Year : 2016 | Volume
: 5 | Issue : 8 | Page : 31--38
Transversus abdominis plane block as an adjuvant in multimodal postoperative analgesia: Relevance and applicability in Nigeria
Hanson Osazuwa Idehen, Charles O Imarengiaye
Department of Anaesthesiology, University of Benin Teaching Hospital, PMB 1154, Benin City, Edo State, Nigeria
Hanson Osazuwa Idehen
Department of Anaesthesiology, University of Benin Teaching Hospital, PMB 1154, Benin City, Edo State
Transversus abdominis plane (TAP) block is a new regional anesthesia technique and very recent in Nigeria. Availability and access to opioids in Nigeria are erratic coupled with its associated side effects; there has been need for alternatives to the use. TAP block has been suggested as an adjunct in multimodal strategy. It provides analgesia mainly for somatic pains for procedures on the anterior abdominal wall excluding visceral pains and therefore may not be too useful as a sole anesthetic technique. TAP block can be instituted using the anatomical (landmark) approach, ultrasound-guided technique, or surgeon«SQ»s assisted approach. Ultrasound-guided approach is most effective with minimal adverse outcome; wholesale adoption and adaptation would expand the options for balanced anesthesia and pain management. Thus, this article documents the clinical usefulness of TAP block in postoperative pain management so as to encourage the routine use of the technique in Nigeria.
|How to cite this article:|
Idehen HO, Imarengiaye CO. Transversus abdominis plane block as an adjuvant in multimodal postoperative analgesia: Relevance and applicability in Nigeria.N Niger J Clin Res 2016;5:31-38
|How to cite this URL:|
Idehen HO, Imarengiaye CO. Transversus abdominis plane block as an adjuvant in multimodal postoperative analgesia: Relevance and applicability in Nigeria. N Niger J Clin Res [serial online] 2016 [cited 2023 Mar 23 ];5:31-38
Available from: https://www.mdcan-uath.org/text.asp?2016/5/8/31/197432
Pain after surgery is a definite outcome. The management of postoperative pain has been underserved, particularly in developing countries such as Nigeria. ,, The reasons for the inadequate management of postoperative pain include but not limited to poor access to opioids.  It has become necessary therefore to evaluate other methods of prolonging postoperative analgesia. Indeed, multimodal analgesia has included regional techniques such as central neuraxial block and peripheral nerve block. The peripheral nerve blocks have been restricted to upper or lower extremities. Recently, plexus block and fascial plane block have been emphasized to address procedures on the anterior abdominal wall. 
Transversus abdominis plane (TAP) block, a relatively new regional technique, was described in 2001 by Rafi.  It is a fascial plane technique which blocks the peripheral nerves supplying the anterior abdominal wall (T7-L1). The pioneering works of Rafi were limited to the anatomical (landmark) approach through the triangle of Petit. This finding was later supported by works carried out by McDonnell et al. using cadaveric and radiological evaluation.  Currently, there is widespread application of TAP block in the multimodal strategy in the postoperative pain management. It has been used successfully in the management of pain following cesarean section, appendectomy, herniorrhaphy, and other incision on the anterior abdominal wall. TAP block has gone beyond the initial landmark approach to include ultrasound-guided approach with single deposition of local analgesic or by continuous application by the use of catheters.
The wholesome application of TAP notwithstanding it is yet to become a routine component of multimodal strategy in postoperative pain management in Nigeria. Therefore, it may be necessary to critically assess the existing literature on TAP block so as to provide a better understanding and engender interest in its practice. The limited access to opioids, in particular preservative-free intrathecal opioids, makes the search for other components in multimodal analgesia imperative. Thus, the aim of this review of literature is to provide an expose on the current advances in the practice of TAP block in the postsurgical pain management and offer further insights into effective adaptation in Nigeria.
