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Veterinary Anaesthesia and Analgesia

Volume 48, Issue 1, January 2021, Pages 101-106

Research Paper

Comparison between two

approaches for the transversus
abdominis plane block in canine
cadavers
Marta Romano a … Pablo E. Otero b

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https://doi.org/10.1016/j.vaa.2020.09.005
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Abstract

Objective
To compare the dye distribution following either two
lateral abdominal or one lateral abdominal and one
subcostal ultrasound-guided transversus abdominis
plane (TAP) injections of a clinically relevant volume of
dye solution in dogs.

Study design
Randomized cadaveric study.

Animals
A total of eight canine cadavers.

Methods
On one side of each cadaver, two TAP injections were
performed on the lateral aspect of the abdomen
(approach LL), caudal to the last rib and cranial to the
iliac crest. On the contralateral hemiabdomen, one
subcostal (caudal to the costal arch) and one lateral
abdominal injection (between last rib and iliac crest),
were performed (approach SL). Side allocation was
randomly determined. A spinal needle was introduced
in-plane to the transducer for each injection of
methylene blue (0.25 mL kg−1). All cadavers were
dissected to assess dye distribution and number of
stained target nerves.

Results
All injections were performed in the TAP. The
proportion of target nerve staining was 53.5% versus
80.4% with approaches LL and SL, respectively (p =
0.005). Approach LL stained the first lumbar (L1) spinal
nerve in 100% of injections and ninth thoracic (T9),
T10, T11, T12, T13 and L2 were stained in 0%, 0%,
37.5%, 62.5%, 87.5% and 87.5% of injections,
respectively. Approach SL stained T11, L1 and L2 in
100% of injections and T9, T10, T12 and T13 were
stained in 37.5%, 87.5%, 75% and 62.5% of injections,
respectively. Approach SL resulted in greater staining
of nerves cranial to T12 compared with approach LL.
The two approaches were equivalent in staining nerves
caudal to T12.

Conclusions and clinical relevance

Approach SL provided a broader distribution of the
injected solution than approach LL, which may result
in a larger blocked area in live animals undergoing
celiotomy.

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Keywords
abdomen; analgesia; regional anesthesia; TAP
block; ultrasound-guided

Introduction
The transversus abdominis plane (TAP) block is used
in humans and animals to provide perioperative
abdominal analgesia by blocking the nerves supplying
sensory innervation to the abdominal wall and
underlying parietal peritoneum (Børglum et al. 2011;
Portela et al. 2014; Skouropoulou et al. 2018). The
ventral branches of thoracic (T) 9–13 and lumbar (L) 1
(hypogastricus cranialis) to L2 (hypogastricus caudalis)
spinal nerves divide into lateral and medial branches
which are responsible for the innervation of the skin
and of the abdominal wall and underlying peritoneum,
respectively (Evans & de Lahunta 2013). As these nerves
are not typically visible with ultrasound, the injection
end point for TAP block is the intermuscular fascial
plane between the obliquus internus and the
transversus abdominis muscles. Local anesthetics
injected within the TAP are assumed to reach the
branches of the thoracolumbar spinal nerves supplying
sensory innervation to the abdominal wall. However,
cadaveric studies in dogs showed that when a single
injection of a large volume of colorant (i.e. 1 mL kg−1)
is injected in the TAP, the solution tends to pool near
the injection site thus failing to adequately stain all the
target nerves (Schroeder et al. 2011; Zoff et al. 2017).
Therefore, multiple TAP injections may result in
better distribution of the injectate. In one study, a
single dye injection between the obliquus internus and
the transversus abdominis muscles reliably stained
T12–L2, but T9, T10 and T11 were rarely or never
stained (Schroeder et al. 2011). Therefore, a two-point
injection technique, caudal to the thirteenth rib and
cranial to the iliac crest, has been proposed to provide
a broader distribution of the injectate (Johnson et al.
2018). However, following injection of 0.3 mL kg−1 per
point, this technique failed to reliably stain nerves
cranial to T12, suggesting that a similar approach in
live patients may be inadequate to provide analgesia
for laparotomy. An alternative, subcostal approach to
the TAP block, has been proposed to target the nerves
supplying sensory innervation to the cranial abdomen
(Drożdżyńska et al. 2017). This approach consists of
depositing local anesthetics between the rectus
abdominis and the transversus abdominis muscles,
caudal to the costal arch. In one study, three subcostal
TAP injections of a total of 1 mL kg−1 of dye solution
per side were performed (Drożdżyńska et al. 2017).
This volume was divided in three aliquots for the three
injection points and resulted in reliable staining of
T10–T12, but although T9 and T13 were frequently
stained, this approach failed to reliably stain the
lumbar spinal nerves (Drożdżyńska et al. 2017).

