BLOK

DINDING ABDOMEN

Workshop Anestesia Regional

CPD
PP. PERDATIN
 tujuan umum

• Menjelaskan pendekatan blok dinding abdomen yang

tepat untuk analgesia perioperatif dan manajemen
nyeri pada dinding thorak

• Melakukan dan mengidentifikasi sonoanatomi

persarafan terkait blok dinding abdomen
 tujuan
• Memahami dasar anatomi & fisiologi blok TAP, Ilioinguinal-
iliohipogastrik, Quadratus Lumborum (QL)

• Memahami indikasi blok TAP, Ilioinguinal-iliohipogastrik, dan QL

• Memahami prinsip dasar teknik blok TAP, Ilioinguinal-

iliohipogastrik, dan QL

• Memahami peralatan dan obat-obatan blok TAP, Ilioinguinal-

iliohipogastrik, dan QL

• Mengetahui efek samping, pencegahan dan cara mengatasinya

pada blok TAP, Ilioinguinal-iliohipogastrik, dan QL
• TAP block

• QL block

• Ilioinguinal-iliohypogastric

teknik blind : tdk bisa diandalkan, krn angka keberhasilan rendah

sangat disarankan menggunakan panduan USG
 Blok dinding abdomen
• TAP, QL, Ilioinguinal-iliohipogastrik

• kesamaan :

• indikasi - kontraindikasi

• komplikasi

• obat yg digunakan

• peralatan
 Blok dinding abdomen
• Indikasi : analgesia intraoperatif abdomen
(biasanya kombinasi dgn GA), analgesia
pascaoperatif

• Kontraindikasi :
• absolut : infeksi area punksi, alergi obat
anest.lokal, pasien menolak
• relatif : ggn.koagulasi / terapi antikoagulan

• Komplikasi : punksi organ viseral (jarang)

 peralatan
• Ultrasound machine with linear transducer (6–18
MHz), sterile sleeve, and gel
• in very obese patients, and when a more posterior
approach is used, a curved transducer
might be needed
• Standard nerve block tray
• Syringes containing local anesthetic
• A 50- to 100-mm, 20- to 21-gauge needle
• Sterile gloves

HADZIC
OBAT ANALGETIK LOKAL
Onset Durasi Durasi
Obat
(mnt) anestesia (jam) analgesia (jam)

2% lidokain 10-15 2-3 3-4

0,5% Ropivakain 15-25 3-5 8-12

0,75% Ropivakain 10-15 4-6 12-18

0,5% Bupivakain 15-25 4-6 12-18

0,5%
15-25 4-6 12-18
Levobupivakain
TAP block
 Background
• The TAP block was first described by McDonnell et
al' in 2006.

• Their original technique was a blind technique using

a blunt regional anesthesia needle and relied on
feeling a double pop as the needle passed through
the layers in an area known as the triangle of Petit

• Since then, the technique has been modified to

utilize ultrasound to confirm placement of the local
anesthetic.
LANDMARK
(BLIND)

• Triangular of Petit (TOP)

• Rafi (2001) : inside TOP,

“single pop”

• McDonnel (2004) : just

cephalad from iliac crest
inside TOP, “double pop”
Landmarks “blind” technique
• Patient supine, arm abducted to allow access to lateral abdomen

• Identify the triangle of Petit (delimited by latissimus dorsi, iliac

crest, and external oblique):
• Can be very difficult in obese patients

• Needle inserted perpendicular to the skin

• “Double pop” felt as needle inserted (blunt needle gives more

obvious pops):
• First pop—fascia between external and internal oblique muscles
• Second pop—fascia between internal oblique and transverse abdominis muscles

• Twenty milliliters of local anesthesia is injected

LANDMARK
(BLIND)
 LANDMARK
(BLIND)
• Success rate : 23,6 - 85%

• the position & size of TOP

are very variety
interpersonally

• TOP area : narrow

• alternative Landmark :
posterior mid-axillary line
Jankovic Z. Transversus abdominis plane block: The
just cephalad from iliac Holy Grail of anaesthesia for (lower) abdominal
crest = LIP (latissimo-iliac surgery. Period Biol, Vol 111, No 2, 2009; 203-8.

point)
 Ultrasound technique
• Landmarks: between costal margin and iliac crest in midaxillary line
• Muscle planes are identified with a high-frequency (8–13 MHz) probe
• Muscles are hypoechoic (dark); fascia is hyperechoic (bright)
• A 100-mm short-bevel needle inserted in-plane, anterior to posterior
(i.e., from the medial side). An out-of-plane approach is also possible
but requires more experience
• Inject a few milliliters of saline to ascertain correct position of needle tip
• Local deposition in the fascial layer between the internal oblique and
transverse abdominis muscles; typically 15–20 mL of 0.25%
bupivacaine or ropivacaine
• Oblique subcostal approach has been tried to increase block height:
probe placed parallel along the costal margin, needle inserted in an in-
plane technique from lateral to medial
US-GUIDED