Terminal branches of the anterior rami of the lower six thoracic nerves (T7-T12) and the first lumbar nerve (L1) course through the lateral abdominal wall within a plane between the internal oblique and transversus abdominis muscles. This intramuscular plane is called the TAP. There is a fascial sheath between the internal oblique and transversus abdominis muscles. The nerves lie deep to this fascia. In the subcostal region, the TAP is between rectus abdominis and transversus abdominis or between rectus and the posterior rectus sheath if transversus is not behind it at that level. These spinal nerves innervate the abdominal wall; these include intercostal nerves (T7-T11), subcostal nerve (T12), and iliohypogastric and ilioinguinal nerve (L1).
The anterior divisions of T7-T11 continue from the intercostal space to enter the abdominal wall between the internal oblique and transversus abdominis muscles until they reach the rectus abdominis, which they perforate and supply, ending as anterior cutaneous branches supplying the skin of the front of the abdomen. Midway in their course, they pierce the external oblique muscle giving off the lateral cutaneous branch which divides into anterior and posterior branches that supply the external oblique muscle and latissmus dorsi respectively.
The anterior branch of T12 communicates with the iliohypogastric nerve and gives a branch to the pyramidalis, a small triangular muscle, anterior to the rectus abdominis. Its contraction tenses the linea alba. The pyramidialis muscle is used to determine midline and location of linea when using longitudinal incision for classical cesarean section. Its lateral cutaneous branch perforates the internal and external oblique muscles and descends over the iliac crest and supplies sensation to the front part of the gluteal region.
The iliohypogastric nerve (L1) divides between the internal oblique and transversus abdominis near the iliac crest into lateral and anterior cutaneous branches; the former supplying part of the skin of the gluteal region while the latter supplies the hypogastric region.
The ilioinguinal nerve (L1) communicates with the iliohypogastric nerve between the internal oblique and transversus abdominis near the anterior part of the iliac crest. It supplies the upper and medial part of the thigh and part of the skin covering the genitalia. 
Techniques for Transversus Abdominis Plane Block
There are three different approaches as described by Young et al.;  they are the anatomical landmark-based approach using lumbar triangle of Petit, surgeon-assisted approach,  and lastly and more recent using the ultrasound-guided approach. 
Anatomical landmark-based approach
Lumbar triangle of Petit is a palpable depression between the posterior border of the external oblique and the anterior border of the latissmus dorsi muscle, as a guide. The puncture site is just above the iliac crest and posterior to the mid-axillary line within the triangle of Petit. Other puncture sites are at the level of the mid-axillary line halfway between iliac crest and costal margin or below the subcostal margin. The triangle of Petit can be difficult to palpate, especially in obese patients. Rafi suggests a needle insertion point 2.5 cm behind the highest point of the iliac crest when the triangle is not clearly palpable.  When there is difficulty in assessing the triangle, lifting patients' head and shoulders from the supine position will contract the abdominal muscles and can assist palpation of the triangle. Using a blunt-tipped 50 mm needle inserted perpendicular to the skin with the appreciation of two gives (loss of resistance) or "pop." The needle passes through the fascial extensions of the internal oblique muscle and fascial plane above transversus abdominis and after aspiration, 25-30 ml of local anesthetic (LA) is injected. A blunt needle makes the loss of resistance more appreciable.
The identification of the plane using the landmark approach described the loss of resistance or "double pop" technique. However, opinion differs on the number of pops (one or two) and the type, amount of LA to be deposited (5 to >20 ml). The "two pop" technique is generally advocated and is supported by the cadaveric and imaging studies. , Nevertheless, Hebbard et al. noted that the "pop" sensations in the classic approach could be imprecise due to anatomic variability, especially in obese patients. This position tends to underscore the limitation with the use of landmark technique. Indeed, real-time visualization of the spread of LA as a definitive endpoint as is often the case with other regional block techniques has been suggested. 
