Dr. Pranav Bansal Associate Professor

Ultrasound guided Transversus Abdominis Plane (TAP) Block

for excision of Inguinal Swelling in a case of Severe Kypho-

Scoliosis

Dept of Anaesthesiology and Critical Care, BPS Govt. Medical College, Khanpur Kalan, Sonipat, Haryana

• A case of severe thoraco-lumbar kyphoscoliosis presented with infected inguinal swelling.

• Kyphoscoliosis was present since childhood and deformity increased progressively over years of development.

• Inguinal swelling was present since past 4 months.

• Resting respiratory rate: 30-34 breaths per minute

• Pulmonary Function Tests revealed FEV1: 42%, FVC: 52%, PEFR: 27% and FEV25-75 : 45% of the predicted values with a restrictive pattern on flow-volume loop.

Case Study:

Anthropometric measurements

•Pectus Excavatum i.e. crowding of ribs and markedly reduced lung fields (Baby lung in X-ray AP view). •Small Abdominal Cavity•Hump on back (severe kyphosis)•Mouth Opening and neck movements within normal limits.

Deviated, stiff and immobile vertebral column with no identifiable intervetebral spaces on palpation. Cobb’s angle 120 ° in X-ray (Lateral view).•Height: 4 feet (f) 8 inches•Upper/ Lower seg. ratio: 2 Ft/2Ft & 8’ •Weight: 40 kg

Physical Examination Findings:

Anaesthetic Procedure•Positioning of patient : Right Lateral Decubitus.

•The curve of vertebral column was immobile and

fixed with limited flexion.

•Attempts made to perform lumbar puncture using

23 G Quinke’s needle via midline, paramedian and

Taylor’s approach were not successful.

•The caudal space was obliterated and the

landmarks were unidentifiable, both radiologically

and clinically, so the approach for caudal epidural

block too failed.

Transversus Abdominis Plane (TAP) Block

•Position: Supine•The curvilinear probe of portable ultrasound machine placed in subcoastal region with an oblique orientation on the small sized anterior abdominal wall.•Muscle planes were identified and 20 G, 1.5 inch needle introduced in transverses abdominis plane.•Local anaesthetics (Inj. Lignocaine 2% [with adrenaline] 7 ml + Inj. Bupivacaine (0.5%) 8 ml + normal saline 10 ml [total volume 25 ml]) were administered. •Satisfactory effect achieved and surgery conduced uneventfully.

TAP Block-Technical Considerations

Ultrasound image during TAP Block. The transversus abdominis muscle can be seen to taper into a fascial line.The approximate needle insertion angle is indicated.

Classical Posterior approach for TAP block in Lumbar triangle of Petit using in-plane needle technique (T10-L1 blockade)

Diagram of transverse section of abdominal wall during landmark TAP block performance (N, needle; ST, subcutaneous tissue; EO, external oblique muscle; IO, internal oblique; TA, transversus abdominis; LD latissumis dorsi; QL, quadratus lumborum)

The Oblique Subcostal approach to TAP block for blocking T7-9 nerve roots.

Uses of TAP Block: Indicated for postoperative analgesia

in surgeries below the umbilicusTAP block been successfully used as

sole anaesthetic technique for inguinal hernia repair and appendectomy.

Bilateral blocks are indicated for postoperative analgesia in surgeries with midline incision like caesarean section, abdominal hysterectomy, laparoscopic surgery and prostatectomy.

TAP Block-Technical Considerations

Complications:•Failure of block•Intraperitoneal injection•bowel hematoma •liver laceration •transient femoral nerve palsy

• Preoperative evaluation should focus on any cardiovascular, respiratory or neurological impairment related to the deformity.

• Preoperative Pulmonary function tests (PFT) and ABG may guide decisions regarding requirement of postoperative ventilatory support.

• Regional Anaesthetic techniques and peripheral nerve blocks are preferable to General anaesthesia wherever possible owing to high risk of postoperative pulmonary complications .

Conclusion• Repeated attempts, inappropriate, inadequate, unpredictable or patchy effect and

complete failure are frequent complications associated with neuroaxial anaesthesia in vertebral deformities.

• Ultrasound guidance is a promising aid in improving the accuracy & efficacy of regional anaesthetic techniques in cases of altered anatomical landmarks or bony deformities like severe kyphoscoliosis.

Anaesthetic Considerations in Severe Kyphoscoliosis