudaI and
ceplaIic spread ol IocaI anestletic occurs wlen it is injected into
tlis compartment.
lowever, tle triangIe ol letit can be dillicuIt to paIpate
especiaIIy in obese persons or cliIdren and tlerelore is ol
Iimited use. 8ince it is lound posteriorIy, tle bIock tlrougl tle
Iumbar triangIe is Iess convenient to perlorm in supine patients.
It varies greatIy in its position and its size is reIativeIy smaII
!. 1ransverse AbdominaI lIexus ßIock | !1
(}ankovic 2009). 1le presence ol adipose tissue aIso clanges tle
position signilicantIy. As a resuIt, it is dillicuIt to lind tle
triangIe soIeIy on paIpation. UItrasound visuaIization aIso is
poorIy aclievabIe.
Moreover, tle Iumbar triangIe may lrequentIy contain smaII
brancles ol tle subcostaI arteries (}ankovic 2009). In an
anatomicaI study, in 11.S¼ ol specimens no triangIe was lound
because tle Iatissimus dorsi was covered by tle LOM (Loukas
2001). linaIIy, unexpected Iumbar lernias may be lound in 1¼ ol
patients (ßurt 2004).
Figure 30" 1 Triangle of @ean4/ouis Petit0
Ultrasound4guided Trans$erse Abdominal Ple?us
UItrasounds can overcome tle probIem ol impaIpabIe muscIe
Iandmarks because tley aIIow reaI-time visuaIization ol tissues,
ol tle needIe and ol tle spread ol tle IocaI anestletic (ligure
!.2, !.õ) (lebbard 2008).
!8 | UItrasound ßIocks lor tle Anterior AbdominaI waII
Figure 30 1 The abdominal 2all $isuali>ed from different positions0
lreoperative bIock administration is recommended as tissue
visuaIization witl uItrasounds may be impaired alter surgery
and tissue manipuIation. Moreover, Iate persistence ol eIevated
IocaI anestletic IeveIs in tle pIasma alter abdominaI bIocks lave
been slown.
A traditionaI or cIassicaI 1Alß may be perlormed by injecting
tle IocaI anestletic between costaI margin and iIiac crest at tle
mid-axiIIary or at tle anterior axiIIary Iine (ligure !.!, !.4).
wlen tle transducer is positioned between costaI margin and
iIiac crest at tle mid-axiIIary or tle anterior axiIIary Iine, tle
tlree muscuIar Iayers ol tle abdominaI waII wiII be seen on tle
screen (ligure !.2). 1le LOM, IOM and tle 1AM are seen as
lypo-ecloic IongitudinaI bands (ligure !.S). 1le IOM is tle
tlickest and tle 1AM is tle deepest. MuscuIar lascias between
tle muscIes are seen as lyper-ecloic and lyper-Iucent.
!. 1ransverse AbdominaI lIexus ßIock | !9
Figure 303 1 Transducer positioning bet2een iliac crest and costal
Figure 305 1 Positioning and ultrasound appearance of classical TAPB
1le needIe is inserted and advanced obIiqueIy witl an in-pIane
approacl, paraIIeI and aIigned to tle Iong axis ol tle transducer.
1le in-pIane approacl wouId possibIy decrease tle risk ol
advancing tle needIe into tle peritoneaI cavity. 1le presence ol
bIood vesseIs must be aIways clecked on tle screen. Aspiration
belore injection is necessary to avoid intravascuIar pIacement.
wlen tle lascia between tle IOM and tle 1AM is reacled witl
tle needIe, a smaII voIume ol IocaI anestletic may be injected. Il
tle lascia expands, tle needIe is pIaced correctIy (ligure !.õ). Il
tle muscIe expands, tle needIe must be repIaced. 1le wloIe
40 | UItrasound ßIocks lor tle Anterior AbdominaI waII
voIume is injected wliIe controIIing tle luII diIatation ol tle
lascia on tle screen.
Figure 306 1 T2o ner$es seen as fascicular and o$al 7points9
bet2een the I-* and the TA* during a classical TAPB0
Figure 308 1 In)ection 2ith the needle and dilatation of the
fascia during a classical TAPB0
!. 1ransverse AbdominaI lIexus ßIock | 41
An aIternative is tle subcostaI 1Alß (ligure !.1). In tlis case
tle transducer is pIaced immediateIy inlerior to tle costaI
margin on tle anterior abdominaI waII (lebbard 2008). 1le
anestletic can be injected witl an in-pIane approacl. A good
uItrasound Iandmark may be tle 1AM pIane at tle mediaI edge
ol tle transverse adbominaI muscIe, near tle border witl tle
rectus muscIe (ligure õ.2)
Figure 30: 1 Subcostal trans$erse abdominal ple?us block0
1le rationaIe lor tle subcostaI 1Alß Iies in tle lact tlat tle
nerves Iocated between tle costaI margin and tle inguinaI
Iigament at tle anterior axiIIary Iine lave a segmentaI origin
lrom 19 to L1. LeveIs more craniaI tlan tlis, 1õ to 18, are not
covered witl tle cIassicaI 1Alß, Iimiting its useluIness to Iower
abdominaI surgery. lowever, a more extensive pattern ol nerve
invoIvement may resuIt il an additionaI injection is made
anterior-mediaI to tle costaI margin (kozen 2008). 1le
42 | UItrasound ßIocks lor tle Anterior AbdominaI waII
dillerence between tle subcostaI 1Alß and tle cIassicaI 1Alß is
tle dillerent extent ol bIock.
1le dermatomeric extent ol tle 1Alß and its indications are
currentIy under discussion. It is not cIear il tle IocaI anestletic
bIocks somatic nerves aIone or il it aIso spreads to bIock
autonomic nerves. kadioIogicaI computerized tomograply and
magnetic resonance imaging lave evidenced tle spread ol IocaI
anestletic beyond tle 1AM pIane to tle quadratus Iumborum
and to tle intratloracic paravertebraI regions (carney 2008,
McuonneII 2004).
1le cIassicaI 1Alß may not reIiabIy provide anaIgesia lor
procedures above tle IeveI ol tle umbiIicus tlat is innervated by
110 endings (ßarrington 2009, 1ran 2009). 1le extension is
generaIIy lrom L1 to 110 (carney 2008, McuonneII 2001 (2)).
lowever, a 11 to L1 extension las been aIso reported
(McuonneII 2001). 1le subcostaI 1Alß may produce a 19 to 11
bIock extent in more tlan õ0¼ ol cases (Lee 2008). In cliIdren,
uItrasound-guided supra-iIiac 1Alß witl 0,2 mIJkg ol anestletic
perlormed by novice operators, produced Iower abdominaI
sensory bIockade ol onIy ! to 4 dermatomes (laImer 2011). OnIy
2S¼ ol 1Al bIocks may lave upper abdominaI bIock extension.
1lus, tle optimaI IocaI anestletic concentration, tle duration ol
ellect and utiIity ol tlese bIocks in reIation to peripleraI and
neuraxiaI bIockade in cliIdren needs cIarilication (laImer 2011).
1le cIinicaI appIication ol tle transverse abdominaI pIexus
bIock may be divided between Iower abdominaI surgery, wlere
tle cIassicaI posterior approacl guarantees an adequate
anaIgesic coverage, and surgery in tle upper quadrants ol tle
abdomen, wlere tle subcostaI 1Alß is prelerabIe to ensure an
adequate anaIgesia (McuonneII 2001 (!), liraj 2009 (2), lebbard
2010). A combination ol tle cIassicaI and subcostaI approacl
lave been aIso described.
!. 1ransverse AbdominaI lIexus ßIock | 4!
1le 1Alß is aIso indicated lor patients unsuitabIe lor epiduraI
anaIgesia (liraj 2011).
44 | UItrasound ßIocks lor tle Anterior AbdominaI waII
4. IIiolypogastric and IIioinguinaI
lerve ßIock
Giovanni Vitale
Blind Iliohypogastric and Ilioinguinal +er$e Block
1le bIock ol iIiolypogastric and iIioinguinaI nerves (IIß) is
perlormed by anestlesioIogists and can be aclieved bIindIy or
under uItrasound visuaIization. Aseptic teclnique and patient
security procedures slouId be strictIy observed. ßelore
perlorming a bIock on an awake patient, sedation witl a
benzodiazepine or an opioid togetler witl oxygen may be
administered. MidazoIam 0.0!S mgJkg andJor lentaIyI 1-1.S
mcgJkg can be used lor adequate sedation. ßIocks can aIso be
administered alter generaI anestlesia induction, in tlis case tle
patient wiII not be abIe to communicate.
Various injection Iandmarks lave been suggested sucl as
1. 1 cm inlerior-mediaI to tle A8I8 (anterior superior iIiac
spine), 1-2 cm mediaI to tle A8I8, 2 cm superior-mediaI to tle
2. tle junction ol tle IateraI one-lourtl on a Iine lrom tle A8I8
to tle umbiIicus
!. tle point just mediaI and inlerior to tle A8I8, S-10 mm in
inlants and 20 mm in adoIescents
4. IIiolypogastric and IIioinguinaI lerve ßIock | 4S
4. tle point 10–20 mm mediaI and 10–20 mm superior to tle
S. tle point just 10 mm mediaI to tle A8I8
õ. one linger-breadtl mediaI to tle A8I8, S cm above and
IateraI to tle mid-inguinaI point
1le Iast approacl is mostIy used lor cliIdren and tle measure
ol tle linger's breadtl is taken at tle proximaI inter-plaIangeaI
joint ol tle cliId's ipsiIateraI index linger. 8ingIe or muItipIe
injections may be done and dillerent puncture sites provide
simiIar ellectiveness (Lim 2002).
1le lascia between tle LOM and tle IOM ollers a lirst
resistance to tle needIe leIt as a ¨pop" or ¨ting" or ¨ping",
wlereas tle lascia between tle IOM and tle 1AM provides a
second resistance. Alter tle second resistance las been leIt, tle
IocaI anestletic may be injected.
1lis 'resistance' may be very subtIe, particuIarIy in smaII
inlants and tlin cliIdren. A useluI tip is to loId a skin loId
between tle tlumb and index ol one land and puncture tle skin
to reacl tle subcutaneous tissue. 1le lirst 'pop' leIt is IikeIy to
be tle aponeurosis ol tle LOM (lrigon 200õ). Anotler way is to
use a slarp introducer to puncture tle skin. A 22C wlitacre
spinaI needIe inserted tlrougl tle introducer into tle
subcutaneous tissue wiII provide a good leedback in terms ol a
distinct 'pop' as tle LOM aponeurosis and tle IOM lascia are
lowever, anatomic and uItrasound controI studies on tle
cIassicaI Iandmarks slow tlat onIy two muscIe Iayers instead ol
tlree may be identilied in S0¼ ol tle patients. 1lis occurs
because tle LOM is Iimited to an aponeurosis in tle mediaI area
adjacent to tle A8I8 (wiIIsclke 200S).