Overall, previous cadaveric studies suggest that large

volume, lateral or subcostal TAP injections may fail to
adequately desensitize the entire abdominal wall in
live dogs. Therefore, the objective of the present study
was to compare the pattern of distribution following
either two TAP injections performed on the lateral
aspect of the abdomen (lateral abdominal injections) or
one lateral abdominal and one subcostal injection of a
clinically applicable volume of dye solution in canine
cadavers. The hypothesis of the study was that the
combination of lateral and subcostal injections would
result in staining of a larger number of nerves
compared with two lateral injections.

Material and methods

A total of eight frozen cadavers of dogs euthanized for
reasons unrelated to this study, and weighing 26 (21–
32) kg were enrolled. The study was approved by the
Institutional Animal Care and Use Committee of the
University of Florida (no. 201810493). Each cadaver was
thawed for 48 hours prior to the experiment, and
positioned in dorsal recumbency. The hair of the
abdomen was clipped. All the injections were
performed by a board-certified anesthesiologist
familiar with ultrasound-guided TAP blocks (MR). Two
lateral TAP injections were performed on one
hemiabdomen (approach LL), and one subcostal and
one lateral injection were performed on the other
hemiabdomen (approach SL; Fig. 1). The side
allocation was randomly selected by drawing folded
strips of paper indicating the treatment from a bowl. A
total volume of 1 mL kg−1 of a solution containing one
part of 0.39% new methylene blue (New Methylene
Blue, Bretcher Formulation; Ricca Chemical Company,
IL, USA) diluted in nine parts of sodium chloride
(NaCl; Baxter Healthcare Corp., IL, USA) was used. The
total volume was divided in four 0.25 mL kg−1 aliquots
per injection site. All injections were performed using
22 gauge, 8.9 cm Quincke spinal needles (BD spinal
needle; Becton Dickinson & Co., NJ, USA) connected to
a syringe (Monoject; Covidien llc, MA, USA) with a
prefilled T port (T Conn. w/Swivel MML; Smiths
Medical ASD Inc., OH, USA). Imaging was performed
using a 50 mm, 13 MHz, linear transducer connected
to a portable ultrasound machine (Edge; Sonosite Inc.,
WA, USA).

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Figure 1. Schematic representation of two approaches

for performing ultrasound-guided transversus
abdominus plane (TAP) injections in a canine cadaver
in dorsal recumbency. The lateral–lateral (LL) approach
was performed by positioning the transducer on the
lateral aspect of the abdomen, immediately caudal to
the last rib and immediately cranial to the iliac crest
with a transverse orientation, with the needle inserted
in-plane in a ventral-to-dorsal direction. The
subcostal–lateral (SL) approach was performed by
positioning the transducer parallel to the costal arch
(subcostal injection) with the needle introduced in a
cranial-to-caudal direction and then midway between
the last rib and the iliac crest with a parasagittal
orientation (lateral injection), with the needle
introduced in-plane in a cranial-to-caudal direction.
The black rectangle represents the transducer and the
white arrows the direction of needle introduction.

