Thoracic & abdominal

wall blocks
MODERATOR: DR THENDRALARSU MD

DR SOWMIYA . S

II YEAR POST GRADUATE

DEPARTMENT OF ANAESTHESIOLOGY

GVMCH
• CHEST WALL BLOCKS
• Thoracic epidural block
• Thoracic paravertebral block (TPVB)
• Erector spina block (ESB)
• PEC I AND PEC II
• Serratus plane block (SPB)
• Intercostal block
• Intrapleural block
 Thoracic epidural
• TEA as either a primary anesthetic or as an adjuvant to GA for cardiac, thoracic,
abdominal, colorectal, genitourinary, and gynecologic surgery
• Anatomy
1.The kyphotic thoracic spine consists of 12 vertebral bodies forming, with
posteriorly- longitudinal ligament,
anteriorly- neural arch,
anterolateral border -pedicles and
posterolateral border - laminae and ligamentum flavum.
2.The spinous processes are aligned steeply in the high- and mid-thoracic regions but become less acutely
inclined in the low-thoracic region.
3. thoracic epidural space contains less fat, thoracic dura is less adherent to bony canal and the ligamentum flava
are less likely to meet in the midline.
4.The anterior thoracic epidural space is filled predominantly with valveless veins, which connect to the Basi
vertebral venous plexus and azygos vein.
5. After injection, local anesthetic spreads towards the nerve roots and through the intervertebral foramina, with
some restriction exerted by the fascia of the posterior longitudinal ligament.
6. Nerve roots are surrounded by arachnoid on entering the epidural space and separate into multiple fascicles
passing to the dorsal root ganglion.
placement of a 16 or 18-G epidural catheter at thoracic
level
• at T6–T7 for thoracic surgeries,
• T7–T8 for thoracoabdominal surgeries,
• T8–T9 for upper abdominal procedures,
• T9–T10 for mid and lower abdominal procedures, and
• T10–T11 for pelvic pouch surgeries through a Touhy
• epidural needle of 18-gauge and using the midline or
paramedian approach and a saline loss of resistance
technique under complete aseptic techniques
Landmarks, identification of epidural space, and techniques
• The C7 Prominent spinous process, the T3 scapular spine, and the inferior border of
the scapula (T7) are useful landmarks used to approximate the puncture site to the
planned segments
Technique

• Under SAP, 3 ml of 2% lidocaine is applied for skin infiltration in sitting or lateral position at the planned inter
spaces.

• The thoracic epidural space is identified by two methods: loss of resistance to saline or air and use of the hanging
drop technique.

• To identify the epidural space with the LOR to air technique, advance the Touhy needle slowly, exerting either
continuous or intermittent pressure on the LOR syringe. As the needle enters the ligamentum flavum, there is usually
a distinct sensation of increased resistance followed by a subtle “give” when light pressure is exerted on the plunger.

• The hanging drop technique relies on the sub atmospheric pressure of the epidural space. A drop of saline is placed at
the hub of the needle once the needle is engaged in ligament. The needle is advanced continuously with the thumb
and index fingers firmly grasping the wings and the third through fifth fingers of both hands positioned against the
patient’s back. Entry into the epidural space is signaled by entry of the drop into the hub of the needle.

• The marking on the needle at the skin represents the depth from the skin to the epidural space. Because the centimeter
markings are not numbered, it may help to count the number of centimeter markings between the skin and the
epidural needle hub and subtract that number from the length of the needle.

• Insert the catheter with the assistance of the insertion device that fits into the epidural needle hub until the 15-cm
mark is visualized entering the needle hub; then, remove the needle without dislodging the catheter
• The catheter should be threaded no more than 5–6 cm into the epidural space and the
catheter should be secured to the patient’s back with the connector at the patient’s shoulder.
• A quantity of 3 ml of 1.5%lidocaine with 15mcg epinephrine is used as a test dose of the
technique after negative aspiration of blood and CSF.
• The intrathecal injection of 45 mg of lidocaine should produce a significant motor nerve block
if the catheter is in the subarachnoid space. A change in heart rate of 20% or greater (or,
alternatively, an increase in heart rate of 10 to 25 beats per minute) within 1 minute suggests
that the catheter has been placed in (or has migrated into) a vessel and should be replaced.
• For thoracic epidural block, an initial dose of 3 to 6 mL of dilute bupivacaine 0.125%–0.25%
or 0.1%–0.2% ropivacaine with or without additives can be followed by 3 mL of 0.25%–0.5%
bupivacaine every 30 min.
• 1-1.5 ml of solution should be injected per segment to be blocked
Thoracic
paravertebral block

Kappis, in 1919, developed the technique of paravertebral injection.