4õ | UItrasound ßIocks lor tle Anterior AbdominaI waII
Table 50" 1 Pediatric distances in millimeters 7mean A SB9 7modified
from $an Schoor !!6< Willschke !!6 and .ong !"!90
leonates A8I8 to Ielt IIl 1.9 - 0.9, (01 to 0.õ1)
A8I8 to riglt IIl 2.0 - 0.1, (!.44 to 0.49)
cliIdren A8I8 to Ielt IIl !.! - 0.8, (S.!1 to 1.S2)
A8I8 to riglt IIl !.9 - 1.0, (S.!9 to 2.!õ)
1 montls - 8
A8I8 to IIl õ.1 - 2.9
8kin to IIl 8.0 - 2.2
IIl to peritoneum !.! - 1.! (1–4.õ)
0-12 montls A8I8 to IIl 8.1-2.1
A8I8 to Ill 9.8-2.õ
8kin to IIl 8.1-1.9
8kin to Ill 9.8-1.9
IIl to peritoneum 8.S-1.1
IIl to peritoneum 9.0-1.1
12-!õ montls A8I8 to IIl 11.õ-!.0
A8I8 to Ill 1!.2-2.õ
8kin to IIl 9.2-1.1
8kin to Ill 9.1-2.0
IIl to peritoneum õ.!-4.1
IIl to peritoneum 4.1-1.8
- !1 montls A8I8 to IIl 1S.2-!.1
A8I8 Ill 18.0-4.!
8kin to IIl õ.S-!.!
8kin to Ill !.8-1.S
IIl to peritoneum 1.!-4.1
IIl to peritoneum 4.S-1.1
ßIind teclniques may be conlusing because ol imprecise
description and insullicient understanding. 1lere is aIso a ligl
potentiaI lor compIications sucl as peritoneaI or visceraI
puncture (weintraud 2008, van 8cloor 200S). 1le reported
laiIure rate remains ligl and variabIe, õ to 4!¼, even in
4. IIiolypogastric and IIioinguinaI lerve ßIock | 41
experienced lands or wlen muItipIe punctures are perlormed
because ol tle ligl anatomicaI and Iandmark variabiIity
(kandlawa 2010). 1le laiIure rate may be as ligl as õ to 40¼
especiaIIy in inlants and cliIdren, even wlen tle nerve is
exposed at surgery (weintraud 2008, Lim 2002). correct
administration ol IocaI anestletic around tle target nerves
occurred in onIy 14¼ and S1¼ ol cases in two studies wlen using
a Iandmark metlod witl a lasciaI cIick (weintraud 2008,
kandlawa 2010). 1le remainder ol tle injections were deposited
in adjacent anatomicaI structures (iIiac muscIe 18¼, 1AM 2õ¼,
IOM 29¼, LOM 9¼, subcutaneous tissue 2¼, and peritoneum 2¼)
(weintraud 2008).
1le data in 1abIe 4.1 slow tle distances lrom tle skin and tle
A8I8 to tle nerves and lrom tle nerves to tle peritoneum in
cliIdren. 1abIe 4.2 slow tle abdominaI muscIe size in aduIts.
Table 50 1 Adult distances in centimeters 7modified from
#ichenberger !!8 and &ankin !!890
AduIts AbsoIute abdominaI muscIe size at tle
mid-axiIIary Iine
IIl to bone distance
at tle A8I8
MaIes !.8õ (riglt: 0.õ4, 9S¼ range 2.S8–S.14) 0.4–1.1
!.88 (Ielt: 0.õ1, 9S¼ range 2.S4–S.22)
lemaIes 2.9õ (riglt: 0.4õ, 9S¼ range 2.04–!.88) 0.4–1.1
2.94 (Ielt: 0.4!, 9S¼ range 2.08–!.80)
1lese data liglIiglt tle lact tlat bIind teclniques may be
imprecise and carry a ligl risk ol boweI, Iiver or spIeen
puncture, especiaIIy in cliIdren. leedIe deptl slouId be
conlirmed by tle lasciaI cIick, since tle risk increases il tle
needIe is introduced too deep wlen tle 'pop' is not identilied
(long 2010).
1lere is a weak correIation between weiglt and tle deptl ol
tle IIl (wiIIsclke 200S). 1lese lindings emplasize tle
useluIness ol uItrasounds lor tlis bIock teclnique and tle lact
tlat needIe tip visuaIization is mandatory (weintraud 2008).
48 | UItrasound ßIocks lor tle Anterior AbdominaI waII
Ultrasonographic %isuali>ation Studies
1le IIß is a sale, lrequentIy used bIock tlat las been improved
in ellicacy and salety by tle use ol uItrasonograplic
visuaIization (wiIIsclke 200õ). 1le uItrasound approacl
increases tle salety ol tlis bIock because tle nerves, tle
surrounding anatomicaI structures and tle needIe are visuaIized.
1le site ol injection is under direct controI and tle voIume ol
tle IocaI anestletic can be individuaIized so tlat it surrounds
tle nerve structures (wiIIsclke 200õ). lreoperative bIock
administration is recommended as tissue visuaIization witl
uItrasounds may be impaired alter surgery and tissue
manipuIation. Moreover, Iate persistence ol eIevated IocaI
anestletic IeveIs in tle pIasma alter abdominaI bIocks lave been
On Iong axis scans, tle nerves lave a lascicuIar pattern made
ol muItipIe lypo-ecloic paraIIeI and Iinear areas separated by
lyper-ecloic bands. 1le lypo-ecloic structures correspond to
tle neuronaI lascicIes tlat run IongitudinaIIy witlin tle nerve,
and tle lyper-ecloic background reIates to tle inter-lascicuIar
epineurium (MartinoIi 2002). On slort axis scans, nerves assume
a loneycomb-Iike appearance witl lypo-ecloic rounded areas
embedded in a lyper-ecloic background (MartinoIi 2002). coIor
uoppIer can leIp dillerentiating tle lypo-ecloic nerve lascicIes
lrom adjacent lypo-ecloic smaII vesseIs (MartinoIi 2002).
lowever tle IIl and tle Ill are smaII nerves tlat can generaIIy
be seen onIy as ovaI lypo-ecloic structures embedded in a
lyper-ecloic border (ligure 4.1).
1le Ill and IIl visuaIization witl uItrasounds may be
possibIe in 100¼ ol cases in cliIdren between 1 montl and 8
years ol age and in 9S¼ ol cases in aduIts (long 2010, wiIIsclke
200S, Liclenberger 200õ). 1le dillicuIties tlat arise because ol
tle smaIIer anatomicaI structures in cliIdren and tle aItered
anatomy ol tle abdominaI waII in pregnancy, can be
4. IIiolypogastric and IIioinguinaI lerve ßIock | 49
compensated by tle greater aqueous consistency and tle
reduced caIcilication ol tissues.
Figure 50" 1 +ormal ultrasound anatomy seen abo$e the ASIS0
Ultrasound4guided Iliohypogastric and
Ilioinguinal +er$e Block
1le transducer is pIaced over tle mid-axiIIary Iine and above
tle iIiac crest (ligure 4.2). 1le best image is tracked by moving
tle transducer aIong tle course ol tle iIiac crest in tle direction
ol tle A8I8 (ligure 4.!). wlen positioning tle transducer, tle
tlree muscuIar Iayers ol tle abdominaI waII wiII be seen on tle
screen. 1le iIiac bone wiII be seen at one side ol tle screen as
bIack. On tle otler side ol tle screen, deeper, tle abdominaI
cavity and eventuaIIy peritoneum or tle boweI may be seen.
1le tlree abdominaI muscIes, tle LOM, tle IOM and tle 1AM,
are seen as lypo-ecloic IongitudinaI bands (ligure 4.1). 1le IOM
is tle tlickest and tle 1AM is tle deepest. 1le muscuIar lascias
between tlem are seen as lyper-ecloic and lyper-Iucent. AIong
tle lascia between tle IOM and tle 1AM, two ovaI structures
S0 | UItrasound ßIocks lor tle Anterior AbdominaI waII
may be seen corresponding to tle Ill and IIl. 1le IIl is tle
cIosest to tle iIiac bone.
Figure 50 1 Positioning for ultrasound4guided block performance0
1le needIe is inserted witl an in-pIane approacl, paraIIeI and
aIigned to tle Iong axis ol tle transducer. 1le needIe is
advanced obIiqueIy. 1le in-pIane approacl wouId possibIy
decrease tle risk ol advancing tle needIe into tle peritoneaI
cavity. AIways controI lor bIood vesseIs and aspirate belore
UItrasounds lave been slown to decrease IocaI anestletic
voIume and improve tle success ol tle bIock (wiIIsclke 200S,
wiIIsclke 200õ, Liclenberger 2009). UItrasound guidance
enlances ellicacy and salety. 1le main disadvantages are tle
cost ol equipment and tle need lor adequate training ol
4. IIiolypogastric and IIioinguinaI lerve ßIock | S1
anestlesioIogists belore cIinicaI appIication ol
uItrasound-guided bIocks. AnestlesioIogists need to deveIop a
good understanding ol tle anatomicaI structures invoIved in tle
bIocks. 1ley need to acquire botl a soIid knowIedge in
uItrasound teclnoIogy and tle practicaI skiIIs to visuaIize nerve
Figure 503 1 Transducer positioning for iliohypogastric and ilioinguinal
ner$e block0
8ince Ill and IIl visuaIization is not aIways possibIe because
it is operator, patient and equipment dependent, tle 1AM pIane
near tle A8I8 may be a more useluI Iandmark (lord 2009). A
good endpoint lor tle inexperienced practitioner ol
uItrasound-guided IIß may be tle pIane between tle 1AM and
tle IOM wlere tle nerves are reported to be lound in 100¼ ol
cases (lord 2009). It is important to note tlat Ill and IIl can
not aIways be reIiabIy identilied, tlis is not a simpIe bIock!
UItrasound novices starting to perlorm IIß slouId scan tle
S2 | UItrasound ßIocks lor tle Anterior AbdominaI waII
region at Ieast 14–1S times belore perlorming tle bIock using
tle muscIe pIanes as an endpoint (lord 2009). ImportantIy, tle
bIock slouId be perlormed above tle A8I8. In concIusion, since a
Iower IocaI anestletic voIume is required lor IIß at tle A8I8
IeveI, seIective bIock ol tlese nerves instead ol cIassicaI 1Alß is
advised (ligure 4.4).
Figure 505 1 The needle approaching the ilioinguinal ner$e under
ultrasound guidance0
S. CenitolemoraI lerve ßIock | S!
S. CenitolemoraI lerve ßIock
Zhirajr Mokini
OccasionaIIy, tle inguinaI lieId bIock (Ilß)JIocaI inliItration
anestlesia (LIA) (see tle detaiIed discussion in clapter 1) seem
to laiI due to pain experienced during spermatic cord
manipuIation. In tlese cases, ideaIIy, a bIock ol tle genitaI
brancl ol genitolemoraI nerve (gClß) slouId be perlormed
because IocaI anestletic inliItration into tle inguinaI canaI
improves tle ellicacy ol tle bIock (Yndgaard 1994).
A seIective gClß is not possibIe except under direct
intraoperative vision (kab 2001). 1le IIl and gCll generaIIy
enter tle deep inguinaI ring and run togetler into tle inguinaI
canaI on tle surlace ol tle spermatic cord. In aII cases tle gCll
innervates tle cremaster muscIe (kab 2001).
1le bIind Iandmark lor tle inguinaI canaI tlat corresponds to
tle underIying spermatic cord is tle point on tle skin, one
linger-breadtl above tle mid-point between tle A8I8 and tle
mid-penopubic loId at tle symplysis pubis (lsu 200S). 1le
typicaI injection site lor tle gClß is relerred to be
superior-IateraI to tle pubic tubercIe in order to inject tle
anestletic near tle spermatic cord (leng 2008). caution slouId
be taken because at tle pubis IeveI tle inlerior epigastric vesseIs
are lound respectiveIy at 1.41 -J- 0.10 cm on tle riglt and 1.49
-J- 0.09 cm on tle Ielt side lrom tle midIine (8aber 2004).