Furthermore, another major limitation to the continued advocacy for the use of the landmark technique is the twin issue of accuracy of needle placement and the potential for damage to the adjacent structures. These concerns are worrisome particularly when the blind technique may lead to increased complication rate. McDermott et al. provide more insight with their well-designed evaluation of the needle placement and the local spread using ultrasound guidance during TAP block.  The results showed that the needle tip and LA spread were in the appropriate plane in only 23.6% of the 36 patients so far studied. Ordinarily, this low success rate for the conduct of TAP may argue against its wholesome application. However, the authors used the "unusual" anterior approach to the landmark technique as against the conventional posterior approach through the triangle of Petit. This limitation offers a window of relief for the continued use of blind TAP block.
Even when the block is successful, another ground for a possible dissenting opinion is the appropriate type and dose of LA for the initialization of the block. Bupivacaine or ropivacaine has been commonly employed in the institution of TAP block. The total dose varies between 2 and 3 mg/kg of ropivacaine or 2 mg/kg of bupivacaine, while others used a predetermined volume between 15 and 25 ml per side of block. Concentration of LA used varied between 0.25%-0.5% bupivacaine and 0.2%-0.75% ropivacaine. Generally, it is expected that increasing LA concentration improves outcome. However, the influence of LA concentration on outcome carried out on TAP block could not be discerned with lower concentration of LA resulting in 100% improved outcome while more concentrated solution could not achieve such feat. TAP block technique is either using single injection technique or by passage of perineural catheter for continuous infusion of LA. 
Most works that were done on TAP were by anesthetist; however, in this new approach, the surgeon performs the block intraoperatively either using a blunt tip needle which is advanced from the inside of the abdominal wall through the parietal peritoneum and transversus abdominis muscle into the traverses abdominis plane , or using blunt dissection through the external and internal muscle leading to the TAP under direct visualization with the injection of LA. 
Laparoscopic-assisted technique was described by Chetwood et al., wherein a classic TAP block (based on anatomical landmarks) was performed while the injection area is observed with an intra-abdominal laparoscopic camera.  Visual peritoneal bulge was seen after LA was delivered within the TAP served as the desired end-point for this technique. Such direct visualization may help to avoid intraperitoneal injection, one of the major potential risks of the TAP block. More recently, the use of blunt needle tip to transverse the abdominal wall from the peritoneal outward and blunt dissection through the external and internal muscle leading to the TAP under direct visualization has been carried out. Another advantage of this technique is that a skilled operator and training in ultrasonography are not needed. Since surgeon-assisted approach avoids intraperitoneal deposition, with accurate end-point because it is done under direct vision; it is persuasive to want to abandon blind anatomical approach for the surgeons assisted approach; however, not all procedures done through laparotomy, hernia repair remains a formidable exception. The type of surgery which is a limitation to the general use of the surgeon-assisted technique makes the blind anatomical approach applicable. Another limitation to the use of surgeon-assisted approach is the none specificity of the site of injection in various studies, some did not state the site of injection, while in others, it is at the lateral border of the rectus muscle; this indirectly helps in locating the inferior epigastric vessels and avoids any damage to these vessels.
Hebbard et al. were the pioneer of ultrasound-guided TAP block in 2007. In locating the TAP, the ultrasound probe is placed transversely across the anterolateral abdominal wall where the three muscles are most prominent. After identifying the TAP, the probe is moved posterior-laterally to lie across the mid-axillary line just superior to iliac crest. The block blunt needle is introduced from medial to lateral using the in-plane technique for direct visualization of the needle.  This ultrasound-guided technique is commonly referred to as posterior approach, but some anesthesiologists still move the probe posterior from the mid-axillary line to where the transversus abdominis muscle begins to taper off. In our opinion, this is the posterior approach. In 2008, Hebbard also described the subcostal approach which is a compelling alternative approach to upper abdominal surgery. In this approach, the ultrasound probe is held below and parallel to the costal margin, oblique to the sagittal plane. A 100-150 mm needle is inserted at a position close to the xiphoid process and in plane to the ultrasound probe. The LA is deposited between the transversus abdominis and rectus abdominis muscles or between the rectus muscle and posterior rectus sheath (if there is no transversus at that level). 