This produces unilateral, segmental, somatic, and sympathetic nerve block, which is effective for
anesthesia and in treating acute and chronic pain of unilateral origin from the chest and
abdomen.
Anatomy and General Considerations
• Anatomically, the PVS is a wedge-shaped area positioned between the heads and
necks of the ribs.
• Boundaries:

-posterior wall is the superior costotransverse ligament,

- the anterolateral wall is the parietal pleura with endothoracic fascia, and
- the medial wall is the lateral surface of the vertebral body and intervertebral disc.
• PVS medially communicates with the epidural space via the intervertebral foramen
inferiorly and superiorly across the head and neck of the ribs.
• PVS space communicates with the intercostal spaces laterally into the intercostals
sulcus
and resultant intercostal blockade
 Indications for thoracic paravertebral block.
Anesthesia

Breast surgery

Chest wound exploration

Postoperative Analgesia (as part of a balanced analgesic regimen)

Thoracotomy
Thoracoabdominal oesophageal surgery
Video-assisted thoracoscopic surgery
Cholecystectomy
Renal surgery
Breast surgery
Multiple rib fracture
Liver resection
Appendicectomy
Minimally invasive cardiac surgery
Techniques (Transverse in line technique)
• Position-sitting or lateral decubitus

• A high freq (10–12 MHz) transducer is used to obtain images in

(transverse) plane at the selected level, with the transducer positioned
just lateral to the spinous process.
• Then transverse processes and ribs are identified as hyperechoic
structures with acoustic shadowing below them.
• Now the transducer is moved slightly caudad into the ICS between
adjacent ribs to identify the thoracic PVS and the adjoining ICS.
• The PVS appears as a wedge-shaped hypoechoic layer demarcated by
the hyperechoic reflections of the pleura and underlying hyperechoic
air artifacts move with respiration.
• The goal of the technique is to insert the needle into the PVS and inject
local anesthetic, resulting in downward displacement of the pleura,
indicating proper spread of the local anesthetic.
Longitudinal out-of-plane technique
• Most common approach & safer

• The best in this method is to start the scanning process 5-10

cm laterally to identify the rounded ribs and parietal pleura
underneath.
• The transducer is then moved progressively more medially
until transverse processes are identified as more squared
structured and deeper to the ribs.
• Once the transverse processes are identified, a needle is
inserted out-of-plane to contact the transverse process and
then, walk off the transverse process 1-1.5 cm deeper to
inject LA.
• While the position of the needle tip may not be seen with
this technique, an injection of the local anesthetic will result
in displacement of the parietal pleura. The needle is inserted out-of-plane to contact the TP (C1-C2 and C3, line 1)
and then walked off the TP (C3, line 2) inferior or superior to TP to enter the
• The process is then repeated for each desired level. paravertebral space and injection local anesthetic (blue).
Technique of “walking off” the transverse process.
A: The needle is shown contacting the transverse process.
B: The needle is shown walking off the superior aspect of
the transverse process.
Contraindications for TPVB
• infection at the site of injection,
• allergy to local anesthetic drug, empyema, and a neoplastic mass occupying the paravertebral
space.
• Coagulopathy, bleeding disorders, or patients receiving anticoagulant drugs are relative
contraindication for TPVB.
One must exercise caution in patients with kyphoscoliosis or deformed spines and those who have
had previous thoracic surgery.
The chest deformity may lead to inadvertent thecal or pleural puncture, and the altered paravertebral
anatomy due to fibrotic obliteration of the paravertebral space or adhesions of the lung to the chest
wall may predispose to pulmonary puncture.
Erector Spinae Plane Nerve Block

• The “erector spinae” comprises a group of muscles including the

iliocostalis, longissimus, and spinalis muscles.
• They run bilaterally from the skull to the pelvis and sacral region,
and from the spinous to the transverse processes, extending to
the ribs.
• Mechanisms of action

- Interfascial spread toward the posterior rami of spinal nerves.