For the LL approach, the transducer was initially

positioned immediately cranial to the umbilicus over
the ventral midline and perpendicular to the long axis
of the dog. When the linea alba was recognized, the
transducer was slid laterally until the belly of the
obliquus internus muscle could be identified
superficially to the transversus abdominis muscle
(Fig. 2a). With the transducer positioned with a
transversal orientation, two in-plane injections were
performed, one immediately caudal to the costal arch
(LL cranial injection) and the other immediately
cranial to the iliac crest (LL caudal injection) (Fig. 1).
The needle was introduced in-plane in a ventral-to-
dorsal direction and continuously visualized while
advanced towards the TAP (Fig. 2b).

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Figure 2. Ultrasound images and schematic

representations (inserts) of two approaches to
transversus abdominus plane (TAP) injections in a
canine cadaver. (a) Lateral–lateral (LL) approach:
ultrasound images of anatomical structures; (b)
injectate distribution in the fascial plane between the
obliquus internus and transversus abdominis muscles
after a lateral TAP injection. Subcostal and lateral (SL)
approach: (c) ultrasound image of the anatomical
structures visualized with the subcostal approach; (d)
injectate distribution in the fascial plane between the
rectus abdominis and transversus abdominis muscles
after a subcostal TAP injection.

The SL approach was performed on the contralateral

side of the cadaver. The subcostal TAP injection was
performed by positioning the transducer parallel to
the costal arch (Fig. 1). The needle was guided in-plane
in a cranial-to-caudal direction and continually
visualized until its tip was advanced into the fascial
plane between the rectus abdominis and the
transversus abdominis muscles (Fig. 2c and d). For the
lateral TAP injection in approach SL, the transducer
was initially positioned immediately cranial to the
umbilicus with a transverse orientation to allow
identification of the linea alba. The transducer was
then slowly slid laterally until the belly of the obliquus
internus muscle could be identified between the
obliquus externus and the transversus abdominis
muscles. The transducer was then rotated 90º and
positioned with a longitudinal orientation (Fig. 1). The
needle was inserted in-plane in a cranial-to-caudal
direction with the tip directed towards the TAP.

Correct positioning of the tip of the needle was

confirmed prior to injection of methylene blue
solution by observing hydrodissection of the TAP
following injection of 0.5 mL saline solution. If
hydrodissection of the target plane was not visualized,
the needle was redirected and the saline test dose
repeated until correct positioning was achieved. When
satisfactory needle positioning was achieved,
methylene blue solution (0.25 mL kg−1) was injected.

The cadavers were dissected 30 minutes after the last

injection was performed to observe the distribution of
the dye. A skin incision was made from the xyphoid
process to the pubis. The rectus sheath was detached
from the linea alba and dissected laterally, and the
aponeurosis of the obliquus internus muscle was
identified and dissected from the linea alba in a dorsal
direction to expose the transversus abdominis muscle
and identify the target nerves. The ventral branches of
T9–L2 were considered the targets for nerve staining,
because these are the nerves that must be blocked to
obtain adequate somatic analgesia for celiotomy in
dogs. These nerves were identified and assessed for
dye staining. Location and staining of nerves T7, T8
and L3 were noted. Individual thoracolumbar nerves
were considered successfully stained if the entire
circumference of the nerve for >1 cm was dyed.

Statistical analysis
D'Agostino–Pearson normality test was used to test for
normal distribution. The t test was used compare the
total number of nerves stained with approaches LL or
SL. The proportion of nerves stained by the LL or SL
approach was calculated by dividing the number of
stained nerves (T9–L2) by 7 (i.e. the number of target
nerves per hemiabdomen). Comparison of the
proportion of nerves stained with the SL or LL
approaches was performed using a two-sided chi-
square with Yates' correction. Branches of T7, T8 and
L3 were not included in the proportion comparisons.
The comparison of the proportion of nerve staining
between SL and LL approaches was performed using a
two-sided Fisher’s exact test. Differences were
considered significant when p < 0.05. Statistical
analyses were performed using GraphPad Prism
Version 8.0 (GraphPad Software Inc., CA, USA).