S4 | UItrasound ßIocks lor tle Anterior AbdominaI waII
kecentIy an uItrasound and non-seIective teclnique witl a
Iinear õ-1! mlz transducer las been deveIoped lor gClß. 8ince
it is not possibIe to aclieve gCll visuaIization witl uItrasounds,
tle teclnique incIudes tle injection ol tle IocaI anestletic inside
and outside tle spermatic cord (leng 2008).
1le transducer is aIigned to visuaIize tle lemoraI artery in tle
Iong axis and tlen is moved upwards towards tle inguinaI
Iigament wlere tle lemoraI artery becomes tle externaI iIiac
artery. 1le spermatic cord is seen superliciaIIy to tle externaI
iIiac artery just opposite to tle internaI inguinaI ring. It appears
as an ovaI or circuIar structure witl 1 or 2 arteries (tle testicuIar
artery and tle artery to tle vas delerens) and tle vas delerens as
a tubuIar structure witlin it (leng 2008). 1le transducer is
moved mediaIIy away lrom tle lemoraI artery and an
out-ol-pIane teclnique is used. 1le linaI position is about 2
linger-breadtls to tle side ol tle pubic tubercIe and
perpendicuIar to tle inguinaI Iine.
wliIe witl tlis teclnique tle spermatic cord is IikeIy to be
lound outside tle inguinaI canaI, anestletic inliItration into tle
inguinaI canaI may provide a greater probabiIity ol bIocking not
onIy tle gCll, but aIso tle IIl andJor tle Ill endings (kab
2001). InguinaI canaI injection wouId be suitabIe lor inguinaI
surgery botl in tle case ol IocaI, generaI or spinaI anestlesia.
An uItrasound-guided gClß witl a 10-18 mlz transducer can
be perlormed. 1le transducer is pIaced under tle inguinaI
Iigament at tle intersection between tle lemicIavear Iine and
tle Iine between tle pubic tubercIe and tle A8I8 (ligure S.1).
1le lemoraI artery is visuaIized transverseIy aIong tle slort axis
(ligure S.2). 8ubsequentIy, tle transducer is moved mediaIIy
towards tle pubic tubercIe. 1le pubic bone is seen as anecloic
(bIack). 1le inguinaI canaI can be seen between tle lemoraI
artery and tle pubic bone. It is Iocated more superliciaI under
tle aponeurosis ol tle LOM as an ovaI sladow containing tle
S. CenitolemoraI lerve ßIock | SS
spermatic cord in it. It is useluI to ask tle patient to cougl in
order to see tissue movement ol tle spermatic cord.
Figure 60" 1 Transducer position for the in)ection into the
inguinal canal0
Figure 60 1 Probe position 7left then right9 and ultrasound
$ie2 7stars indicate the inguinal canal90
Sõ | UItrasound ßIocks lor tle Anterior AbdominaI waII
1lis movement wiII be more evident in tle case ol an inguinaI
lernia. An in-pIane needIe is inserted. A 10-20 mI ol anestletic is
injected into tle inguinaI canaI just alter tle needIe penetrates
tle LOM aponeurosis (ligure S.!). A ¨pop" is aIso leIt wliIe tle
needIe penetrates tle aponeurosis. 1le spread ol tle anestletic
wiII bIock tle gCll andJor tle IIl and Ill. IntracanaIar tissues
wiII be lydro-dissected and may be observed as geIatinous
during surgery at tle dissection ol tle aponeurosis ol tle LOM
(ligure S.4).
Figure 603 1 /eft inguinal canal in)ection0 The t2o images of the
procedure described in Figure 60 ha$e been reconstructed0
Il a stimuIated needIe is used, visibIe testicIe retraction and
twitcling ol tle cremaster muscIe may be occasionaIIy present.
8ince tle gCll runs togetler witl tle cremasteric vesseIs
ensleatled by tle cremasteric lascia, needIe aspiration is
mandatory (kab 2001). It is advisabIe to inject tle IocaI
anestletic just under tle aponeurosis ol tle LOM and not to
S. CenitolemoraI lerve ßIock | S1
penetrate tle spermatic cord because ol tle risk ol spermatic
artery and delerens duct puncture or peritoneaI puncture in tle
case ol a lernia.
Figure 605 1 The inguinal canal has been successfully infiltrated0
AIso, tle use ol epineplrine is not recommended because ol
tle possibIe constrictive ellect on tle testicuIar artery (leng
2008). ßoweI presence in tle case ol inguinaI lernia must aIso be
tracked (ligure 1.1).
1ripIe inguinaI bIock (iIiolypogastric, iIioinguinaI and
genitolemoraI) las been reported by some studies in association
witl generaI or spinaI anestlesia or in tle setting ol a IlßJLIA
teclnique (ligure S.S). UItrasound-guided IIß and gClß may
provide optimaI intraoperative and postoperative anaIgesia witl
Iow rates ol intraoperative anaIgo-sedation requirements, quick
recovery and quick disclarge criteria aclievement.
S8 | UItrasound ßIocks lor tle Anterior AbdominaI waII
8ince compIete bIock may not occur, intraoperative
anaIgo-sedation or IocaI anestletic suppIement by tle surgeon
may be required lor patient comlort. Moreover, subcutaneous
injection aIong tle incision Iine is necessary lor a good IlßJLIA
because ol tle variabiIity ol innervation ol tle Ill and IIl and
tle leterogeneous allerences lrom otler nerves.
Figure 606 1 From left to right, Iliohypogastric and ilioinguinal ner$e
block< genitofemoral ner$e block and 2ound infiltration 7Triple block90
Alter uItrasound-guided IIß and gClß, a 90 mm needIe is
entireIy advanced in tle subcutaneous tissue under tle incision
Iine. Injection is made wliIe sIowIy retracting tle needIe and
aspirating lrom time to time. uepending on tle patient's body
mass index, 10 to !0 mI are generaIIy required. 1lis bIock
provides optimaI operative conditions, aImost immediate
disclarge criteria aclievement, Iow anaIgesic requirement and
ligl patient satislaction. 1le teclnique las severaI advantages
S. CenitolemoraI lerve ßIock | S9
especiaIIy in tle case ol patients witl severe comorbidities lor
wlom generaI or spinaI anestlesia may be risky.
õ0 | UItrasound ßIocks lor tle Anterior AbdominaI waII
õ. kectus 8leatl ßIock
Savino Spadaro, Tommaso Mauri
1le centraI portion ol tle anterior abdominaI waII is
innervated by tle anterior brancles ol tle spinaI nerve roots
lrom 1õ to L1.
1le nerves enter tle rectus abdominaI muscIe near tle
midIine and Iie between it and tle posterior sleatl (kozen 2008).
1le superior and inlerior epigastric vesseIs run IongitudinaIIy
tlrougl tle mediaI portion ol tle muscIe (ligure 1!.!).
1le existence ol myolasciaI intersection points on tle anterior
border ol tle rectus muscIe Iimits tle spread ol a IocaI
anestletic soIution. 1le tendinous intersections ol tle rectus
muscIe are not present at tle posterior rectus sleatl, wlicl
aIIows IocaI anestletic to spread ceplaIic-caudaIIy witlin tle
ipsiIateraI compartment lrom a singIe injection site (ligure õ.1,
1le k8ß las been used to provide surgicaI anestlesia as weII as
postoperative anaIgesia lor Iaparotomy or Iaparoscopic
procedures invoIving tle abdominaI midIine (linnerty 2010).
1le bIock appears to be sale and easy to Iearn and perlorm. It
provides tle anestlesioIogist witl anotler metlod ol ellective
and apparentIy Iong-Iasting anaIgesia lor common day-case
procedures. 1le k8ß slouId be perlormed biIateraIIy witl
reIativeIy Iarge voIumes ol IocaI anestletic.
õ. kectus 8leatl ßIock | õ1
Figure 80" 1 &ectus sheath under ultrasound guidance0
Figure 80 1 &ectus abdominal muscle 7&A*9 and the triple
musculo4aponeurotic layer0
It can be combined witl otler bIocks, sucl as tle IIß, to
aclieve wider bIockade lor transverse incisions beIow tle
umbiIicus (Yentis 2000). lowever, in tlese cases 1Alß slouId be
1le bIind teclnique is perlormed using ¨pop" sensations to
determine tle positioning ol tle needIe's tip. 1le needIe is
inserted biIateraIIy at 1 to ! cm lrom tle midIine. 1le posterior
õ2 | UItrasound ßIocks lor tle Anterior AbdominaI waII
rectus sleatl is tlin - il tle peritoneum is inadvertentIy pierced,
boweI perloration may occur.
1le advantages ol uItrasound guidance lor k8ß are simiIar to
tlose lor 1Alß. A 100¼ success rate las been reported in tle
abiIity to visuaIize tle spread ol anestletic between tle kAM
and tle posterior sleatl (wiIIsclke 200õ (2)). In a study, tle
anestletic was pIaced in tle correct pIane in onIy 4S¼ ol cases
using a Ioss ol resistance teclnique by trainees witl no previous
experience and in 89¼ ol cases using uItrasound guidance (uoIan
2009). 1le dillerence became more pronounced as patient body
mass index increased. 21¼ ol injections perlormed using tle Ioss
ol resistance teclnique were intraperitoneaI and !S¼ too
UItrasound-guided k8ß is carried out witl tle transducer
pIaced in tle IongitudinaI pIane near tle IateraI edge ol tle
rectus sleatl (ligure õ.!). 1le distribution ol tle IocaI
anestletic can be monitored under reaI-time imaging. 1le IocaI
anestletic is injected between tle kAM and tle posterior sleatl
(ligure õ.1). 8kin incision can be perlormed 1S minutes or Iater
alter pIacement ol tle bIock.
Figure 803 1 &ectus sheath under ultrasound guidance0
õ. kectus 8leatl ßIock | õ!
Table 80" 1 Technical aspects of the abdominal blocks0
IIß 1Alß k8ß ClßJInguinaI
leedIe 2S-22 C,
!S-90 mm,
witl or
injection Iine
2S-22 C,
!S-90 mm,
witl or
injection Iine
2S-22 C,
!S-90 mm,
witl or
injection Iine
2S-22 C,
!S-90 mm,
witl or
injection Iine
1ransducer Linear 10-20
Linear 10-20
Linear 10-20
Linear 10-20
1eclnique LOX J
10 mI eacl
10-!0 mI eacl
10-!0 mI eacl
10-20 mI eacl
8ome important concIusions on tle abdominaI bIocks can be
drawn on tle basis ol tle anatomicaI data wlicl are conlirmed
by severaI cIinicaI studies.
1. Landmark teclniques may be uncIear and inaccurate lor
positioning tle needIe tip near tle nerves. Moreover tley carry
a ligl risk ol compIications.
2. UItrasound teclniques provide direct visuaIization and give
better resuIts in terms ol bIock ellicacy, IocaI anestletic dose
reduction and incidence ol compIications.
!. 1le visceraI peritoneum, tle abdominaI organs and testis
wiII not be bIocked witl 1Alß, IIß, k8ß and gClß. AbdominaI
bIocks are onIy one component ol a muItimodaI anaIgesic
teclnique and suppIementaI anaIgesia witl non-steroidaI or
opiate anaIgesics is necessary.
4. 1le cIassicaI 1Alß is indicated lor procedures invoIving L1
to 110 extent. 8ubcostaI 1Alß is indicated lor procedures
invoIving 112 to 18 extent.