• Posterior approach

• cadaveric study : LA
spreading = T10 - L1
EOM

IOM
RAM

TAM

EOM

IOM

TAM
EOM

IOM

TAM
US-GUIDED

• Subcostal approach

• LA spreading : T7-T11
 RAM

TAM

PC

EOM OEM
LS
RAM

IOM
TAM

TAM

PC
 TAP injections could be classified as follows : (Hebbard P, 2014)

• deep to the rectus

• Upper subcostal TAP
• mainly covering T7 and T8
• lateral to rectus
• Lower subcostal TAP
• mainly covering T9, T10 and T11
• midway between costal margin and iliac crest in the
• Lateral TAP mid-clavicular line
• mainly covering T11 and T12
• near the iliac crest lateral to the anterior superior
• Ilio-inguinal TAP iliac spine
• mainly covering T12 and L1
• injections in the TAP in the area of the triangle of
QL block
 Introduction
• Quadratus lumborum(QL) block has been described by Blanco
and used as an analgesic for abdominoplasties(unpublished).

• The radiological study on posterior approach of Transversus

Abdominis Plane block (now called QL block) in volunteers has
shown the spread of the dye and local anaesthetics from T4-L1.

• The local anesthetic potentialy spreads cranially along the

muscle, posterior to the arcuate ligaments of the diaphragm and
reaches the thoracoabdominal nerves ( T6-T12) as they
transferse the lower thoracic paravertebral space.

• Described at the ESRA (GB & I) Annual Scientific Meeting in

Exeter at 2007.
 Anatomy
• The Quadratus lumborum is a muscle of the posterior abdominal wall

• The deepest abdominal muscle and commonly referred to as a back

muscle

• The shape is irregular and quadrilateral

• It originates from the iliac crest and inserts into the transferse
processes of the first four lumbar vertebrae (L1-L4) and the inferior
border of the (T12).

• It inserts from the lower border of the last rib for about half its length,
and by four small tendons from the apices of the transverse
processes of the upper four lumbar vertebrae
• obat anest.lokal pada
QL blok menyebar pada
fasia thorakolumbal,
fasia transversalis dan
fasia endotorasik
• penyebaran
menghasilkan blok yang
lebih konsisten
dibandingkan TAB block
 sonoanatomi QL

• The characteristic sonoanatomy for the transmuscular approach is that

of a shamrock.
• The stem of the shamrock is the transverse process of L4, and the
leaves are the paraspinal muscles, quadratus lumborum and psoas
mayor.
 Classification

• There is 3 type of Quadratus Lumborum Block:

• QLB type I = injection at anterior thoracolumbar
fascia between QL and internal transv.muscle
• QLB type II = injection at middle thoracolumbar
fascia (posterior QL)
• QLB type III = transmuscular QL injection
 Ilioinguinal -
iliohypogastric block
 Anatomy

Ilioinguinal-iliohypogastric nerve
The iliohypogastric nerve is formed
by the ventral ramus L1 and a
branch of T12.
Anatomy
It emerges from the lateral border
of the psoas major muscle, passes
across the ventral surface of the
quadratus lumborum, and
descends to the iliac crest.

As it approaches the anterior

superior iliac spine, the nerve
pierces the transverse abdominal
muscle to take its course beneath
the internal oblique and transverse
abdominal muscles

The ilioin-guinal nerve, which is

formed by the ventral rami L1–2,
follows a similar course.
Ultrasound Guidance in Regional Anaesthesia-Principles and practical implementation, 2e (Oxford University Press)
 Injection Techniques for Ilioinguinal, Iliohypogastric,
and Genitofemoral Nerve Block
Atlas of Ultrasound -Guided
American Society of Interventional Pain Physician

• A number of injection techniques for II and IH nerves

using landmark-based. Unfortunately, all these
techniques suggest a needle entry anterior to the ASIS,
due to highly variable anatomy. Thus, the failure range
between 10% and 45%.
• The misguided needle may result in femoral nerve
blockade and bowel perforation and pelvic hematoma.
• There are two key elements contributing to the
improvement in success rate. One is to perform the
injection cephalad and posterior to the ASIS, where
both the II and IH nerves (>90%) can be consistently
found between the TA muscles at this point
• The three methods (four landmarks) described for
ilioinguinal and iliohypogastric nerves injection are
given in references. PS pubic symphysis, ASIS anterior
superior iliac spine
 Ultrasound guidance technique
Ultrasound Guidance in Regional Anaesthesia-Principles and practical
implementation, 2e (Oxford University Press)

Atlas of Ultrasound-Guided

• In adults, the ilioinguinal and iliohypogastric

nerves are best visible 1–2cm cranial and
lateral to the anterior superior iliac spine.
• Nerves found between internal oblique
abdominal muscle and the transverse
abdominal muscle. Picture below shows a
typical ultrasound picture of this region.
• The position of the ultrasound probe is
transverse in relation to the nerves.
• The accuracy of ultrasound guidance has
been validated with the injection site superior
to ASIS and the block success rate was 95%
thank you