Combined caudal retrocostal and lateral ultrasound-guided approach for transversus abdominis plane injection: A descriptive pilot study in pig cadavers.

Abstract

Transversus abdominis plane (TAP) block is a regional anesthetic technique used to desensitize the abdominal wall in several species. This study aimed to describe the anatomical characteristics of the abdominal wall and to identify a feasible approach for an US-guided TAP injection that would result in adequate staining of the relevant nerves in the abdominal wall in pig cadavers. Fresh cadavers from five Landrace pigs (age, 12 weeks; body weight, 35.5 ± 1.6 kg) were used. One pig (n = 1) was anatomically dissected, and four pigs (n = 4; i.e., 8 hemiabdomens) were used for TAP injections and evaluation of dye spread. The volume of 0.3 mL/kg/injection point of methylene blue was injected bilaterally. In the caudal retrocostal approach, the injection was performed ventral to the most caudal part of the costal arch. In the lateral approach, the injection was performed between the last rib and iliac crest. A needle was inserted in plane for the caudal retrocostal and the lateral approach caudocranially and craniocaudally, respectively. Successful staining was defined as presence of dye on the nerve for a length of >1 cm in its entire circumference. The TAP was found between different muscle layers in the described anatomical regions. In the caudal retrocostal approach the TAP was found between the external abdominal oblique and transversus abdominis muscle bellies. In the lateral approach the TAP was found between the internal abdominal oblique and transversus abdominis muscles. The approach combining lateral and caudal retrocostal injections at the studied volume stained a median of 5 (3-6) target nerves from the fourth-last thoracic nerve to L2 (six nerves). Combined caudal retrocostal and lateral TAP injections of 0.3 mL/kg/injection point, resulted in staining of target nerve branches which supply the periumbilical and caudal abdominal wall in pig cadavers.