- Anterior diffusion of the local anesthetic into the
paravertebral space.
• ESPB achieves a block of the posterior, lateral, and anterior thoracic wall
Sonoanatomy
• High frequency probe is placed in a parasagittal longitudinal position, around 3cm from the
midline
• Identify the ribs and adjacent pleural line, and set your depth such that the pleural line and lung
are in the bottom third of your image
• Move the probe medially — transverse processes will appear more square-like, and the pleural
line with disappear
• At higher thoracic levels, e.g., above T5; trapezius, rhomboid major and erector spinae muscles can be
identified as three layers superficial to the transverse processes.

• In the lower and mid-thoracic levels, only the trapezius and erector spinae muscles can be seen.

• The ESPB is a fascial plane block; therefore, success depends on the volume of local anesthetic injected
between the muscle and transverse process

• LA spreads anteriorly to the paravertebral space and laterally to reach intercostal nerves, and spreads along the
plane in a craniocaudal manner, covering 3-4 levels above and below

• The mechanism of analgesic action is believed to result from diffusion of local anesthetic anteriorly to the
ventral and dorsal rami of spinal nerves
• INJECTION PROCEDURE
1. Insert the needle in-plane from a cranial to caudad direction until the needle tip contacts
the transverse process.
2. Inject 1-3 mL of local anesthetic to confirm proper injection plane by visualization of a
spread deep to the erector spinae muscles and superficial to the transverse process.
3. Complete the nerve block with 20-30 mL of local anesthetic.
PEC
• Neural innervation- ant. Chest wall
• Pectoral nerves - from the brachial plexus cords:

a. Lateral pectoral nerve - from C5-7, runs between pectoralis major and minor to supply pectoralis major.
b. Medial pectoral nerve - from C8-T1, runs deep to pectoralis minor to supply pectoralis major and minor.
• T2-6 spinal nerves - run in a plane between the intercostal muscles and give off lateral and anterior branches :

a. Lateral – pierces the intercostal muscles/serratus anterior in the mid axillary line to give off anterior and posterior
cutaneous branches.
b. Anterior – pierces the intercostal muscles and serratus anterior anteriorly to supply the medial breast.
• Long thoracic nerve – from C5-7, runs on outer surface of serratus anterior to the axilla where it supplies serratus anterior.
• Thoracodorsal nerve – from C6-8 via the posterior cord, runs deep in the posterior axillary wall to supply latissimus dorsi.
PEC I

Injection of local anesthetic in the fascial plane between the pectoralis major and minor
muscles.
Pectoral nerves - from the brachial plexus cords:
• a. Lateral pectoral nerve - from C5-7, runs between pectoralis major and minor to supply
pectoralis major.
• b. Medial pectoral nerve - from C8-T1, runs deep to pectoralis minor to supply pectoralis major
and minor.
Uses: for analgesia after breast surgery, analgesic for pacemaker insertion, pain due to
extravasation of the fluid into pectoralis muscles after shoulder arthroscopy.
Technique

