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A Simple Modification to the Transversus Abdominis Plane Block Provides Safe and Effective Analgesia in TRAM/DIEP Flap Patients

West, Chris M.R.C.S.(Eng.); Milner, Chris S. M.R.C.S.(Eng.), Ph.D.

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Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 146e-147e
doi: 10.1097/PRS.0b013e3181e3b531
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Sir:

Breast reconstruction surgery by abdominal free tissue transfer [transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap] results in considerable pain following disruption of the anterior abdominal wall, mediated through the thoracolumbar nerves T6 to L1. These nerves travel as mixed segmental nerves and communicate widely within the anatomical plane between internal oblique and transversus abdominis: the transversus abdominis plane.1

Knowledge of this anatomical layout has allowed a regional anesthesia technique to be developed where local anesthetic is delivered through a percutaneous needle into the transversus abdominis plane.2 This technique has been shown to provide postoperative analgesia in a range of surgical procedures involving access to the abdomen and pelvis.3 The original technique was described in 2001 by Rafi, who described a needle passed percutaneously through the lumber triangle of Petit.2 One of the major limitations of this technique is that it has to be delivered percutaneously, and therefore recent studies have advocated the use of ultrasonographic guidance to ensure that the local anesthetic is delivered in the appropriate anatomical location.4

We describe a simple modification to the transversus abdominis plane block technique that produces safe and effective postoperative analgesia in TRAM/DIEP flap surgery, where a reduction in such postoperative pain is associated with reduced morbidity in these patients.5 The transversus abdominis plane block is delivered under direct vision by the surgeon intraoperatively and as a result eliminates the need for ultrasonographic guidance and also the risk of incorrect placement of the block. The technique we describe involves bilaterally infiltrating 30 ml of 0.25% Chirocaine, following the landmark of the midaxillary line, immediately above the iliac crest (Fig. 1). An 18-gauge BD Blunt Fill Needle (no. 305180; BD, Franklin Lakes, N.J.) is connected to a syringe containing the local anesthetic solution. This is passed perpendicularly through the abdominal wall. A “pop” is felt as the needle passes through the external oblique fascia, and a second pop is felt as the needle is advanced farther and passes through the internal oblique layer into the transversus abdominis plane (Fig. 2). The syringe is aspirated to ensure that it is not intravascular before the local anesthetic is infiltrated. No resistance should be felt when infiltrating. We perform the block immediately before closure of the abdomen to ensure maximum length of postoperative effect.

Fig. 1.
Fig. 1.:
Intraoperative photograph of the anterior abdominal wall with the adipocutaneous skin flap reflected off the underlying musculature. The iliac crest is demarcated (stippled area), as is the midaxillary line (dashed line). EO, external oblique muscle.
Fig. 2.
Fig. 2.:
The transversus abdominis plane block is introduced at the level of the midaxillary line just superior to the iliac crest, with the blunt-tip needle directed tangentially toward the midline.

The modification to the transversus abdominis plane block technique we describe is simple and safe to administer and has a number of advantages over previously described techniques. It can be administered without the use of ultrasonography, thereby reducing delays at the beginning or end of the operation. Furthermore, direct visualization of needle placement also minimizes the chance of incorrect needle placement. As it can be administered immediately before closure of the abdomen, the duration of anesthetic effect is maximized for the subsequent postoperative period. We have used this technique to provide safe and effective analgesia to patients undergoing breast reconstruction with TRAM/DIEP flaps and have encountered no complications through its use. We believe it can be used as an effective supplement to other methods of analgesia currently in use.

Chris West, M.R.C.S.(Eng.)

Department of Plastic and Reconstructive Surgery

St. John's Hospital

Livingston, West Lothian

Chris S. Milner, M.R.C.S.(Eng.), Ph.D.

Department of Plastic and Reconstructive Surgery

Leicester Royal Infirmary

Leicester, United Kingdom

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

REFERENCES

1.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. Clin Anat. 2008;21:325–333.
2.Rafi AN. Abdominal field block: A new approach via the lumbar triangle. Anaesthesia. 2001;56:1024–1026.
3.McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg. 2008;106:186–191.
4.Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care. 2007;35:616–617.
5.Correll DJ, Viscusi ER, Grunwald Z, Moore JH Jr. Epidural analgesia compared with intravenous morphine patient-controlled analgesia: Postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction. Reg Anesth Pain Med. 2001;26:444–449.

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