Results
A total of eight LL-cranial and eight LL-caudal
injections were performed with the LL approach, and
eight subcostal and eight lateral injections were
performed with the SL approach. The ventral branches
of T7 or T8 were not identified within the TAP. The
hypogastricus caudalis nerve (L2) was divided into two
main branches running into the TAP in three cadavers.
All 32 injections were made at the intended locations,
between the transversus abdominis and the obliquus
internus muscles and between the transversus
abdominis and the rectus abdominis muscles for the
lateral and subcostal injections, respectively.

With the LL approach, the spread of the cranial and

caudal injections was overlapping in two
hemiabdomens. With the SL approach, a gap of
undyed tissue corresponding to T13 was observed
between the cranial and caudal injections in three
hemiabdomens. The LL and SL approaches stained 3.7
± 0.7 and 5.6 ± 0.5 out of seven target thoracolumbar
nerves per hemiabdomen, respectively (p < 0.0001). The
total number of nerves stained with the SL approach
was 45 out of 56 (80.3%) and was significantly higher
(p = 0.005) than the number of nerves stained with the
LL approach, which was 30 out of 56 (53.5%). When
comparing individual nerves, the SL approach resulted
in significantly higher success rate of staining of T10
(p = 0.0014) and T11 (p = 0.0256) compared with the LL
approach (Fig. 3), whereas there was no significant
difference between the two approaches in staining of
nerves caudal to T12.

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Figure 3. Specific ventral branches of the

thoracolumbar nerves (T9–L3) per hemiabdomen
stained with either two lateral transversus abdominus
plane (TAP) injections (LL approach) or one subcostal
and one lateral TAP injections (SL approach) in eight
canine cadavers. A total of 16 injections were
performed for each approach. ∗p = 0.0014; †p = 0.0256.

Discussion
The SL approach resulted in a broader distribution of
the injected solution compared with the LL approach,
staining 80.36% of the target ventral branches of the
T9–L2 spinal nerves versus 53.5% in eight canine
cadavers. The results of this study suggest that a total
volume of 1 mL kg−1 of local anesthetic injected with a
bilateral SL approach in live dogs may provide a
broader area of desensitization to the abdominal wall
and underlying peritoneum compared with a bilateral
LL approach. However, care should be taken when
generalizing the results obtained with this cadaveric
study to live animals.

In the present study, the LL approach failed to stain

the T9 and T10 nerve branches and stained T11 in
37.5% of injections. Similarly, a previous study
proposed that a similar approach would not
desensitize the cranial abdomen in live dogs
undergoing celiotomy (Johnson et al. 2018). In the
present study, the LL approach resulted in staining of
T13 in seven out of eight injections. By contrast, in
another study, 100% staining of T13 was achieved
using a similar approach (Johnson et al. 2018). This
difference may be the result of the low number of
injections performed or result from using different
volumes of dye solution; 0.25 mL kg−1 in the present
study versus 0.3 mL kg−1 used by Johnson et al. (2018).

An unstained gap was identified between the subcostal

and the lateral injection following the SL approach,
leaving T13 undyed in 37.5% of the hemiabdomens.
Other factors should be considered before
extrapolating the possible clinical implications of this
finding to live animals administered local anesthetic
using a similar approach (de Miguel Garcia et al. 2020).
Abdominal dermatomal innervation overlaps;
therefore, adequate somatic analgesia may be achieved
in live dogs undergoing celiotomy even when a single
nerve is not blocked. In addition, other factors such as
the systemic effects of the absorbed local anesthetic
(Rahiri et al. 2017) and spread in live tissue after
injection facilitated by breathing movements and
lymphatic drainage (Otero et al. 2020) may influence
the effectiveness of a similar approach in live animals.