• with the probe at the mid clavicular level and angled

infero-laterally, first locate the axillary artery and vein.
• Next move the probe laterally until pectoralis minor
and serratus anterior are identified.
• Locate the 2nd rib immediately under the axillary
artery, then count the 3rd rib, and with further lateral
probe movement, the 4th rib.
• With the image centered at the level of the 3rd rib,
advance the needle in- plane from medial to lateral in
an oblique manner until the tip lies between
pectoralis major and minor.
• Inject 10 mL LA between pectoralis major and minor.
Pecs II Nerve Block
T2-6 spinal nerves - run in a plane between the intercostal muscles and give off lateral and anterior
branches :
• a. Lateral – pierces the intercostal muscles/serratus anterior in the mid axillary line to give off
anterior and posterior cutaneous branches.
• b. Anterior – pierces the intercostal muscles and serratus anterior anteriorly to supply the medial
breast.
• Nerves blocked– T2-4 spinal nerves (including intercostobrachial nerve) and long thoracic nerve.
• Indications are (more extensive breast surgery involving serratus anterior and the axilla) tumor
resection, sentinel node excision, axillary clearance, tissue expanders.
• The local anesthetic should cover two important compartments of the fascia
involved: The pectoral compartment with the pectoral nerves and the intercostal
branches for the axilla and chest.
• LA deposition – 20 mL LA injection between pectoralis minor (laterally) and
serratus anterior at the 3rd rib level (this injection aims to enter the axilla to
reach the target nerves, but LA will only enter the axilla if the fascia on the
pectoralis minor lateral border is breached by surgery).
• Technique – The nerve block is performed with the patient supine, either with
the arm abducted 90 degrees or by his or her side.
• With the transducer at the midclavicular level and angled infero-laterally, the
axillary artery and vein and the second rib can be identified
• The transducer is then moved laterally until the pectoralis minor and serratus
anterior are identified. With further lateral transducer movement, the third and
fourth rib can then be identified.
• First perform a PECS 1 injection between pectoralis major and minor, then a
second 20 mL injection between pectoralis minor and serratus anterior .
Pecs II sonogram: steps to locate points of
injection.

• A: Left: Start from the clavicle;

right: Count ribs down to the axilla.
• B: Left: First injection between the pectoralis
major
and pectoralis minor; right: Angle probe to
locate inferolaterally.
• C: Left: Above the
serratus muscle; right: Underneath the
serratus muscle;
SERRATUS PLANE BLOCK
• Nerve blocked: thoracodorsal , thoracic intercostal nerves. The serratus plane
nerve block is performed in the axillary region, at a more lateral and posterior location
than the Pecs I and II nerve blocks.
• Lateral part of the thorax is blocked.
• Indication: latissimus dorsi flap reconstruction.
• 2 planes are described for the block, superficial i.e. above the muscle, deep: below the
serratus anterior.
• The two main anatomical landmarks are the latissimus dorsi and the serratus anterior muscles.
• The thoracodorsal artery runs in the fascial plane between the two.
• Lying on the side or supine with the arm brought forward is the preferable patient position.
• There are two main methods for identifying the plane for the serratus nerve block.
• The first method requires counting the ribs from the clavicle while moving the transducer laterally and distally until the fourth and fifth ribs
are identified .The transducer is orientated in the coronal plane and then tilted posteriorly until the latissimus dorsi is identified .The serratus
muscle, a thick, hypoechoic muscle deep to the latissimus dorsi is imaged over the ribs. Translating the transducer posteriorly facilitates the
identification of the plane between the serratus anterior and latissimus dorsi muscles.

• An alternative method is to place the transducer across the axilla, where the latissimus dorsi will appear more prominent. The location of the
thoracodorsal artery is easier to identify this way. Both in-plane and out-of-plane approaches are appropriate.
• Following the identification of sonographic landmarks, regional anesthesia can be achieved using a 6–13-MHz, linear transducer and an
injectate of 0.4 mL/kg of long-acting local anesthetic.
Intercostal Nerve Block
• Anatomy
• The intercostal nerves originate from the thoracic spinal cord
and have four major branches
1. gray rami communicans to the sympathetic ganglion
2. posterior cutaneous nerve that supplies the paravertebral
muscles and overlying skin
3. lateral cutaneous nerve that divides into an anterior and
posterior division to supply most of the chest and the abdominal
wall
4. anterior cutaneous nerve. It supplies the anterior chest and
abdominal wall adjacent to the midline
• Intercostal nerve lies inferior to the intercostal vein and artery.
• It may be blocked at several sites along its course most commonly at the angle of the rib.
Patient Positioning

• Place the patient prone with a pillow under the mid abdomen to straighten the lumbar curve and increase
the size of the intercostal spaces posteriorly.