S. AItlougl tle cIassicaI 1Alß is ellective lor IIß, a seIective
IIß is recommended because Iower doses ol IocaI anestletic are
õ4 | UItrasound ßIocks lor tle Anterior AbdominaI waII
õ. 1le best site lor needIe pIacement lor IIß is above tle A8I8,
at tle intersection between tle iIiac crest margin and tle
mid-axiIIary Iine, at tle 1AM pIane.
1. gClß can be aclieved, aItlougl non-seIectiveIy. 1le
uItrasound teclnique is liglIy recommended.
8. 1ripIe inguinaI bIock is necessary lor adequate IlßJLIA in
awake and sedated patients undergoing inguinaI surgery.
9. 1le k8ß is ellective lor procedures invoIving midIine
incision. UItrasounds are liglIy recommended. Il Iarge voIumes
ol IocaI anestletic are used, consider tle saler 1Alß.
1. InguinaI lernia kepair | õS
1. InguinaI lernia kepair
Roberto Fumagalli
InguinaI lernia repair is tle most lrequent operation in
generaI surgery accounting lor 10-1S¼ ol aII operations (ligure
1.1). At tle lirst day alter lerniorrlaply, moderate or severe
pain occurs in 2S¼ ol tle patients at rest and in õ0¼ during
activity, and on day õ tle incidence is 11¼ and !!¼, respectiveIy
(caIIesen 1998). leitler tle type ol lernia nor tle type ol repair
seem to inlIuence postoperative pain scores, aItlougl young
patients lave more activity-reIated pain alter inguinaI
lerniorrlaply (caIIesen 1998, Lau 2001). converseIy, anestletic
teclnique may allect pain severity alter inguinaI lerniorrlaply
(caIIesen 1998, 8ong 2000).
Inguinal Field BlockC/ocal Infiltration Anesthesia
8tep by step IlßJLIA teclnique perlormed by surgeons was
lirst described at tle beginning ol tle previous century and
incIudes a stepwise inliItration witl IocaI anestletic ol tle skin,
ol subcutaneous tissue, ol muscIe and lasciaI Iayers, ol spermatic
cord and ol peritoneaI sac (cusling 1900). 1le procedure is
perlormed by tle surgeon wliIe operating. IIß and gClß can be
perlormed directIy in tle operative lieId, aItlougl it is very
IikeIy tlat tle IocaI anestletic soIution wiII reacl tle nerves in
õõ | UItrasound ßIocks lor tle Anterior AbdominaI waII
any case (Amid 1994). 8ome reports lave described IIß during
Iaparoscopic lernia repair.
Figure :0" 1 %oluminous bilateral inguinal4scrotal hernia containing
1le use ol Iong acting anestletics las increased tle
postoperative pain lree period. Use ol IocaI anestlesia aIIows tle
patient to cougl and strain during tle procedure, to identily
additionaI lernias as weII as test tle competency ol tle repair at
tle end ol tle surgery. An anestlesioIogist is present to monitor
tle patient's vitaI signs and provide suppIementary anaIgesia
and sedation.
1lis teclnique and its variations seem to be tle prelerred one
lor aII cases ol reducibIe and even voIuminous or biIateraI
inguinaI lernias. 1le teclnique is recommended lor its salety,
intra- and postoperative ellectiveness on pain, reduced or absent
1. InguinaI lernia kepair | õ1
compIications, Iow anaIgesic request, rapid reappraisaI ol tle
abiIity to waIk and void, ease ol perioperative management,
slorter lospitaI stay, rapid disclarge and economicaI
convenience (kark 199õ, kark 1998, 8ong 2000, Andersen 200S,
Aasbo 2002). uuring IocaI inliItration anestlesia, tlere is
generaIIy a Iow sedation requirement and potentiaIIy no need
lor anestlesioIogist or nurse presence.
1lese benelits are useluI especiaIIy in tle eIderIy and in
patients witl cardiac or puImonary disease. IlßJLIA las aIso
been associated witl better postoperative puImonary lunction
tests (ConuIIu 2002). ligl patient satislaction scores lave been
reported as weII (caIIesen 2001).
uespite tlese advantages, IocaI inliItration anestlesia is rareIy
perlormed outside dedicated lernia centers and its use may be
as Iow as 2¼ (kettIe 2001). OnIy about õ0¼ ol patients undergo
tlis procedure in tle ambuIatory setting (caIIesen 2001,
ßay-lieIsen 2001). Limited Iearning ol tle teclnique is one ol
tle most important causes. Anotler expIanation may be
intraoperative patient discomlort and pain. 1le lear ol
intraoperative pain and signilicant patient distress is dependent
on tle operator's abiIity and allects surgicaI prelerences. 1le
surgeon must landIe tle tissues more careluIIy wliIe operating
because surrounding tissues, peritoneum and testis are not
bIocked. AItlougl intraoperative pain is a reaI probIem witl tle
IlßJLIA teclnique, skiIIed and experienced surgeons can
perlorm tle operation even witlout tle attendance ol an
anestlesioIogist or nurse (Andersen 200S, caIIesen 2001, caIIesen
2001 (2)). A study relerred tlat tle majority ol patients wlo
received IlßJLIA experienced miId pain during tle operation,
tlougl tlis was not measured, and a minority recorded some
anxiety (1easdaIe 1982). 1le probIem ol intraoperative
discomlort may be underestimated because studies reler onIy
tle need lor intraoperative rescue anaIgo-sedation and not pain
scores. 1le use ol sedation may be associated witl increased
õ8 | UItrasound ßIocks lor tle Anterior AbdominaI waII
patient satislaction compared witl unmonitored anestlesia
(8ong 2000). linaIIy, tle traditionaI use ol monitored anestlesia
care witl propoloI and opioids or spinaI and generaI anestlesia
may lave negativeIy inlIuenced its dillusion (caIIesen 2001,
1oivonen 2004).
A documented probIem ol tle IlßJLIA is tlat it may require
suppIementary IocaI anestletic and sedation witl moderate to
ligl doses ol benzodiazepines, requiring tle attendance ol an
anestlesioIogist (uing 199S). IlßJLIA and IIß lave not been
evaIuated in overweiglt and obese patients, wlere Iarger IocaI
anestletic voIumes are needed, aItlougl tley are reported to be
sale especiaIIy il tle mixture is diIuted. Moreover, a ligler
intensity ol intra- and postoperative pain and a ligler incidence
ol compIications lave been reported in obese patients (lieIsen
200S, keid 2009).
8ome autlors state tlat IlßJLIA ol tripIe bIock perlormed
belore surgery is more time consuming, requires Iarger voIume
ol tle IocaI anestletic soIution, does not aIways resuIt in
satislactory anestlesia because ol tle bIind nature ol tle
procedure, and accidentaI needIe puncture ol tle inguinaI
nerves may resuIt in proIonged postoperative pain or
neuropatlic pain witlin tleir innervation lieId (Amid 1994).
lowever, actuaI anestlesia bIock teclniques oller seIective
nerve bIock aclievement witl Iow voIumes ol IocaI anestletic,
direct visuaIization il uItrasounds are used, optimaI pain controI,
last recovery and disclarge ol patients and Iow anaIgesic
requirements. A randomized study in cliIdren undergoing groin
surgery perlormed to compare postoperative anaIgesia witl IIß
perlormed eitler percutaneousIy by tle anestlesioIogist belore
surgery or by tle surgeon under intraoperative direct vision,
reveaIed no statisticaI dillerence in pain scores between tle
groups (1rotter 199S).
1. InguinaI lernia kepair | õ9
Iliohypogastric and Ilioinguinal +er$e Block
InguinaI lernia is tle type ol surgery in wlicl tle IIß las been
mostIy practiced and studied. 1le IIß las been associated to
monitored anestlesia care, generaI anestlesia or spinaI
anestlesia to decrease tle initiaI pain alter inguinaI
lerniorrlaply (8ong 2000, uing 199S, Andersen 2002, Aasbo
2002, 1oivonen 2004, 1oivonen 2001).
A combined IIß togetler witl an inliItration procedure may
provide improved intraoperative anaIgesia, decreased
requirements lor additionaI sedation and monitoring and
increased patient acceptance (Andersen 200S, kelIet 200S).
Many resuIts indicate tlat IIß slouId be aIways perlormed alter
a generaI or spinaI anestlesia. Moreover, preemptive IIß may be
ellective in decreasing postoperative anaIgesic requirements and
proIonging tle time to lirst rescue anaIgesia (Ong 200S).
kopivacaine lor Ilß and IIß under propoloI and opioid
anaIgo-sedation compared to generaI anestlesia witl wound
inliItration, resuIted in a signilicantIy more rapid transler to tle
recovery unit and disclarge, Iess need ol anaIgesics during tle
lirst postoperative week and signilicantIy laster and Iess painluI
reappraisaI ol normaI activities (Aasbo 2002).
1le adding ol IIß improves pain reIiel lor 4 to 24 lours and
reduces anaIgesic consumption compared to spinaI and generaI
anestlesia aIone (1verskoy 1990). latients require tle lirst
opioid or non-steroid anaIgesic rescue signilicantIy Iater and
start to eat and mobiIize sooner (lelra 199S, Abad-1orrent 1991,
ßugedo 1990). 1lese benelits occur in spite ol pain score
dillerences at rest or in movement (larrison 1994). 1le
beneliciaI ellects ol IlßJLIA on pain scores, anaIgesic
consumption and return to normaI activities may Iast lor õ lours
to up to 10 days (larcli 1998, MurIoy 1999, ßugedo 1990,
1oivonen 2001).
1le lactors contributing to deIays in tle time-to-lome
readiness incIude nausea, vomiting, inabiIity to void, drowsiness,
10 | UItrasound ßIocks lor tle Anterior AbdominaI waII
posturaI lypotension, post spinaI leadacle, proIonged motor
bIockage, and administrative and sociaI deIays.
CeneraI anestlesia is associated witl a signilicantIy ligler
incidence ol sore tlroat, drowsiness, postoperative nausea and
vomiting. A ligler incidence ol postoperative pruritus, urinary
retention, Iumbar backacle and tle Iongest time to aclieve
lome disclarge criteria occurs alter spinaI anestlesia (8ong
2000, 1oivonen 2004). latients wlo receive IIß and spinaI
anestlesia lave laster awakening and orientation times tlan
patients wlo receive generaI anestlesia.
compared witl standardized generaI and spinaI anestlesia, IIß
las been associated witl Iower pain scores at disclarge, Iess
anaIgesic requirement, a decreased time-to-lome readiness, a
Iower incidence ol side ellects and Iower totaI perioperative
costs (8ong 2000). ßIock group patients consumed more propoloI
tlan generaI anestlesia patients, but Iess lentanyI.
In a retrospective study tle use ol IIß lor patients undergoing
lerniorrlaply resuIted in no need lor recovery room care
(YiImazIar 200õ). 1ime to recovery and disclarge criteria
aclievement is signilicantIy Iower even wlen a seIective spinaI
anestlesia teclnique is perlormed (tlat las slorter recovery
times compared to non seIective spinaI anestlesia), or
subaraclnoid opioid is associated (loIi 2009, Cupta 200!).
8. InguinaI 8urgery in cliIdren | 11
8. InguinaI 8urgery in cliIdren
Giulio Napoletano
InguinaI surgery comprises inguinaI lernia repair, orcl-
idopexy, orcliectomy, removaI ol cyst ol tle spermatic cord,
Iigation ol patent processus vaginaIis and lydroceIectomy. 1le
bIocks ol tle nerves ol tle abdominaI waII lave been evaIuated
in combination to generaI and spinaI anestlesia and in
comparison to muItimodaI anaIgesia.
