Correspondence
Anaesthesia 2014, 69, 1051–1064
spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011; 66: 1023–30. 6. Finnerty O, McDonnell JG. Transversus abdominis plane block. Current Opinion in Anesthesiology 2012; 25: 610–4. 7. Rao Kadam V, Van Wijk RM, Moran JI, Miller D. Epidural versus continuous transversus abdominis plane catheter technique for postoperative analgesia after abdominal surgery. Anaesthesia and Intensive Care 2013; 41: 476–81. doi:10.1111/anae.12783
TAP block terminology We congratulate Niraj et al. on their recent paper comparing the analgesic efficacy of the four-quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia vs epidural analgesia in patients undergoing laparoscopic colorectal surgery [1]. However, we would like to comment on both their terminology and their analgesic strategy. Niraj et al.’s ‘four-quadrant TAP block’ is identical to the ‘bilateral dual TAP (BD-TAP) block’ published previously [2, 3], in which both an upper and a lower TAP block are administered bilaterally to each hemi-abdomen to anaesthetise both the intercostal (upper TAP) plexus and the deep circumflex iliac artery plexus (lower TAP plexus), as described by Rozen et al. [4]. Dual TAP blocks administered separately to each hemi-abdomen have already been shown to be necessary if anaesthesia of the entire anterolateral abdominal wall is intended [3]. As ‘four-quadrant TAP block’ refers to the four anatomical quadrants of the anterior abdominal wall, we would encourage adherence to the original name ‘BD-TAP block’, which refers more correctly
to the extent of the anatomical TAP, namely the fascial space superficial to the entire transversus abdominis muscle which covers both the lateral and the anterior parts of the abdominal wall. Similarly, Niraj et al. use the term ‘posterior TAP block’ to describe injection of local anaesthetic and insertion of catheters into the neurovascular plane between the internal oblique and transversus abdominis muscles, with the transducer placed axially in the mid-axillary line on the lateral abdominal wall, when the term has previously been used to specify injections into the triangle of Petit [5–8]. Injections between the internal oblique and transversus abdominis muscles in the mid-axillary line are called ‘lateral TAP blocks’ (T10-L1) [3, 6, 8]. Segmental nerves T6-T9 emerge from the costal margin between the midline of the abdominal wall and the anterior axillary line to enter the TAP in the intercostal (upper TAP) plexus, whereas other large nerve trunk communications (in the lateral abdominal wall) are associated with the ascending deep circumflex iliac artery (lower TAP plexus) [4], and consequently the local anaesthetic spread, extent of sensory block and duration of analgesia produced by these approaches are significantly different. Again, we urge referral to the nomenclature established previously [3, 6, 8], to avoid confusion. To this end, ’subcostal TAP block’, which infers block of the subcostal nerve (T12), should more properly have been referred to as ‘upper TAP block’, as it involves injection into the epigastric region to anaesthetise the intercostal nerves (T6-T9) [2–4].
© 2014 The Association of Anaesthetists of Great Britain and Ireland
We commend Niraj et al. [1] for promoting administration of local anaesthetic to both the epigastric area and the lateral abdominal wall for laparoscopic surgery, pain after which is multifactorial and related to surgical incisions, intra-abdominal surgical trauma and insufflation of the peritoneum and abdominal wall muscles, causing traction of the blood vessels and nerves and the release of inflammatory mediators. However, because the authors were comparing their technique with epidural analgesia, we wonder if it might have been more appropriate to use continuous TAP blockade of the upper abdominal wall, in addition to that of the lower abdominal wall they describe. J. Børglum Copenhagen University Hospital, Bispebjerg, Denmark Email:
[email protected] F. W. Abdallah St. Michael’s Hospital, Toronto, Canada J. G. McDonnell National University of Ireland, Galway, Ireland B. Moriggl Innsbruck Medical University, Innsbruck, Austria T. F. Bendtsen Aarhus University Hospital, Aarhus, Denmark No external funding and no conflict of interest declared. Previously posted on the Anaesthesia correspondence website http://www.anaesthesiacorre spondence.com
References 1. Niraj G, Kelkar A, Hart E, et al. Comparison of analgesic efficacy of four-quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia 1055
Anaesthesia 2014, 69, 1051–1064
2.
3.
4.
5.
6.
7.
8.
with epidural analgesia in patients undergoing laparoscopic colorectal surgery: an open-label, randomised, non-inferiority trial. Anaesthesia 2014; 69: 348–53. Børglum J, Maschmann C, Belhage B, Jensen K. Ultrasound-guided bilateral dual transversus abdominis plane block: a new four-point approach. Acta Anaesthesiologica Scandinavia 2011; 55: 658–63. Børglum J, Jensen K, Christensen AF, et al. Distribution patterns, dermatomal anesthesia and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block. Regional Anesthesia and Pain Medicine 2012; 37: 294–301. Rozen WM, Tran TM, Ashton MW, Barrington MJ, Ivanusic JJ, Taylor GI. Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clinical Anatomy 2008; 21: 325–33. McDonnell JG, ODonnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesthesia and Analgesia 2007; 104: 193–7. Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell JG. Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia 2011; 66: 1023–30. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: the effects of surgery, dosing, technique, and timing on analgesic outcomes. A systematic review. Regional Anesthesia and Pain Medicine 2012; 37: 193–209. Abdallah FW, Laffey JG, Halpern SH, Brull R. Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: a meta-analysis. British Journal of Anaesthesia 2013; 111: 721–35. doi:10.1111/anae.12812
Subcostal TAP block and postoperative respiratory function after abdominal surgery Compared with epidural analgesia for abdominal surgery, subcostal transversus abdominis plane (TAP) 1056
Correspondence
Table 1 Visual analogue (VAScoughing), spirometric forced expiratory volume (Equiet, Emax) before and 4
Before block After block
pain scores at rest (VASquiet) and coughing measurements (FVC, forced vital capacity; FEV1, in 1 s) and ultrasonic diaphragmatic excursion h after completion of the subcostal TAP block.
VASquiet
VAScoughing
FVC; l (% predicted)
FEV1; l (% predicted)
Equiet; cm
Emax; cm
4
7
0.94 (19%)
0.73 (17%)
0.58
1.05
1
4
0.87 (17%)
0.81 (19%)
0.82
1.28
Figure 1 Right diaphragmatic motion on M-mode sonography confirming severe diaphragmatic dysfunction at rest, during deep inspiration, 4 h after the completion of bilateral TAP block. block has been shown to provide similar postoperative analgesia at rest and during coughing [1–4]. Recently, we provided effective analgesia using bilateral subcostal TAP block (20 ml ropivacaine 0.5% on each side) for a patient after splenectomy (Table 1). However, there was little change in the restrictive respiratory pattern secondary to pain (Table 1; Fig. 1). Reduced pulmonary function after major abdominal surgery is well recognised, and is an important risk factor for respiratory complications [5]. Of the several analgesic methods that can be used after upper abdominal surgery, only epidural analgesia provides visceral analgesia, which may be
beneficial in the recovery of pulmonary function. To date, no study has compared alterations in respiratory function after subcostal TAP block vs epidural analgesia following abdominal surgery. Therefore, until such a comparison (using spirometry and diaphragmatic ultrasound), TAP block cannot be considered a satisfactory alternative to epidural analgesia in patients with compromised respiratory function. C. Carrie M. Biais Centre Hospitalier Universitaire de Bordeaux Pellegrin, Bordeaux, France Email:
[email protected]
© 2014 The Association of Anaesthetists of Great Britain and Ireland