Technique
A. The patient is placed prone.
A line is drawn along the lateral border of the paraspinal muscles.
The upper end is angled medially to avoid the scapula.
Cross-marks denote the inferior border of the rib and the location
to perform the block.
B. The index finger of the nondominant hand pulls the skin over-lying
the inferior border of the rib upward.
C. The dominant hand is resting against the patient.
The needle is inserted at a 60° angle to the skin and advanced until
the rib is contacted.
D. The fingers of the nondominant hand grasp and stabilize the
needle.
E. The needle is “walked” off the inferior border of the rib.
F. The needle is advanced 3 mm so that the tip is within the
neurovascular bundle.
G. Inject 1 to 2 mL of local anesthetic solution while maintaining the
needle in a stable position with the nondominant hand.
The sitting patient should lean slightly forward and be supported. The
arms should pull the scapulae laterally to facilitate access to the posterior
rib angles above T7.
The inferior edges of the ribs to be blocked are marked just lateral to the
lateral border of the sacrospinalis (paraspinous) muscle group,
corresponding to the angles of the ribs.
Points of needle entry are marked at 6–8 cm from the midline in most
adults.
ICNB above T7 may be difficult because of the scapulae and an alternative technique such as paravertebral or epidural block
should be considered
Uses
• used for postoperative analgesia after surgeries like thoracotomy, mastectomy, cholecystectomy, gastrostomy
• Neurolytic ICNB’s are used to treat chronic painful conditions like post thoracotomy and mastectomy pain
• Also used in rib fractures.
Complications
• Local anesthetic toxicity: Because of rapid absorption from this site. Local anesthetic solution for intercostal blocks
should contain 1:200,000 of adrenaline.
• Obtain a postprocedural upright chest radiograph to ensure that the patient does not have an iatrogenic pneumothorax.
• Infection.
INTRAPLEURAL BLOCK
Anatomy
Anterior rami of the thoracic spinal nerves exit the intervertebral foramina and are typically initially located in
the endothoracic fascia, just superficial to the parietal pleura.
• Two serous membranes form the pleural cavity.
• The parietal pleura covers the internal side of the chest wall, while the visceral pleura covers the lungs
• The parietal pleura is adherent to the thoracic wall via the endothoracic fascia.
Indications

• Indications are open cholecystectomy, multiple rib fractures and chronic painful conditions like malignancy,
acute herpes zoster and post herpetic neuralgia
Position
• The patient should be placed in either the supine or lateral position.
• The procedure site is selected within the region of the thorax spanning from the 4 to 7
intercostal space.
• The insertion site is immediately cephalad of the rib to avoid direct trauma to the
neurovascular bundle, which is located inferior to each rib.
Technique
• The operative area is cleaned with antiseptic, and a sterile drape or towels are placed.
• Hang an isotonic crystalloid solution with tubing to connect it to a 3-way connector. Connect syringe and the 16G Tuohy needle to
the remaining 2 ports.
• Tubing, needle, 3-way connector, and glass syringe have all been filled with the crystalloid solution.
• Advance the needle over the rib and into the intended intercostal space after the procedure site has been anesthetized.
• Advancement of the needle is performed during expiration to reduce the risk of visceral pleura puncture.
• Ensure that the 3-way connector is closed to the bag of crystalloid solution , but open to allow for continuity between the Tuohy
needle and the glass syringe.
• slowly advance the needle until the parietal pleura has been punctured, which can be confirmed by a loss of resistance on the glass
syringe. Then 3-way connector should be open to three ports to allow the crystalloid solution to flow freely while the syringe is
completely depressed.
• after confirming a loss of resistance and closing the 3-way connector to the provider, the saline syringe may be replaced by a
syringe containing injectate (usually local anesthetic). Once the medication is injected, the entire system may be removed.
• it is important to maintain a closed system once the Tuohy needle has entered the intrapleural space to avoid the entrainment of air.
Complications
• Pneumothorax
• Chest wall hematoma
• Systemic absorption of LA
• Horner’s syndrome
Abdominal wall blocks
• TAP
• Quadratum lumborum block
• Rectus sheath
• Ilioinguinal and iIiohypogastric nerve
blocks
Transabdominal block
• TAP block is limited to somatic anesthesia of the abdominal wall and highly dependent on interfascial spread

• Anatomy

The transversus abdominis plane is the fascial plane between internal oblique and the transversus abdominis muscle.