1le IIß is among tle most common (10¼ ol aII peripleraI
nerve bIocks) used mainIy lor cliIdren between 4 and 1 years ol
age (ßan 2010). InguinaI lernia repair is tle most lrequent
operation in wlicl iIiolypogastric and iIioinguinaI nerve bIock
is administered togetler witl generaI anestlesia. 1le bIock
appears to be sale and ellective in reducing pain scores and
anaIgesic request (uaIens 2001). lowever, tle success rate may
be as Iow as 10-80¼ witl bIind teclniques and compIications
may occur (Lim 2002, leII 1981). Intraoperative IIß decreases
postoperative pain, anaIgesic use, and promotes earIy
ambuIation, recovery and disclarge in cliIdren undergoing
lernia repair.
12 | UItrasound ßIocks lor tle Anterior AbdominaI waII
Iliohypogastric and Ilioinguinal +er$e Block and
Wound Infiltration
Many studies lave compared IIß to LIA. 8impIe inliItration ol
tle wound witl IocaI anestletic soIution slouId be encouraged
in pediatric anestlesia as it may become as ellective as IIß. IIß
las been slown to be more ellective tlan simpIe wound
inliItration lor postoperative pain and anaIgesic request in
inguinaI surgery (caetano 200õ). AIso, IIß associated witl LIA
may improve anaIgesia alter inguinaI surgery.
UItrasound-guided IIß is ellective in reducing intra- and
postoperative pain in cliIdren undergoing inguinaI lernia
repair, orclidopexy or lydroceIe repair (wiIIsclke 200S).
UItrasounds reduce tle required voIume ol IocaI anestletic
(wiIIsclke 200õ). 1le reduction in tle dose is aIso necessary
because ol reported ligler pIasma IeveIs ol IocaI anestletic alter
uItrasound-guided bIocks (weintraud 2009).
Iliohypogastric and Ilioinguinal +er$e Block and
'audal Anesthesia
1le IIß lor inguinaI procedures may provide anaIgesia
comparabIe to a caudaI injection, possibIy witl a Ionger mean
duration (lannaIIal 1981, Marklam 198õ). 1le adverse ellects ol
motor bIock and urinary retention are eIiminated. leart rate,
Iinear anaIogues score, totaI amount ol anaIgesic and time ol
lirst administration ol anaIgesics lave been evaIuated as criteria
lor tle ellicacy ol tle anaIgesic teclnique.
1le IIß compared to a caudaI bIock reveaIed simiIar recovery
times and no dillerence in postoperative pain or discomlort
scores alter inguinaI lernia repair (lannaIIal 1981). ßotl
procedures lave a simiIar duration ol action ol at Ieast õ lours.
lo dillerence in tle number ol patients witlout pain lor 4 l or
in tlose requiring anaIgesics by 24 l las been reported
compared to caudaI bIock (lisler 199!). 8imiIarIy, cliIdren
8. InguinaI 8urgery in cliIdren | 1!
undergoing lerniotomy, orclidopexy or Iigation ol patent
processus vaginaIis, slow no statisticaIIy signilicant dillerences
between IIß and caudaI anaIgesia (Marklam 198õ). latients witl
caudaI anestlesia lave proIonged disclarge times wlen
compared to patients wlo receive IIß (8pIinter 199S). LarIier
micturition and Iess compIications in tle IIß group is an
important advantage over tle caudaI bIock (Marklam 198õ).
caudaI epiduraI bIocks may be more ellective tlan IIß pIus LIA
in controIIing pain alter lerniorrlaply witl Iaparoscopy and
resuIt in earIier disclarge to lome (1obias 199S).
lain controI witl caudaI bIocks can be improved by increasing
tle concentration ol IocaI anestletic. 1lis wiII increase tle
incidence ol adverse ellects. 1le adverse ellects associated witl
caudaI bIocks may be urinary retention, deIayed ambuIation and
accidentaI subaraclnoid or intravascuIar injection. lowever, IIß
may aIso be associated witl serious compIications, especiaIIy in
cliIdren. (lor a detaiIed discussion ol compIications pIease reler
to clapter 1!.)
Many autlors beIieve tlat tle compIication risk witl caudaI
bIocks on cliIdren undergoing minor surgicaI procedures is not
justilied. 1le risk ol compIications is certainIy greater in
neonates and inlants.
Orclidopexy is a procedure usuaIIy perlormed in cliIdren
tlrougl an inguinaI incision simiIar to tlat ol tle inguinaI
lerniorrlaply, but it invoIves more testicuIar and spermatic
cord traction. It must be remembered tlat testicuIar innervation
can be traced up to 110 and lrom tle aortic and renaI
sympatletic pIexus (kaabacli 200S). Moreover innervation ol
spermatic cord by tle gCll slouId be taken into account. lor
tlese reasons, tle IIß aIone is unabIe to prevent eitler tle
painluI stimuIation lrom traction ol tle spermatic cord or
manipuIation ol tle testis and peritoneum (}agannatlan 2009).
In a study, an uItrasound-guided IIß added to a caudaI bIock
decreased tle severity ol pain in inguinaI lernia repair,
14 | UItrasound ßIocks lor tle Anterior AbdominaI waII
lydroceIectomy, orcliectomy and orclidopexy, but tlese data
and tle time to lirst rescue anaIgesic were signilicant onIy in
inguinaI lernia repair patients (}agannatlan 2009). 1le addition
ol a spermatic cord bIock to an IIß may reduce anaIgesic
requirements in orclidopexy (ßIatt 2001). lercutaneous IIß -
gClß in cliIdren undergoing inguinaI lerniorraply resuIted in
Iower pain scores lor 8 lours and Iower anaIgesic requirements
(linkIe 1981). conlIicting resuIts lave been slown by a study in
wlicl tle benelit ol tle additionaI gClß to IIß was Iimited onIy
to tle time ol sac traction witlout any postoperative ellect
(8asaoka 200S).
9. Obstetric and CynecoIogic 8urgery | 1S
9. Obstetric and CynecoIogic 8urgery
Zhirajr Mokini
Anterior abdominaI waII bIocks lave been evaIuated in
gynecoIogic and obstetric surgery. 1le llannenstieI section lor
open gynecoIogic and obstetric surgery allects tle groin
territory innervated by IIl and IIl. ObviousIy, a biIateraI bIock is
required in tlese types ol surgery. MuItimodaI anaIgesia witl
anterior abdominaI waII regionaI bIocks appIied to Iaparoscopic
or open intra-abdominaI surgery seem to be particuIarIy useluI
in reducing postoperative opioid requirements (ßamigboye
2009). A recent survey among obstetric anestlesioIogists in tle
United kingdom slowed tlat 21.õ¼ ol tlem used 1Alß lor
cesarean sections (kearns 2011).
It is important lowever to provide patients witl adequate
anaIgesia in reIation to tle surgicaI procedure because bIocks
cannot oller visceraI pain controI. Objective evaIuation in terms
ol pain reduction may be dillicuIt because tle visceraI
component ol postoperative pain may be subjectiveIy described
as moderate to severe. 1lis is wly many studies report
signilicant reduction in opioid requirements witlout signilicant
dillerences in pain scores. VisceraI pain can be ellectiveIy
reIieved witl neuraxiaI or systemic opioid administration, but at
tle price ol uncomlortabIe side ellects (kanazi 2010).
1õ | UItrasound ßIocks lor tle Anterior AbdominaI waII
-bstetric Surgery
1le IIß las been evaIuated alter generaI anestlesia and spinaI
anestlesia. OveraII, tle quaIity ol postoperative anaIgesia was
improved compared to pIacebo witl reduced pain reports, an
increased time lor lirst rescue anaIgesic and reduced opioid
need. lain scores and anaIgesic requirements may be reduced
lor tle lirst 24 lours (Canta 1994, ßeIavy 2009).
1lese resuIts suggest tlat tle IIß slouId be aIways perlormed
alter cesarean deIivery under generaI anestlesia or spinaI
anestlesia wlen neuraxiaI opioids are not used (ßeIavy 2009).
lowever, adverse ellects reIated to opioids lave been reported
to be not reduced by IIß. A recent coclrane review indicated
tlat women wlo undergo cesarean section under regionaI
anestlesia witl IIß lave decreased opioid consumption but no
dillerence in visuaI anaIogue pain scores (ßamigboye 2009).
1le bIock ol tle transverse abdominaI muscIe pIexus, in wlicl
tle IIl and tle IIl run, provided better anaIgesia witl reduced
opioid request and deIayed time to rescue anaIgesic compared
witl pIacebo (McuonneII 2008). More patients lave been
reported to be abIe to put tle babies to tle breast at 8 lours
(kuppuveIumani 199!).
leuraxiaI opioid is currentIy tle ¨goId standard" treatment
lor pain alter cesarean deIivery. ßiIateraI uItrasound-guided
1Alß in patients undergoing cesarean deIivery under
subaraclnoid anestlesia witl lentanyI resuIted in signilicantIy
reduced totaI morpline use lor 24 l (ßeIavy 2009, ßaaj 2010).
1Alß and subaraclnoid anestlesia witl lentanyI compared to
intravenous morpline and reguIar non-steroidaI anaIgesics
reduced totaI morpline requirements by õ0¼-10¼ and
postoperative pain in tle lirst 48 lours (McuonneII 2008, ßaaj
Opioid-reIated, dose-dependent, side-ellects incIuding nausea,
vomiting, pruritus and sedation, may occur. ueIayed maternaI
respiratory depression due to ceplaIic spread ol lydropliIic
9. Obstetric and CynecoIogic 8urgery | 11
opioids is anotler risk. 8ide ellects reduce overaII patient
satislaction, and teclniques tlat reduce opioid requirements
may be ol benelit.
8ome autlors state tlat IIß or 1Alß may oller no benelit on
pain controI compared to neuraxiaI morpline (costeIIo 2009,
kanazi 2010, McMorrow 2011). 1le addition ol morpline to tle
IocaI anestletic is easier to perlorm, is Iess time-consuming and
does not require extra equipment or skiIIs to be perlormed
(kanazi 2010). lowever, subaraclnoid morpline 0.1-0.2 mg
provided better anaIgesia but witl more adverse ellects (costeIIo
2009, kanazi 2010, luddy 2010). In a study, patients receiving
botl subaraclnoid anestlesia witl 0,1 mg morpline and a 1Alß
lad a ligler incidence ol pruritus and anti-emetic use. Less pain
on movement and Iater postoperative morpline request were
slown by patients receiving subaraclnoid morpline compared
to saIine (McMorrow 2011).
Gynecologic Surgery
lew triaIs lave evaIuated abdominaI bIocks lor gynecoIogic
surgery. ßiIateraI IIß lor totaI abdominaI lysterectomy or
proIapse repair tlrougl a llannenstieI incision under generaI
anestlesia las slown to reduce prevaIentIy dynamic pain and
morpline need. In a study tle reduction ol morpline was S1¼
(21 -J- 9 mg vs. 41 -J- 24 mg) during tle lirst two postoperative
days witl a more rapid controI ol earIy postoperative pain
(OrioIa 2001).
ßiIateraI 1Alß in totaI abdominaI lysterectomy signilicantIy
reduced morpline requirements at aII time points lor 48 lours.
A Ionger time to lirst morpline request and reduced
postoperative pain scores at rest and on movement were slown
compared to tle pIacebo (carney 2008 (2)).