This study evaluates the TAP distribution of an

amount of solution applicable to clinical practice
following a combination of subcostal and lateral
approaches. A volume of 1 mL kg−1 of colorant per
hemiabdomen was used in a previous study on
subcostal TAP injections (Drożdżyńska et al. 2017). In
that study, the use of subcostal injections alone failed
to reliably stain the lumbar branches, suggesting it
may be inadequate to provide analgesia to the caudal
abdomen when used in live dogs, despite the high
volume injected (Drożdżyńska et al. 2017). When
bupivacaine concentrations ≥0.25% are used, injections
of such a high volume of local anesthetic would exceed
the recommended maximum dose in live dogs if
multiple injections were performed (Liu et al. 1982). In
the present study, a total of 1 mL kg−1 of solution was
used and equally divided among the four injection
points. If a similar volume of bupivacaine 0.25% was
used in live dogs, the total bupivacaine administered
would be 2.5 mg kg−1, considered within limits for safe
dosing in dogs. Mild toxic effects have been reported
in dogs following IV bupivacaine administration of 3
mg kg−1 (Liu et al. 1982).

In the present study, the SL approach reliably stained

T11, L1 and L2. However, a lower success rate was
identified in staining T9, T10, T12 and T13. The
injectate appeared to have stained the nerves located in
proximity to the injection point, whereas the
distribution to adjacent nerves was limited. This is in
agreement with previous reports showing that the
injectate tends to pool at the injection site rather than
spread craniocaudally. This finding suggests that
dividing the total volume in three aliquots instead of
two and performing three injections per
hemiabdomen may improve the distribution of the
injectate, increasing the rate of nerve staining to all
target nerves. Further studies are warranted to
investigate this aspect.

In the present study, T9 and L3 were only stained in

0% and 25% of injections using the LL approach, and
in 37.5% and 25% of injections using SL approach. The
abdominal area of innervation of the intercostal nerve
T9 is the portion of the abdominal wall located
immediately caudal to the xyphoid process. The area of
innervation of the ilioinguinal nerve L3 is the inguinal
region, and its area of innervation does not extend to
midline (Bailey et al. 1984). The clinical significance of
a failure to block these nerves in live dogs undergoing
celiotomy is unknown but their areas of innervation
are commonly spared by surgical intervention.

In a previous canine cadaveric study, the intercostal

nerves T7 and T8 were also present in the TAP in 20%
and 60% of the cadavers, respectively (Castañeda-
Herrera et al. 2017). The presence of these nerves
within the TAP could not be identified in any of the
canine cadavers used in the present study.

This study has several limitations. Although all efforts

have been made to use the same technique for all
injections, movements of the needle while performing
the injections may have influenced the distribution of
the dye solution. Because the operator performing the
injections could not be blinded to the technique, this
may have introduced a source of bias. The distribution
of a solution in a cadaver model may differ from the
distribution encountered in live animals as a result of
factors including tissue changes related to freezing and
thawing, systemic absorption of the drug, lymphatic
drainage (Otero et al. 2020) and changes in abdominal
pressure as a result of breathing movements which
may affect the distribution of the injected solution.

Conclusions
The combination of a subcostal and a lateral
abdominal TAP injection resulted in broader
distribution of injected dye solution than two lateral
abdominal injections. Although neither of the
approaches evaluated consistently stained all ventral
spinal nerves of T9–L2, the results suggest that the SL
approach may be superior to the LL approach and that
the SL approach should be evaluated in live dogs
undergoing celiotomy. Investigating the distribution
of the injected solution following one subcostal and
two lateral TAP injections per hemiabdomen in
cadavers is warranted.

Acknowledgements
This project was funded by the College of Veterinary
Medicine, University of Florida.

Authors’ contributions
MR: study design, injections, data collection,
interpretation of results, preparation of manuscript.
DAP: study design, data collection, dissections, data
acquisition, interpretation of results, preparation and
revision of manuscript. AT: data collection, dissections.
PEO: interpretation of results, manuscript revision.

Conflict of interest statement

The authors declare no conflict of interest.

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