• The anterior abdominal wall (skin, muscles, and parietal peritoneum) is innervated by the anterior rami of the lower six
thoracic nerves (T7-T12) and the first lumbar nerve (L1).

• Terminal branches of these somatic nerves course through the lateral abdominal wall within a plane between the internal
oblique and transversus abdominis muscles.
• The upper fibrous anterior part of the muscle lies posterior to the rectus abdominis muscle and reaches the xiphoid
process.

• The posterior aponeuroses of the transversus abdominis and internal oblique muscles fuse and attach to the
thoracolumbar fascia (TLF).
Imaging of the abdominal wall between the costal margin
and the iliac crest reveals three muscle layers, separated
by a hyperechoic fascia: the outermost external oblique
(EOM), the internal oblique (IOM), and the transversus
abdominis muscles (TAM)
• Subcostal approach to the TAP nerve
block ideally anesthetizes the
intercostal nerves T6–T9 between the
rectus abdominis sheath and the
transversus abdominis muscle.
• Lateral TAP nerve block in the
midaxillary line between the thoracic
cage and iliac crest as well as
between the internal oblique and
transversus abdominis muscles
ideally should reach intercostal
nerves T10– T11 and the subcostal
nerve T12.
• Anterior TAP nerve block medial to
the anterior superior iliac spine
blocks L1 segment nerves.
• Posterior approach to nerve block
the TAP plexuses via the triangle of
Petit
Technique
• With the patient supine, the skin is disinfected and the transducer placed on the skin .

• The iliac crest and costal margin should be palpated and the space between them in the
mid-axillary line (usually 8–10 cm) identified as the initial transducer location.
• The three muscle layers should be identified .

• Sliding the transducer slightly cephalad or caudad will aid the identification.

• Once the transverse abdominal plane is identified, a skin wheal is made 2 to 3 cm

medial to the medial aspect of the transducer, and the needle is inserted in-plane in a
medial to lateral orientation .
• The needle is guided through the subcutaneous tissue, EOM, and IOM.

• A “pop” may be felt as the needle tip enters the plane between the two muscles.

• After gentle aspiration, 1 to 2 mL of local anesthetic is injected to verify the location of

the needle tip.
• 20 mL of local anesthetic per side is usually sufficient for successful blockade.

• In children, a volume of 0.4 mL/kg per side is adequate for effective analgesia
Transmuscular QL Nerve Block
• A curved array transducer for the transmuscular QL (TQL) nerve block is placed in the axial plane on the patient’s flank just cranial to the iliac crest.
• The “shamrock sign” is visualized:
The transverse process of vertebra L4 is the stem, whereas the erector spinae posteriorly, QL laterally, and psoas major anteriorly represent
the three leaves of the trefoil.
• The target for injection is the fascial plane between the QL and psoas major muscles.
• The needle is inserted using an in-plane technique from the posterior end of the transducer through the QL muscle.
• The injectate should ideally spread from the injection site inside the fascial plane between the QL and psoas major muscles to the thoracic
paravertebral space with a goal to accomplish segmental somatic and visceral analgesia from T4 to L1.

A. Cross section with the ultrasound probe

location.
B: Ultrasound image of the lateral
abdominal wall.
Type 1 QL Nerve Block

• For the type 1 QL (QL1) nerve block, a linear transducer is

placed in the axial plane in the midaxillary line and moved
posteriorly until the posterior aponeurosis of the
transversus abdominis muscle becomes visible as a strong
specular reflector.
• The target is just deep to the aponeurosis but superficial to
the TF at the lateral margin of the QL muscle.
• The QL1 nerve block is identical to the fascia transversalis
plane nerve block.
• The needle is inserted from either the anterior or the
posterior end of the transducer and advanced until the
needle tip just penetrates the posterior aponeurosis of the
transversus abdominis muscle.
• Local anesthetic is injected between the aponeurosis and
the TF at the lateral margin of the QL muscle.
• The main effect is anesthesia of the lateral cutaneous
branches of the iliohypogastric, ilioinguinal, and subcostal
nerves (T12–L1).
Type 2 QL Nerve Block