The Extent Of Transversus Abdominis Plane Blocks Spread Or The Level Of Block
The introduction of the TAP block was based on the anatomical (blind) approach. However, the spread and level of block achieved using a single TAP injection vary among authors. The earlier studies showed a T7-L1 spread with a single posterior injection making the block suitable for midline abdominal incisions, ,, but other studies have failed to demonstrate a spread cephalad to T10 making TAP block more suitable for lower abdominal surgery. , These discrepancies in the spread could be due to the fact that segmental nerves T7-T9 enters TAP medial to anterior axillary line while T9-L1 runs in the TAP lateral to the anterior axillary line.  There are an extensive branching and communication of the segmental nerves in the TAP. In particular, the T9-L1 branches form a so-called "TAP plexus" that runs with the deep circumflex iliac artery. This may partly account for the ability of a single injection to cover several segmental levels.
It was concluded by Carney et al. that the pattern of LA spread differs depending on the site of injection into the TAP plane;  posterior approaches using both landmark and ultrasound identification resulted in predominately posterior spread around the quadratus lumborum to the paravertebral space from T5 to L1 vertebral level while mid-axillary TAP block gave faint enhancement in the paravertebral space at T12-L2, and anterior subcostal and mid-axillary ultrasound approaches resulted predominately in anterior spread with the TAP plane with little posterior spread. It is important to note that the triangle of Petit is posterior to the mid-axillary line.
Others have also argued that the differences in spread and effect of TAP block may be related to the anatomical variations in patients. Studies on cadavers and radiological evaluation in humans ,, have provided more insight into the anatomy of the triangle of Petit (the main landmark in the conduct of TAP block during blind anatomical approach) and the spread of LA in the plane. Loukas et al. demonstrated the dimensions and surface area of the triangle of Petit in 80 adult cadavers.  The surface area of the triangle were found to be small <8 cm 2 and intermediate (8-12 cm 2 ) in about 70% of the specimens and the triangles on the right tended to be larger than the left. In addition, the triangle of Petit was not delineated in 17.5% of the cadavers. These anatomical variations may explain some of the difficulties and failures of the techniques in some patients using the landmark approach. In a multistage combined cadaveric and radiological evaluation in human volunteers, McDonnell et al.  provided the detailed anatomical characteristics of the triangle of Petit and the spread of agents introduced into the TAP through the triangle. Reliable deposition of methylene blue was demonstrated in the cadaveric studies using the triangle of Petit and the "double-pop" technique. The computerized tomographic imaging component of the study showed the presence of dye in both the TAP and the superficial plane between the external oblique and internal oblique muscles (oblique plane). Finally, the magnetic resonance imaging studies demonstrated the spread within the TAP from the superior margin of the iliac crest to the level of the costal margin and posteriorly to the quadratus lumborum muscles in all the volunteers. In sum, these studies demonstrated that the triangle of Petit is an identifiable landmark with an optimal ease in accessing the TAP.
Attempts were made to describe a precise location of the triangle of Petit by Jankovic et al. in 26 cadavers.  The measurements by the authors revealed the center of the lumbar triangle to be an average of 6.9 cm posterior to the mid-axillary point at the iliac crest and 9.3 cm posterior to the mid-axillary line at the skin surface position. The center of the triangle was 1.4 cm above the iliac crest at skin level. The authors concluded that the triangle of Petit is more posterior than otherwise thought. This variability in the anatomy of the triangle of Petit and the relative small size has implication for the use of the landmark approach to the TAP block. Thus, using anatomical approach with so many variations in its location as a landmark may make the block less reliable. In addition, if technical difficulties exist, the risk of complication is heightened. It is therefore clinically prudent to seek other approaches or methods that may improve the reliability of the triangle of Petit as a landmark for TAP block. However, the use of ultrasound scan at the triangle of Petit (posterior ultrasound-guided approach) produces an extensive, predictable, and posterior spread of contrast, similar to that seen with the landmark TAP block if correctly placed which has a success rate of 85% among experienced practitioners.