1le reduction in pain scores is olten not signilicant,
suggesting tle existence ol additionaI pain lrom deep peIvic
dissection and suturing ol tle vaginaI vauIt during lysterectomy
18 | UItrasound ßIocks lor tle Anterior AbdominaI waII
(keIIy 199õ). kecentIy, a triaI on women undergoing pubic to
umbiIicaI midIine incision lor leterogeneous gynecoIogic
maIignancy, slowed no benelit ol uItrasound-guided 1Alß on
anaIgesic requirement, pain scores, adverse ellects and
satislaction over muItimodaI anaIgesia (Crillitls 2010).
10. Otler AbdominaI 8urgery lrocedures | 19
10. Otler AbdominaI 8urgery
Andrea radella, Tommaso Mauri
/o2er Abdominal Surgery
Lower abdominaI surgery incIudes varicoceIectomy, appen-
dicectomy, open prostatectomy, Iumbectomy and intra-aortic
procedures witl lemoraI artery cannuIation.
8urgicaI reports on awake varicoceIectomy slow tle ellicacy
ol IocaI anestletic inliItration beneatl tle aponeurosis ol tle
LOM into tle inguinaI canaI to bIock tle iIioinguinaI and
genitolemoraI nerves (lsu 200S). kecentIy, an ellective
uItrasound-guided spermatic cord bIock was reported (wiplIi
In tle onIy randomized study in aduIts undergoing
varicoceIectomy under generaI anestlesia and an IIß belore
surgery, patients experienced signilicantIy reduced
postoperative pain scores at rest and during mobiIization, Iess
anaIgesic consumption, Iess nausea and vomiting and were aII
disclarged at õ lours (Yazigi 2002).
1le IIß and tle 1Alß lave aIso been evaIuated in tle
perlormance ol appendicectomy. 1le IIß perlormed belore
surgery in cliIdren undergoing appendicectomy slowed better
80 | UItrasound ßIocks lor tle Anterior AbdominaI waII
pain scores and Iess anaIgesic consumption lor õ lours
(courreges 199õ). 1le reduced pain and postoperative morpline
consumption ellects ol uItrasound-guided 1Alß in
appendicectomy may Iast lor 24 lours (liraj 2009 (2)). 1Alß lor
Iaparoscopic appendicectomy in cliIdren las been slown to
oller no important cIinicaI benelit over IocaI anestletic port-site
inliItration (8andeman 2011).
ßiIateraI IIß or 1Alß las been reported to be ellective lor pain
controI in retropubic prostatectomy and lemoraI artery
cannuIation at tle IeveI ol groin (O'uonneII 200õ, 8erpetinis
2008). UItrasound-guided 1Alß las aIso been evaIuated in
patients scleduIed lor major ortlopedic surgery and anterior
iIiac crest larvest lor autoIogous bone gralt, witl pain aboIisled
lor tle lirst 48 lours (cliono 2010).
Upper Abdominal Surgery
1Alß is an ellective metlod ol bIocking tle sensory allerents
suppIying tle anterior abdominaI waII. lowever, tle cIassicaI
1Alß may not reIiabIy produce anaIgesia above tle umbiIicus
(8libata 2001). 1le subcostaI 1Alß invoIves injection
immediateIy inlerior to tle costaI margin. It las been reported
to provide anaIgesia lor incisions extending above tle umbiIicus
(lebbard 2008). A lurtler deveIopment ol tle subcostaI 1Alß is
tle possibiIity to pIace a catleter aIong tle obIique subcostaI
Iine in tle 1AM pIane lor continuous inlusion ol IocaI anestletic
(liraj 2011, lebbard 2010). An uItrasound-guided teclnique witl
a 1uoly epiduraI needIe and catleter may be used in tlis case.
Bo2el surgery
1Alß in aduIts undergoing Iarge boweI resection via a midIine
abdominaI incision resuIted in a signilicant reduction ol pain
scores and morpline requirements lor tle lirst 24 postoperative
lours (21.9 - 8.9 mg vs. 80.4 - 19.2 mg) (McuonneII 2001 (2)).
10. Otler AbdominaI 8urgery lrocedures | 81
1Alß empIoyed lor Iaparoscopic coIonic-rectaI resections
reduces overaII postoperative morpline (!1.! vs. S1.8 mg) and
lospitaI stay (conaglan 2010). In a retrospective anaIysis ol
patients undergoing Iaparoscopic coIonic-rectaI resection, an
uItrasound-guided 1Alß signilicantIy reduced time to tle
resumption ol diet and postoperative lospitaI stay (7alar 2010).
UItrasound-guided 1Alß in patients undergoing Iaparoscopic
cloIecystectomy was associated witl a signilicant reduction in
tle administration ol intraoperative sulentanyI and
postoperative morpline (10.S -J- 1.1 vs. 22.8 - 4.! mg)
(LI-uawIatIy 2009).
Didney surgery
1Alß may reduce pain scores and morpline requirements in
patients undergoing renaI transpIant (}ankovic 2009 (2)). lain
scores and intraoperative opioid need may be reduced lor 12
lours (Mukltar 2010). kidney transpIant recipients receiving IIß
and bIock ol 111 to 12 intercostaI nerves slow reduced
postoperative pain and totaI morpline consumption (12.1 -J-
10.S mg vs. !4.9 -J- S.9 mg) (8loeibi 2009). 8ubcostaI biIateraI
1Alß witl catleters compared to epiduraI anaIgesia in aduIt
patients undergoing eIective open lepatic-biIiary or kidney
surgery, provided no signilicant dillerences in pain scores at rest
and during cougling at 8, 24, 48 and 12 l alter surgery.
1ramadoI consumption was signilicantIy greater in tle 1Al
group (liraj 2011). latients received bupivacaine 0.!1S¼
biIateraIIy every 8 l in tle 1AM pIane and an epiduraI inlusion
ol bupivacaine 0.12S¼ witl lentanyI 2 mcgJmI.
A noveI 'semi bIind' teclnique ol administering tle 1Alß
tlrougl tle Iaparoscopic camera during neplrectomy las been
described (cletwood 2011).
82 | UItrasound ßIocks lor tle Anterior AbdominaI waII
Plastic surgery
Intraoperative 1Alß reduces postoperative anaIgesic
consumption in patients undergoing body contouring
abdominopIasty witl lIank Iiposuction (Araco 2010, Araco 2010
(2)). Alter tle lIap resection, tle libers ol tle LOM and IOM are
separated untiI tle 1AM is visuaIized and IocaI anestletic is
injected biIateraIIy. 8imiIarIy, patients receiving a combination
ol intercostaI, iIiolypogastric, iIioinguinaI and pararectus bIocks
lor abdominopIasty, slowed successluI Iong-term reIiel ol pain
and a signilicantIy reduced recovery time, aIIowing tle patient
to return to normaI activities and work mucl sooner (leng
11. AbdominaI MidIine 8urgery | 8!
11. AbdominaI MidIine 8urgery
Savino Spadaro, Tommaso Mauri
1le rectus sleatl bIock (k8ß) is sale, easy to Iearn and
perlorm, and provides tle anestlesioIogist witl anotler metlod
lor ellective and Iong-Iasting anaIgesia lor common day-case
1le k8ß las been described botl in aduIts and in cliIdren.
AItlougl regionaI anestlesia teclniques are commonIy used lor
postoperative pain controI in cliIdren, tlere lave been lew
studies investigating tle ellicacy ol k8ß. 1le teclnique is
recommended lor midIine Iaparoscopy wlere it provides
ellective anaIgesia. 1le onset ol anaIgesia is usuaIIy evident
witlin live to ten minutes and provides exceIIent operative
conditions witl muscuIar reIaxation (8mitl 1988). In cliIdren,
k8ß is a simpIe bIock tlat provides intra- and postoperative
anaIgesia lor umbiIicaI, paraumbeIicaI and epigastric lernia
repair. Anotler potentiaI use ol k8ß is lor anaIgesia alter
pyIoromyotomy. In aduIts, tle k8ß may be an aIternative to
epiduraI anestlesia lor some surgicaI procedures (Azemati 200S).
1le k8ß las aIso been described as particuIarIy useluI to
improve postoperative anaIgesia alter midIine Iaparotomy lor
umbiIicaI or epigastric lernia repair in ligl risk patients.
lowever, a piIot study laiIed to demonstrate tle advantage ol
k8ß over inliItration lor umbiIicaI lernia repair (Isaac 200õ).
84 | UItrasound ßIocks lor tle Anterior AbdominaI waII
12. LocaI Anestletics, llarmacokinetics
and Adjuvants
Amedeo !ostantini
1le action ol IocaI anestletics is eIicited tlrougl a specilic
bIock ol tle sodium clanneIs in tle peripleraI and centraI
nervous system. 1ley bIock botl nerve impuIse generation and
propagation. LocaI anestletics lave a particuIarIy ligl IeveI ol
activity in tle centraI nervous system and tle cardiovascuIar
wlen using IocaI anestletics lor regionaI anestlesia bIocks,
patient salety procedures sucl as a sale vein access, oxygen
avaiIabiIity, intensive care equipment, adequate monitoring,
immediate avaiIabiIity ol generaI anestlesia, and a steriIe
procedure slouId be assured according to nationaI and
internationaI guideIines (ßertini 200õ). CuideIines lor an
adequate postoperative pain treatment strategy and
management ol IocaI anestletic systemic toxicity must be aIso
taken into account (8avoia 2010, leaI 2010).
Bose< 'oncentration and %olume 'orrelations
1le concentration is delined as tle mass ol a constituent (tle
IocaI anestletic) divided by tle voIume ol tle mixture (voIume
ol soIution) (1abIe 12.1).
12. LocaI Anestletics, llarmacokinetics and Adjuvants | 8S
Table "0" – Bose< $olume and concentration correlations0
c = concentration (mgJmI) c = M J V
M = Mass (mg) M = c x V
V = VoIume (mI) V = M J c
1le riglt approacl to a IocaI anestletic dosing is to caIcuIate
tle dose per kg ol weiglt and to diIute it in order to obtain tle
desired voIume or concentration. 1le totaI dose (tle product ol
voIume x concentration) slouId be taiIored to tle minimum
mass ol IocaI anestletic necessary to aclieve tle desired cIinicaI
ellect (1abIe 12.2, 12.!, 12.4).
Table "0 – &ecommended doses of the long4lasting local anesthetics0
kecommended doses kopivacaine Levobupivacaine ßupivacaine
AduIts 2-!.S mgJkg 2-! mgJkg 2-! mgJkg
cliIdren dose 1-! mgJkg 1-2 mgJkg 1-2 mgJkg
cliIdren voIume 0.01S-0.S mIJkg 0.01S-0.S mIJkg 0.01S-0.S mIJkg
Table "03 4 *a?imum recommended doses of the long4lasting local
anesthetics in adults0
LocaI anestletic InliItration anestlesia
(doses witl epineplrin are in brackets)
kopivacaine 200-22S mg
Levobupivacaine 1S0 mg
ßupivacaine 1S0-11S (22S) mg
Table "05 – 'oncentration ranges of the long4lasting local anesthetics
for infiltration and ner$e block anesthesia0
kecommended concentrations kopivacaine Levobupivacaine ßupivacaine
AduIts 2-1.S mgJmI 1.2S-S mgJmI 1.2S-S mgJmI
cliIdren 1-1.S mgJmI 1-S mgJmI 1.2S-S mgJmI
8õ | UItrasound ßIocks lor tle Anterior AbdominaI waII
1le decision to use Iarger voIumes ol a ligler concentration
to aclieve a Ionger bIock must be weigled against tle potentiaI
risks ol ligler systemic absorption. 8peciaI attention slouId be
posed to obese patients in wlicl a dosing on a miIIigram ol IocaI
anestletic-per-kiIogram ol weiglt basis wouId be dangerous. In
tlese patients, a dosing based on tle ideaI weiglt may be more
Maximum recommended doses are vaIid in reIation to normaI
conditions (10 kg leaItly persons) and do not constitute a
maximum (kosenberg 2004). 1ley must be varied individuaIIy
depending on tle type and site ol bIock, tle weiglt and tle
cIinicaI condition ol tle patient.