• In the type 2 QL (QL2) nerve block, a linear transducer is placed in the

axial plane in the midaxillary line and moved posteriorly as in the QL1
nerve block, until the LIFT, which encapsulates the paraspinal muscles,
becomes visible between the latissimus dorsi and QL muscles.
• The target is the deep layer (the PRS) of the middle layer of the TLF. The
needle is inserted from the lateral end of the transducer.
• The needle tip is advanced until it is inside the middle layer of the TLF
close to the LIFT.
• The local anesthetic is injected intrafascially and apparently provides
analgesia equivalent to TQL nerve block but with faster onset.
• The QL region is relatively vascular as the lumbar arteries lie posterior to
the muscle. Absorption of the local anesthetic into the circulation
depends primarily on the vascularity of the site of deposition.
• As the QL muscle is well vascularized and a large volume of local
anesthetic is needed, the dose should be calculated accurately to prevent
high peak plasma concentrations of local anesthetics in this type of nerve
block.
Main features of QL nerve blocks.

QLB1 QLB2
TQLB

Clinical Abdominal surgery below Abdominal surgery either Abdominal surgery either above
indications the umbilicus. above or below the or below the umbilicus
umbilicus
Dermatomes L1 T4 to T12-L1; blocks the T4 to T12-L1; blocks the anterior
covered anterior and the lateral and the lateral cutaneous
cutaneous branches of the branches of the nerves
nerves
Injection site Potential space medial to Posterior to the QL Anterior to the QL muscle,
the abdominal wall muscle, outside the between the QL and the psoas
muscles and lateral to QL middle layer of the TLF major muscles, outside the
muscle, anterolateral anterior layer of the TLF and
border of the QL muscle, fascia transversalis, close to the
at the junction with the intervertebral foramen
transversalis fascia,
outside the anterior layer
of the TLF and fascia
transversalis
Indications as of the TAP nerve block &QL block
• Large-bowel resection, open/laparoscopic appendectomy, and
cholecystectomy
• LSCS,total abdominal hysterectomy
• Open prostatectomy, renal transplant surgery, nephrectomy,
abdominoplasty, iliac crest bone graft
• Ileostomy
• Exploratory laparotomy, bilateral nerve blocks for midline incisions
 Rectus sheath blocks

Anatomy
• The rectus sheath is formed from the aponeuroses

of the fascial sheaths of all three lateral abdominal wall muscles.