The difficulty in confirming correct needle placement in the anatomical approach when using loss of resistance technique have led to block failure,  wrongly deposited LA,  and rarely injury to the underlying structures.  This leads to the development of ultrasound-guided approaches which aims to observe the TAP directly, ensuring that the needle is placed correctly and no other structures are injured potentially, thus reducing the risk of blocks failure, injury to adjacent structures, and improve success rate.
The effectiveness of TAP block using either blind anatomical or ultrasound-guided techniques is not in doubt. There appears to be a scanty documentation on the comparison of the anatomical method with the ultrasound-guided approach to the conduct of TAP block. In one study, El Seri and Makled compared the effectiveness of the landmark technique and the ultrasound-guided approach in patients undergoing cesarean section under general anesthesia. The findings indicate that the ultrasound-guided method resulted in superior analgesia with fewer side effects.  This result should be interpreted within the methodological limitations of the study. This outcome could have been influenced by the different needle insertion points. In the blind anatomical technique a point between the iliac crest and subcostal region was used, which is the anterior approach while the ultrasound guided TAP block used positions were subcutaneous fat, external oblique, internal oblique, transversus abdominis muscle, peritoneum and intraperitoneal structure were viewed satisfactorily. Although the study was conducted in a randomized and blinded fashion, the method of blinding the assessor was unclear.
Transversus Abdominis Plane Block And Multimodal Analgesic Strategy
TAP block can be used as a form of multimodal pain control for abdominal surgery because it only allows sensory blockade of the lower abdominal wall. It is therefore recommended that the TAP block can only reliably be used for analgesia in surgery of the lower abdomen because the uppermost sensory level is around T9/T10 which is adequate for hernia repair, open appendicectomy, cesarean section, total abdominal hysterectomy, and radical prostatectomy. A subcostal TAP block can provide analgesia for abdominal surgery extending above the umbilicus. 
It cannot be used as a sole anesthetic technique, except in a few instances.  The perceived advantage of TAP block over general and central neuraxial anesthesia is its inability to cause myocardial depression and vasodilatation, respectively, which is beneficial to sympathetically driven circulation in high-risk patients. TAP block like other peripheral nerve block only affects somatic innervation leaving the sympathetic efferent intact. TAP block is particularly useful for cases when an epidural is contraindicated or refused. 
Transversus Abdominis Plane Block And Clinical Uses In Postoperative Pain Management
TAP block studies in cadavers ,,, and in human (observational studies) , initially showed positive outcome; this was short lived as comparative trials examining TAP block for abdominal surgery were inconsistent. In some studies, TAP block showed good pain control, ,,,, while in others, it failed to have any analgesic benefit. ,,,,,,,,,,,,, In two of the studies where there was no analgesic benefit, this result was not surprising because morphine was used intrathecally. , The unique pharmacology of morphine with longer analgesic profile  compared to the postoperative analgesic period of TAP was responsible for the result (first analgesic request in TAP group compared with placebo is a mean or median delay of about 2-3 h and may sometimes be shorter). In sum, it is the pharmacokinetics of morphine that is responsible for the seeming negative outcome of TAP block. Despite TAP block short duration of first analgesic request, its decreasing analgesic effect persisted for 36 h. , It should be considered as part of a multimodal analgesic strategy including the use of systemic agents to control residual pain.
Furthermore, in the third study with negative outcome, this might have resulted because some patients had abdominal incision above the umbilicus (longitudinal).  The use of standard TAP block for above umbilical incision will not suffice except if a subcostal block is added. Nevertheless, bilateral subcostal TAP block for a midline incision is sacrosanct for management of midline surgeries, especially supraumbilical ones. The nonutilization of it in their study may appear to be a flaw in their methodology and has erroneous influence in interpreting their results. The TAP block is not effective in managing postoperative pain for all types of abdominal surgery, and its analgesic efficacy is therefore dependent on the surgical procedure, block technique, LA dose and volume, and timing of injection.