Monitoring according to tle teclnique ol administration and
to tle expected pIasma concentration is liglIy advised
(kosenberg 2004).
/ong4lasting local anesthetics
1le Iong Iasting amide anestletics, bupivacaine,
Ievobupivacaine and ropivacaine, are liglIy IipopliIic moIecuIes
ol simiIar properties and ellicacy. concentrations ol 2.S to
S mgJmI ol tle Iong Iasting anestletics are generaIIy used lor
IlßJLIA, IIß and 1Alß (ßay-lieIsen 1999, MuIroy 1999). 1le
ellicacy and bIock duration is dose dependent (MuIroy 1999).
As relIected by cIinicaI studies, tle duration ol anaIgesia alter
IlßJLIA, IIß and 1Alß alter a singIe injection ol Iong Iasting IocaI
anestletics typicaIIy Iasts Iess tlan 12 l. lowever, tle benelits
on tle subjective pain IeveIs at rest and under stress, on tle
postoperative amount ol anaIgesics and on postoperative
mobiIization may Iast lor 24 lours to 10 days (lettersson 1998,
uing 199S, larrison 1994).
Among tle Iong-Iasting IocaI anestletics, ropivacaine is
prelerred lor abdominaI bIocks because it is Iess cardiotoxic tlan
bupivacaine (knudsen 1991). kopivacaine (and Ievobupivacaine,
12. LocaI Anestletics, llarmacokinetics and Adjuvants | 81
tle Ievoenantiomer ol bupivacaine) causes cardiovascuIar and
cl8 toxicity at ligler doses tlan bupivacaine (ßardsIey 1998).
llarmacokinetic parameters (lor exampIe pIasma
concentrations ol IocaI anestletics) vary wideIy between
individuaIs. 1le plarmacokinetic variabIes depend on tle
absorption lrom tle site ol injection, tle distribution in tle
tissues and body lIuids according to Iipid soIubiIity and protein
binding, and tle metaboIism and cIearance ol tle drug.
1le amount ol lat allects tissue accumuIation. 1le passage ol
tle IocaI anestletic into tle bIood wiII depend on tle totaI dose,
tle capiIIarity ol tle site ol injection and on tle ratio between
tle voIume ol tle drug and tle surlace in contact witl it. A
smaIIer absorption surlace may counterbaIance a ligl drug
concentration wlereas tle unpredictabIe spread ol a Iarge
voIume ol IocaI anestletic may become a reason lor side ellects
(kosenberg 2004).
1le pattern ol tle absorption rate lor dillerent bIocks is
generaIIy intercostaI - epiduraI JcaudaI - bracliaI pIexus -
sciatic bIock - subcutaneous. 1le absorption alter an IIß or a
1Alß may be laster tlan a caudaI bIock (AIa-kokko 2000,
AIa-kokko 2002, 8tow 1988). Moreover, absorption may be
inlIuenced by IocaI or systemic inlIammation (kosenberg 2004).
1le emergence lrom anestlesia may be aIso associated witl
increased absorption and a second pIasma peak (8mitl 199õ).
Absorption from the abdominal 2all
1le plarmacokinetics ol IocaI anestletics in tle 1AM pIane is
an area ol current investigation. 1le common Iandmarks are
cIose to important vesseIs tlat run tlrougl tle lascias. 1le 1AM
pIane las a big surlace tlat requires ligl voIumes ol diIuted
soIutions in order to aclieve an extended bIock. Lven at a diIute
concentration, Iarge voIumes ol IocaI anestletics may cause
88 | UItrasound ßIocks lor tle Anterior AbdominaI waII
serious consequences alter an intravascuIar injection or il tlere
is rapid uptake lrom tle tissues. Moreover, it is to be considered
tlat an IlßJLIA invoIves solt tissue inliItration. IntraperitoneaI
injection may be aIso dangerous because ol tle ligl absorption
rate. kepeated injections may be associated witl proIonged
systemic absorption and witl unexpectedIy ligl and persistent
eIevations ol pIasma concentrations during an IlßJLIA (MuIroy
2009). 1lerelore, it is not recommended to repeat abdominaI
bIocks or suppIementary anestletic injections witlin tle
eIimination Iile ol tle IocaI anestletic.
Pharmacokinetic studies and the abdominal 2all blocks
1le pIasma IeveIs ol tle IocaI anestletics alter abdominaI
bIocks rise graduaIIy in a dose-proportionaI laslion in 1S to õ0
minutes and remain near tle peak IeveIs lor a õ0 to 120 minute
period (MuIroy 1999, lettersson 1998, Crillitls 2010 (2)). 1lese
data indicate tle need lor caution wlen perlorming
suppIementaI injections ol IocaI anestletic.
uespite tle proIonged eIevation ol pIasma IeveIs, no signs ol
IocaI anestletic toxicity lave been reported even witl !00 to
!1S mg doses ol ropivacaine (MuIroy 1999, lettersson 1998, wuIl
1999, wuIl 2001, Martin 1981, lettersson 1999). lowever, most
studies lave used premedication witl a benzodiazepine and
many are conducted under generaI anestlesia wlicl may lave
occuIted transitory neuroIogicaI ellects. 1le 1Alß perlormed at
tle concIusion ol surgery lor pain reIiel or lor briel operations,
may be potentiaIIy neurotoxic because ol tle eIevated pIasma
concentrations in conscious patients.
1le uItrasound-guided IIß and 1Alß lave been associated witl
a laster absorption and more eIevated pIasma concentrations in
botl aduIts and cliIdren due to tle great surlace ol contact
(wiIIsclke 200S, wiIIsclke 200õ, kettner 2009). 1lus, a reduction
ol tle voIume ol IocaI anestletic slouId be considered wlen
using an uItrasound-guided teclnique lor abdominaI bIocks in
12. LocaI Anestletics, llarmacokinetics and Adjuvants | 89
aduIts and cliIdren (Crillitls 2010). 1le anaIgesic ellect ol tle
1Alß may partiaIIy depend on tle rise in serum concentration ol
tle IocaI anestletic (kato 2009).
Blood 'learance
In normaI leaItly persons, tle amide IocaI anestletics are
bound to pIasma -1-acid-gIycoprotein tlat ellectiveIy prevents α
tle presence ol ligl concentrations ol unbound and active IocaI
anestletic. 8urgery lurtler stimuIates tle syntlesis ol -1-acid- α
gIycoprotein lrom tle Iiver, reducing tle risk ol toxicity
(Aronsen 1912, lettersson 1998).
1le cIearance ol IocaI anestletics is dependent on tle renaI
and lepatic lIow and cardiac lunction. In advanced leart, kidney
and Iiver laiIure and tlerapy witl cytoclrome isoenzyme
inlibitors Iike antimycotics, tle dose ol tle IocaI anestletic
slouId be reduced by 10 to S0¼ (kosenberg 2004).
Age reIated clanges in bIood lIow and organ lunction may
increase tle nerve sensitivity to a IocaI anestletic bIock, and a
smaIIer dose is needed to aclieve tle same ellect. LocaI
anestletic doses need to be reduced by up to 20¼ in tle eIderIy
(kosenberg 2004).
1le Iate stage ol pregnancy is claracterized by a
plysioIogicaIIy enlanced sensitivity ol nerves to IocaI
anestletics. ßIocks slouId be perlormed witl tle Iowest possibIe
doses lor slort periods aiming to reduce tle need lor otler
anaIgesics (kosenberg 2004).
Pediatric 'onsiderations
leonates and cliIdren up to 4 montls ol age lave Iow pIasma
concentrations ol -1-acid-gIycoprotein and tlus a greater α
amount ol lree drug in tle bIood (Mclamara 2002). A more
conservative dose slouId be used wlen perlorming an
abdominaI bIock in inlants and neonates (· 1S kg) because a
90 | UItrasound ßIocks lor tle Anterior AbdominaI waII
ligler absorption ol IocaI anestletic las been slown (8mitl
199õ). 1le cause may be tle increased cardiac outputJbody mass
index ratio, tle decreased tissue accumuIation and tle reduced
Iiver metaboIism. wlen Iarge doses ol IocaI anestletic are used,
tle dose per kiIogram slouId be reduced by about 1S¼
(kosenberg 2004).
cliIdren under two years ol age lave been reported to lave
signilicantIy ligler pain scores tlan tlose above tlis age
(1rotter 199S). kopivacaine as a Iong-Iasting agent lor IIß in
cliIdren may be more ellective wlen used witl a ligl
concentrationJsmaII voIume tlan wlen used witl a ligl
voIumeJIow concentration (1rila 2009). Il smaIIer voIumes ol
IocaI anestletic are used, uItrasounds become a necessary tooI in
order to improve tle clance lor a successluI bIock.
8everaI studies lave evaIuated tle use ol adjuvants to IocaI
anestletics (cIonidine, ketamine ecc) lor improving
postoperative anaIgesia alter tle anterior abdominaI bIocks.
cIonidine added to intermediate or Iong-acting IocaI
anestletics lor singIe-slot peripleraI nerve or pIexus bIocks
proIongs tle duration ol anaIgesia and motor bIock by about 2 l
but at tle cost ol an increased risk ol lypotension, lainting, and
sedation and witl an uncIear dose-responsiveness kinetics
(löpping 2009).
cIonidine used lor tle abdominaI bIocks or IlßJLIA las not
slown to give a cIinicaIIy important benelit in aduIts and cliI-
dren (ßeaussier 200S, kaabacli 200S, uagler 200õ, LIIiott 1991). A
common adverse ellect is ortlostatic lypotension during tle
lirst postoperative lours. In tlese types ol bIock, as a
consequence ol tle spread into a wide zone, tle accumuIation ol
cIonidine near nerves may be decreased. 1lus cIonidine wouId
not reacl tle riglt IeveI to allect nerve conduction or laciIitate
tle action ol tle IocaI anestletic (kaabacli 200S).
1!. compIications | 91
1!. compIications
Zhirajr Mokini
Transient Femoral +er$e Block
1le most lrequentIy described compIication alter an IIß is tle
transient postoperative bIock ol tle lemoraI nerve (kosario 1994,
kosario 1991). It may occur botl alter seIective IIß or 1Alß or
alter an IlßJLIA perlormed by tle surgeon.
1le transient lemoraI nerve bIock (1llß) may be partiaI or
compIete, sensory andJor motor (wuIl 1999). 1le transient
lemoraI nerve bIock incIudes a reduced sensation ol tle skin
overIying tle anterior and Iower mediaI portion ol tle tligl and
weakness ol tle tligl expressed as a dillicuIty in standing up
and waIking (Lrez 2002).
8peciaI attention is required, since tlere may be a 2.S to õ lour
deIay between tle injection ol tle anestletic and tle onset ol
1llß (kIuger 1998). Once tle 1llß is present, it may persist lor
up to !õ lours (8aIib 2001). compIete spontaneous recovery
belore 12 lours las been generaIIy reported (Lrez 2002, kosario
1le 1llß is a potentiaI cause ol deIay in patient disclarge and
a cause ol possibIe compIications Iike minor injuries or even
lractures lrom subsequent laIIs (8zeII 1994). 1le awareness ol
92 | UItrasound ßIocks lor tle Anterior AbdominaI waII
tlis compIication is important to avoid morbidity, and patients
slouId be inlormed ol tle transitory nature ol tlis compIication.
