x
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Summary
In this review, we discuss the central non-neuraxial regional anaesthesia blocks of the abdomen,
including intercostal and intrapleural blocks, rectus sheath and ilioinguinal-iliohypogastric blocks,
transversus abdominis plane blocks and paravertebral blocks.
. ......................................................................................................
Correspondence to: Dr John McDonnell
E-mail: johngmcdonnell@gmail.com
The inability to provide safe, reproducible analgesia after surgery. Unfortunately, it is not always possible or
abdominal surgery remains one of the impediments to the appropriate to provide epidural-based analgesia to this
introduction of regional anaesthesia techniques for this patient population. The shift towards short-stay surgery,
surgical population. The abdominal wall is supplied by the the introduction of fast-track surgery protocols, the
lower six thoracic and upper two lumbar sensory nerves, general unavailability of monitored beds and the incidence
either through extensions of the intercostal branches or, of sepsis or a bleeding diathesis has resulted in patients,
for the more caudal nerves, through the musculature of being denied a central neuraxial mode of analgesia. There
the abdominal wall. These nerves pass through a number is thus the need for reliable alternatives to intrathecal and
of plexuses and there is therefore a variation in the course epidural-based analgesia for abdominal surgery.
of individual nerves from one patient to another [1]. As a
result, the use of anatomical knowledge to achieve
Intercostal and intrapleural blocks
analgesia after abdominal surgery and the evolution of
approaches over time have resulted in a variety of analgesic The intercostal nerve block is aimed at the ventral rami of
techniques there are used in current clinical practice. the sensory nerve that runs in the small neurovascular
The extensive origin of the nerves that must be blocked bundle at the inferior aspect of each rib (Fig. 1). The
to provide analgesia for large abdominal incisions poses dorsal rami supply sensation to the musculature and skin
significant problems in the search for suitable regional of the middle back. This block is recognised for its
anaesthesia techniques. Limited operative fields are much analgesic role in rib fractures and thoracotomy, and also in
more amenable to regional techniques. Technological upper abdominal procedures such as open cholecystec-
advances, such as real-time ultrasonography, allow more tomy [3, 4]. As a single block, the duration of action is
accurate identification of plexuses and peripheral nerves, limited, and repeated injection or continuous infusion
with a corresponding improvement in block success [2]. As should be considered, depending on the duration of
a result, there is a better appreciation of individual anatomy. analgesia required [5]. There is no described fascial sheath
These advances also allow the anaesthetist to perform around the intercostal nerve branches and the deposition
blocks more distally, e.g. in the abdominal field. Although of local anaesthetic (LA) solution in close proximity is
regional anaesthesia is not the only change in managing sufficient to block the nerve. The natural defects in the
these patients, the introduction of new techniques or new intercostal muscle, that allow spread of LA solution to the
approaches to old techniques has resulted in ever-increas- nerve, also allow it to spread around the internal aspect of
ing numbers of patients who receive non-central neuraxial the ribs to reach the intercostal spaces above and below
blockade for abdominal surgery, and warrants discussion. [6, 7]. Therefore, the sensory block can extend beyond
The low thoracic epidural remains the ‘gold standard’ the injection site, although clinical use of this has not
for the delivery of postoperative analgesia after abdominal been documented and multiple level injections should
TN
ULTRASOUND
PROBE
ST
TA - Transversus abdonminus
IO - Internal oblique
EO - External oblique
TN - Touhy needle
ST - Subcutaneous tissue
Skin QL - Quadtratus lumborum
LD - Lattisiums dorsi
IL - Longissius, Iliocostalis
LS - Lumbar spine
PM - Psoas muscle
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