Spinal morphine and TAP block separately have been shown to provide better analgesic effect, one would expect that their combination will give a superior analgesic profile; surprisingly, this was not the case as their combination did not have a synergetic effect with ultimate aim at reducing the postoperative total opioid requirement.  Overall, the current clinical standard is to administer the TAP block to those patients who have not received morphine in their neuraxial anesthetic. Furthermore, the advantages of intrathecal morphine over ultrasound-guided TAP block because it is cheaper to administer and with a longer duration of action is not without a price. These are the unwanted side effects such as postoperative nausea and vomiting (PONV), pruritus, respiratory depression which can occur up to 12 h after administration, and a period when the patient is not being as closely monitored.
TAP block is commonly performed in adult patients; its use in cesarean delivery through Pfannenstiel incision is very popular compared to other surgical procedures such as gynecological and nongynecological surgeries (colorectal surgery, open and laparoscopic appendectomy, hernia repair, suprapubic prostatectomy, and even in laparoscopic cholecystectomy). TAP has also been carried out in pediatric age group. ,,
Most reports demonstrate the efficacy of TAP blocks by highlighting some combination of reduced postoperative opioid requirement, lower pain score, and reduction in opioid-related side effects. Particularly, studies show that preoperative TAP block improves postoperative pain. Ahed et al. found that TAP block given preemptively improves postoperative pain after inguinal hernia repair using blind landmark technique. One of the possible reasons put forward by the authors for the effectiveness of preemptive administration of TAP block is that TAP is relatively poorly vascularized space and drug clearance may be slowed down. Preemptive administration of block reduces the nociceptive input to the central nervous system after surgery, which may have attenuated central sensitization leading to less postoperative pain.
The efficacy of the ultrasound-guided TAP block was demonstrated by Niraj et al., and they found it to be effective in open appendectomy. TAP block was administered preemptively after induction of general anesthesia using 20 ml of 0.5% bupivacaine. Intraoperative analgesia was maintained with 0.1 mg/kg of morphine and 1 g of acetaminophen. Time of assessment was limited to first 24 h and at 30 min and the 24 th h. TAP block reduced morphine consumption (mg) at 24 h (28  vs. 50 , P < 0.002). Pain scores at rest and on coughing were significantly reduced at the two time points assessed after the TAP block. There was a significant difference in the incidence and severity of PONV in the two groups at 30 min after surgery but not at 24 h after surgery. The standard group required significantly more rescue antiemetics than the TAP group. There was no significant difference between the groups in diclofenac usage during the first 24 h after surgery. The difference in the duration of postoperative stay between the two groups was not significant.
The effect of TAP block on patients who had cesarean surgeries has been evaluated; Belavy et al.  demonstrated superior analgesia and significantly decreased 24-h morphine consumption following C-section. Patients either received TAP block and spinal anesthesia using plain LA or just spinal with plain LA.
Effects of TAP block on oncological surgeries were not let out. Bharti et al.  randomized 40 patients undergoing colorectal surgery to standard treatment (diclofenac and intravenous morphine) and bilateral intraoperative TAP block with either 0.25% bupivacaine (n = 20) or saline (n = 20). Injection of LA into the transversus abdominis space was done from inside the abdominal, from the peritoneum to the TAP. This reduces the risk of visceral injury. The observation of thickening of abdominal wall, appreciation of facial click during needle insertion, ease of injection of LA, and absence of swelling or bleb formation after injection can help in the detection of correct plane. The bupivacaine group had a significant reduction in 24-h morphine requirements as well as a significant reduction in early postoperative pain scores both at rest and with coughing. However, the time to first analgesic request was not prolonged. Furthermore, early postoperative sedation scores were significantly lower in the bupivacaine group, and patient satisfaction was higher (6.8 ± 1.1 mg versus 3.5 ± 1.5 mg; P < 0.001).