1le incidence ol inadvertent lemoraI nerve bIock ranges lrom
0.21¼ to 28¼ in aduIts and cliIdren (Lipp 2000, Lim 2002, Lipp
2004). Most reports are lrom pediatric patients wlo seem to
lave an increased risk ol 1llß (Lrez 2002). 1le 1llß may be Iess
IikeIy to occur in lemaIes tlan maIes because ol a dillerent
distance between tle lemoraI nerve and tle point ol injection
lor tle IIß. 1le 1llß las not been reported yet alter an
uItrasound-guided nerve bIock.
1le IIß given under direct vision by surgeons appear to lave a
Iower incidence ol 1llß. 1le transient lemoraI nerve bIock las
been reported aIso alter IaparoscopicaIIy guided IIß (Lange
1le meclanism invoIved in tle 1llß deveIopment may be due
to tle direct instiIIation around tle lemoraI nerve or tle
anestletic dillusion under tle iIiac lascia. 1le IocaI anestletic
may reacl tle pIane deep to tle iIiac lascia and tle lemoraI
nerve wlen it is deposited between tle 1AM and transversaIis
lascia or directIy under tle iIiac lascia around tle lemoraI nerve
(kosario 1994, kosario 1991, Lrez 2002). It is to be remembered
tlat tle lemoraI nerve runs over tle iIiopsoas muscIe in cIose
proximity to tle inguinaI canaI (Lrez 2002).
LocaI anestletic introduction into tle pIane between tle
quadratus Iumborum and tle psoas major muscIe, bIocking tle
Iumbar pIexus roots, may be aIso tle cause lor lemoraI nerve
bIock (winnie 191!). Moreover, tle injection into tle pIane ol
tle 1AM can increase tle risk ol tlis compIication (kosario
Apart lrom IocaI anestletic bIock, 1llß may loIIow lemoraI
nerve trauma, suture invoIvement, entrapment witl stapIes,
compression or lematoma botl alter open or Iaparoscopic
lernia repair (Carcía-Ureña 200S).
1!. compIications | 9!
Peritoneal and %isceral Puncture
UItrasonograplic studies lave conlirmed tlat especiaIIy in
cliIdren, not onIy tle abdominaI waII is tlinner and body size
and tle operating area are smaIIer, but aIso tle IIl and tle IIl
are very cIose to tle peritoneum in an age-dependent manner
(wiIIsclke 200S, long 2010).
IntraperitoneaI injection las been reported botl in cliIdren
and aduIts alter an IIß or 1Alß (}ankovic 2008). An uItrasound
controI study reported tlat tle IocaI anestletic soIution was
deposited into tle peritoneum in 2¼ ol cases, emplasizing tle
considerabIe risk ol peritoneaI or visceraI puncture (ligure 1!.1)
(weintraud 2008).
Figure "30" 1 /arge and small bo2el under the abdominal 2all0
Otler rareIy reported compIications are coIonic or smaII boweI
puncture and peIvic lematoma (}olr 1999, lrigon 200õ, Amory
200!, Vaisman 2001). 1le presence ol visceraI puncture may
remain undetected il tle bIock is perlormed lor a type ol surgery
94 | UItrasound ßIocks lor tle Anterior AbdominaI waII
sucl as inguinaI repair or orclidopexy tlat do not incIude boweI
exposure. In tlree cliIdren lrom õ to 14 years ol age, subserosaI
lematomas ol tle coIon and smaII boweI lave been reported
loIIowing an IIß under generaI anestlesia respectiveIy lor
spermatic vein Iigation, appendicectomy and Ielt inguinaI lernia
(}olr 1999, lrigon 200õ, Amory 200!).
In one case, smaII boweI lematoma required resection ol a
boweI Ioop. 1le recovery was uneventluI and tle cliId was
disclarged on day 8 (Amory 200!). 8ubcutaneous IocaI
lematoma at tle puncture site las been aIso reported (Lrez
Liver trauma las been aIso described alter a 1Alß (larooq
2008, O'uonneII 2009, Lancaster 2010). In one case tle Iiver was
enIarged and reacled tle riglt iIiac crest. lepatomegaIy or
spIenomegaIy witl tle Iiver or spIeen margin reacling tle iIiac
crest may be a risk lactor lor puncture (larooq 2008, O'uonneII
2009). It wouId be prudent to paIpate tle edge ol tle Iiver and
spIeen belore perlorming tle procedure, and tlis is particuIarIy
important in patients ol smaII stature.
laiIure to recognize tle ¨pops" may resuIt in needIe
advancement deeper tlan tle 1AM and into tle peritoneaI
cavity (O'uonneII 2009).
Aspiration prior to injection and image cleck lor vascuIar
structures reduces tle risk ol direct intravascuIar
administration ol tle anestletic agent (ligure 1!.2).
In order to reduce tle risk ol puncturing intra-abdominaI
structures, some autlors strongIy suggest tle routine use ol
uItrasonograply (weintraud 2008, lredrickson 2008). leedIe tip
and correct tissue visuaIization is advocated in aII cases
(Lancaster 2010). Moreover, an in-pIane approacl may aIIow
easier visuaIization ol tle muscIe Iayers and needIe tip position.
1!. compIications | 9S
Figure "30 1 A small artery 7A9 seen as a pulsating image near the
ilioinguinal ner$e 7+90
'omplications of &ectus Sheath Block
compIications are rare but can incIude puncture ol tle inlerior
epigastric vesseIs and peritoneaI injection (ligure 1!.!).
leritoneaI injection is liglIy possibIe witl a Ioss ol resistance
teclnique and can be avoided by using uItrasounds. Aspiration
prior to injection reduces tle risk ol direct intravascuIar
administration ol tle anestletic agent. 1le bIock is tlouglt to
be particuIarIy dillicuIt in tle obese and tlose patients witl
abdominaI distension. A retroperitoneaI lematoma in tle riglt
paraaortic region extending lrom tle IeveI ol tle umbiIicus
down to tle peIvic brim, las been reported alter a bIind
periumbiIicaI k8ß (Yuen 2004).
9õ | UItrasound ßIocks lor tle Anterior AbdominaI waII
Figure "303 1 &ight and left rectus sheath and deep inferior epigastric
artery that 2as seen as pulsating on real4time image 7A90
'omplications of Genitofemoral +er$e Block
ßecause ol tle presence ol muItipIe vesseIs in tle spermatic
cord (pampinilorm pIexus and testicuIar arteries), tle bIind
teclnique is associated witl tle possibiIity ol an intravascuIar
IocaI anestletic injection and subsequent systemic intoxication.
1le perloration and damage ol tle testicuIar artery witl tle
potentiaI ol subsequent bIeeding and lematoma lormation is
aIso a weII-described serious side-ellect ol tle bIind teclnique
(CoIdstein 198!).
1le injection slouId be perlormed witl an uItrasound
teclnique and administered just beIow tle ¨cIick" ol tle
externaI obIique aponeurosis and alter aspiration.
14. kelerences | 91
14. kelerences
Aasbo V, 1luen A, kaeder }. Improved Iong-Iasting postoperative anaIgesia,
recovery lunction and patient satislaction alter inguinaI lernia repair witl
inguinaI lieId bIock compared witl generaI anaestlesia. Acta Anaestl
8cand 2002,4õ:õ14-8.
Abad-1orrent A, caIabuig k, 8ueiras A, et aI. Lllicacy ol tle iIioinguinaI and
iIiolypogastric bIock in tle treatment ol tle postoperative pain ol inguinaI
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1S. Index | 111
1S. Index
absorption.................................... 81
adjuvants...................................... 90
anterior abdominaI waII
innervation.................................. 1õ
anterior abdominaI waII structure
....................................................... 1!
appendicectomy.......................... 19
bIind iIiolypogastric and
iIioinguinaI nerve bIock.............. 44
bIind transverse abdominaI
pIexus bIock................................. !õ
bIood cIearance............................89
bIood suppIy to tle anterior
abdominaI waII............................ 1S
boweI puncture............................ 9!
caudaI bIock................................. 12
cesarean section.......................... 1õ
communication between
anatomicaI pIanes....................... 2!
compIications ol rectus sleatl
bIock............................................. 9S
compIications ol genitolemoraI
nerve bIock...................................9õ
cyst ol tle spermatic cord.......... 11
dose, concentration and voIume
correIations.................................. 84
equipment.................................... !1
lIank Iiposuction.......................... 82
locus.............................................. !0
genitolemoraI nerve................... 20
gynecoIogic surgery.................... 11
lydroceIectomy........................... 11
lysterectomy............................... 11
iIiolypogastric and iIioinguinaI
nerve bIock...................................õ9
iIiolypogastric and iIioinguinaI
nerve bIock and caudaI anestlesia
....................................................... 12
iIiolypogastric and iIioinguinaI
nerve bIock and wound
iIiolypogastric and iIioinguinaI
nerves........................................... 18
imaging......................................... 21
in-pIane........................................ !1
inguinaI canaI.............................. 20
inguinaI lieId bIockJIocaI
inliItration anestlesia................ õS
inguinaI lernia repair.................11
inguinaI lernia repair.................õS
intraperitoneaI ........................... 9!
}ean-Louis letit............................ !1
Iong axis ol tle transducer ........!1
Iong-Iasting IocaI anestletics.....8õ
Iower abdominaI surgery............19
Iumbectomy................................. 19
midIine Iaparoscopy.................... 8!
needIe........................................... !1
obstetric surgery......................... 1õ
orclidopexy................................. 11
orcliectomy................................. 11
out-ol-pIane................................. !1
pediatric....................................... 89
pediatric considerations............. 89
112 | UItrasound ßIocks lor tle Anterior AbdominaI waII
peritoneaI and visceraI puncture
....................................................... 9!
plannenstieI................................. 11
plarmacokinetic......................... 88
piezoeIectric................................ 2õ
piezoeIectric ellect...................... 2õ
pIasma concentrations................81
presets.......................................... !0
rectus sleatl............................... 22
slort axis ..................................... !1
sound waves................................. 24
spatiaI compound imaging......... !0
spread........................................... 42
teclnicaI aspects......................... õ!
time-gain compensation............. !0
transducers.................................. 29
transient lemoraI nerve bIock... 91
transverse abdominaI pIexus..... !S
transverse abdominaI pIexus
bIock............................................. !S
uItrasonograplic visuaIization
studies.......................................... 48
uItrasound and tle needIe..........!1
uItrasound-guided iIiolypogastric
and iIioinguinaI nerve bIock...... 49
uItrasound-guided transverse
abdominaI pIexus bIock.............. !1
upper abdominaI surgery........... 80
varicoceIectomy.......................... 19

687034 783942 9

ISBN 978-3-942687-03-4
Regional anesthesia techniques aie
an essential tool in the setting of a
multimodal analgesia stiategy.
Te tiansveise abdominal plexus
block, the iectus sheath block and the
iliohypogastiic, ilioinguinal and
genitofemoial block aie among the
most piomising techniques foi somatic
pain contiol in adult and pediatiic
Tis guide piovides the necessaiy
infoimation to staf anesthesiologists
and iesidents foi a safe and efective
peifoimance of anteiioi abdominal
wall blocks.
edited by
Mokini, Vitale, Costantini, Fumagalli, et al.
Ultiasound Blocks
foi the Anteiioi
Abdominal Wall i
the Flying Publisher Guide to