• The external oblique (EOM), internal oblique (IOM), and transversus abdominis (TAM) muscles each at its medial border converging to form
the lateral border of the RAM, termed the linea semilunaris.
• The anterior and posterior lamina of the EOM and the anterior lamina of the IOM fuse together and continue further medially to form the
anterior portion of the rectus sheath.
• The posterior lamina of the IOM and anterior and posterior lamina of the TAM fuse together and continue medially dorsal to the RAM to
form the posterior portion of the rectus sheath .
• At the medial border of the RAM, the anterior and posterior portions of the rectus sheath come together, with the fibers coursing further
medially toward the medial border of the contralateral RAM forming the midline linea alba.
• A bilateral rectus sheath block provides analgesia to the anteromedial abdominal wall and periumbilical area (spinal
dermatomes T9, T10, and T11).
• The technique blocks the anterior cutaneous branches of the intercostal nerves, and it is well suited for postoperative
analgesia for midline abdominal incisions.
• The anterior portion of the rectus sheath extends along the entire
vertical length of the RAM.
• In contrast, the posterior portion of the rectus sheath extends only
along the upper two-thirds of the RAM.
• In the lower one-third, the posterior portion of the rectus sheath
stops approximately midway between the umbilicus and
symphysis pubis.
• At this anatomical transition point(the arcuate line), the
aponeuroses that had formed the posterior portion of the rectus
sheath now also course over the ventral surface of the RAM .
• The transversalis fascia is a thin layer of connective tissue located
just deep to posterior portion of the rectus sheath .
• Located just deep to the transversalis fascia is the parietal
peritoneum.
• Inferior to the arcuate line, the transversalis fascia is located
immediately deep to the posterior border of the RAM.
Anatomical Course of the Thoracolumbar Nerves
• The sensorimotor innervation of the anterior abdominal wall is supplied by the ventral rami of the
thoracolumbar spinal (T7-L1) segmental nerves.
• The thoracolumbar nerves course along the anterolateral wall within the transversus abdominis
plane (TAP), eventually encroaching upon the lateral aspect of the rectus sheath contribute to the
formation of a nerve plexus that runs cranio-caudally within the muscle in close relation to the
lateral branch of the deep epigastric artery.
• The thoracolumbar nerves typically pierce the posterior border (89%) and less commonly the
lateral border (11%) of the RAM, with the nerves piercing the posterior border within 1.6 to 2.6
cm from the lateral edge of the RAM.
• The nerves provide both muscular and cutaneous branches to innervate the muscle fibers and
overlying skin.
Technique • Typically, a 21-gauge, 10 cm needle is inserted 3-8cm lateral to the
lateral edge of the transducer and guided “in-plane” .
• The needle is advanced in-plane from lateral to medial and
superficial to deep. should penetrate through the lateral aspect of the
linea semilunaris and enter the lateral aspect of the RAM.
• The needle is further advanced until it is positioned deep to the
potential space between the deepest (posterior) border of the RAM,
but superficial to the posterior aspect of the rectus sheath. This
target site will be referred to as the “posterior rectus sheath
compartment.”
• At this point, a small (1-3 ml) volume of local anesthetic (or sterile
saline) is injected to confirm correct placement within the posterior
rectus sheath compartment, indicated by the appearance of an
anechoic fluid collection
• Subsequently, 15-20 ml of local anesthetic is incrementally injected
while observing for the expanding anechoic fluid collection
• After local anesthetic injection, the transducer can be translated in a
cephalad-to-caudad fashion to visualize cephalad-to-caudad spread
within the posterior rectus sheath compartment.
• The same procedure is repeated on the contralateral side.
Ilioinguinal/Iliohypogastric Nerve Block
• Anatomy

Both the iliohypogastric (IH) and ilioinguinal (II) nerves arise from L1 and emerge from the
upper part of the lateral border of the psoas major muscle.
• The ilioinguinal nerve is a smaller nerve and courses caudad to the iliohypogastric nerve.
• Both nerves cross obliquely anterior to the quadratus lumborum and iliacus muscles and perforate
the transverse abdominis muscle near the anterior part of the iliac crest.
• In the anterior abdominal trunk, the nerves travel between the transverse abdominis and the
internal oblique muscles.

Blockade of the II and IH nerves is indicated for analgesia following inguinal hernia repair
because the nerves provide sensory innervation to the skin of the lower abdominal wall in
addition to the upper hip and upper thigh.
• Because the lateral cutaneous branch of the IH nerve may pierce the internal and external oblique
muscles immediately above the iliac crest, it is worthwhile to block the nerves as proximal as
possible (i.e., posterior to the anterior superior iliac spine) before the nerve branches.
Technique
• Position the patient supine.
• Expose the lower abdomen, the iliac

crest and the groin area. Mark the anterior superior iliac spine (ASIS).
• After skin and transducer preparation, place a linear 10-12 MHz transducer oblique along a line joining the ASIS and the
umbilicus immediately superior and medial to the ASIS.
• Insert a 5-8 cm 22 G needle parallel to and inline with the transducer and the ultrasound beam.
• The needle tip should be advanced in the fascial plane between the internal oblique and transverse abdominis muscle layers.
• Because this plane is a narrow space, it is worthwhile to inject small amount of fluid (1-2 mL of saline or local anesthetic) to
hydro dissect the appropriate plane.
• A total of 10-20 ml of local anesthetic is injected into this plane.