The clinical relevance of TAP block in the ameliorating acute pain may be difficult to replicate in patients with chronic or cancer pain. TAP block did not provide additional benefit to multimodal benefit in gynecological cancer surgery.  In a placebo-controlled trial comparing bilateral ultrasound guided TAP block (2×20ml 0.5% ropivacaine or 0.9% saline) in adult female patients undergoing midline laparatomy for known or presumed gynaecological malignancy. There were many methodological flaws/differences in this study. Tap block was placed after wound closure (postoperatively) unlike in Niraj et al., who placed theirs preemptively. A major setback in their study was not using the subcostal approach for those patients who had their incision extended above the umbilicus, patient group being heterogeneous. Finally, many of the patients were obese which could cause technical challenges in performing the block. In sum, all these could have led to the negative outcome of this study. These limitations notwithstanding TAP block appears inadequate in patients with cancer.
TAP block is superior to blind landmark ilioinguinal/iliohypogastric nerve block in opened inguinal hernia repair.  Surprisingly, in another study, TAP block was inferior to iliohypogastric nerve block.  The use of smaller volume 0.2 ml/kg than the standard volume of 0.5 ml/kg was said to be responsible for this outcome.
One study on TAP block has also been used to provide further insight into the controversy involving the superiority between preincision (preemptive/prevention) and postincision (treatment) mode of managing pain, in which preincision application of TAP block demonstrated superiority compared to postincision TAP.  Studies have also compared pre- or post-incision TAP with placebo and better analgesic profile was seen more in the preincision group. 
Complications associated with the TAP block are peritoneal injection,  with a few case reports of liver puncture initially thought to be due to the blind landmark technique only,  but similar complications resulting from ultrasound-guided TAP block have also been recorded.  In general, complications are more commonly associated with the blind landmark technique than ultrasound-guided technique.  Other complications include LA toxicity, failure of TAP block, , and bowel injury. , Wrong placement of needle tip can lead to failed TAP block apart from the feared complication of visceral injury. Bowel injury has been reported with the use of long bevel needle for puncture.  A short bevel needle enhances the recognition of fascial planes, this when used prevents excessive needle insertion, and colonic puncture might have been avoided. Surprisingly, another study reported bowel injury following the use of atraumatic short needle.  This complication of bowel injury resulting from needles of different length and configuration underscores the fact that regional anesthesia in children is never completely risk-free.
Clinical Implication And Applicability For Nigeria
There are few hospitals in Nigeria that are equipped to perform ultrasound-guided regional anesthesia. In our hospital, we have one ultrasound machine for ultrasound-guided regional anesthesia serving 12 theater suites spread over four different locations. This has been of immense benefit to the patients training and research. In our facility, TAP block has been used as a component of multimodal strategy for postoperative pain after appendectomy, myomectomy, cesarean section, and other procedures with infraumbilical incisions. In other centers, the clinical usefulness of TAP blocks may be limited by the nonavailability of appropriate equipment including ultrasound machine. It may be argued that clinicians should not abandon TAP block for reasons related to poor access to ultrasound machine. In our institution, some practitioners still employ the landmark approach to TAP block. This may have been due to long practice or restricted access to the ultrasound machine. It may be worthwhile to encourage the prudent use of the landmark approach for teaching the skills and prolongation of postoperative analgesia. The technology for the landmark approach is cheap. The 22G needle is blunted by multiple movements over the broken edge of the ampoule. In an aseptic environment, the triangle of Petit is identified. The blunt needle is introduced perpendicular to the skin. It is advanced gently until 2 pops are felt. LA solution preferably bupivacaine (0.25%/20-30 ml) is injected without resistance. Thus, this can serve as alternative addition to the multimodal analgesic strategy in the absence of opioids and ultrasound machine.
Many studies have shown the importance of TAP block in postoperative pain management; it should therefore be considered as part of a multimodal analgesic strategy in Nigeria including the use of systemic agents to control residual pain. The landmark approach should be encouraged particularly in low-resource setting like ours in the Sub-Sahara region where the availability of ultrasound-guided TAP block is still at its infancy and expertise has a long learning curve. This can be done by having didactic lectures; tutorials and hands-on workshop side-by-side with ultrasound-guided technique were available.
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