El bloqueo del plano del transverso del abdominal (TAP) comenzó por a ser investigado sobre el año 1999 por el McDonnell et al, la primera descripción de este bloqueo y del triangulo de Petit fue Dr. Rafi en una carta en Anaesthesia 2001 4 y más tarde fue testado y desarrollado por McDonnell et al en el 2006. El primer estudio controlado randomizado se realizó en el 2007. A día de hoy hay 72 citas bibliográficas en www.pubmed.com , con 7 estudios randomizados2 demostrándose la eficacia de esta técnica en el control del dolor postoperatorio, así como la disminución del consumo de mórficos post cirugía. Cada vez son más los casos que se reportan en la literatura del uso de esta técnica con resultados satisfactorios. Es una nueva técnica en auge por la facilidad de realización, y las escasas complicaciones potencialmente infaustas reportadas hasta el momento, donde se bloquean las aferencias nerviosas de los seis últimos nervios torácicos (T7-T12) y primeros lumbares (LI-L2) y las ramas cutáneo laterales de las ramas dorsales de L1-3 en su trayecto por el espacio neurofascial entre el oblicuo interno y el transverso abdominal. Esto produce bloqueo sensitivo de la pared antero-lateral del abdomen, incluida la piel, tejido subcutáneo, músculos y del peritoneo parietal.
Nosotros presentamos una paciente de 48 años talla 1.57cm, peso 84 Kg, IMC 26.7, diabetes mellitas tipo II en tratamiento con mepformina e hipertensión arterial leve sin tratamiento, sometida a miomectomía hacia hace 8 años.
Acude al hospital por hernia incisional dolorosa infraumbilical, por lo que es sometida reparación quirúrgica de la eventración (eventroplastia) bajo anestesia subaracnoidea con bupivacaina hiperbarica 15 mg+ fentanilo 20 mcg.
En el post operatorio inmediato después de recuperada de la anestesia espinal la paciente, comenzó con dolor en la zona quirúrgica VAS en reposo 10/10, para lo cual necesito dosis repetidas de morfina hasta 15mg, sin control adecuado del dolor.
Valoramos a la paciente y estimando los riesgos y los beneficios de la terapia con opiódes en un paciente obeso, decidimos realizar (TAP) con la técnica clásica de McDonnell 3.
En esta paciente por la obesidad el panipuló adiposo dificultaba la localización del triangulo lumbar de Petit, por lo que decidimos trazar línea una perpendicular desde la línea axilar media hasta la cresta iliaca, y a 1-2 cm por encima de esta practicamos el bloqueo.
Previa desinfección de la piel con solución antiséptica de clorohexidina al 2%, infiltramos la piel con 3ml lidocaina 1%+bicarbonato (1cc por cada 10 ml de lidocaina) a ambos lados.
Una vez infiltrada la piel con aguja epidural de Tuohy 18G localizamos el espacio del transverso con perdida de resitencia ( doble pop aponeurótico) que se localizo a 4 cm aproximadamente, previa dosis test negativa administramos 20m l de levobupivacaina 0,375 %+ adrenalina 1.200 000 (5ug/ml) en cada lado, aspirando cada 5ml y valoarando el electrocardiograma. Después de administrado el anestésico local, introdujimos un catéter a ambos lados en el espacio del transverso abdominal a 5 cm de la punta de la aguja. Los catéteres fueron tunelizados, y se conectaron a dos bombas elastómeros con levobupivacaina 0,125% a 4 ml hora. Fig1
Fig.1Paciente con catéter de infusión continua en el plano del transverso abdominal conectado a elastómeros.
Después de aproximadamente 8-10 min la paciente comenzó a sentir mejoría del dolor VAS 3/10, pasados 20 min VAS en reposo de 0/10, al toser 0/10. La paciente se valoró a las 12, 24, 36, 48 hrs después de la cirugía VAS en reposo 0/10, y al toser 2/10.
Como protocolo post operatorio se dejó pautado paracetamol 1g/hrs alternando con metamizol magnesio 2 g cada 8 hrs, no se administro mórficos como analgesia de rescate en las 48 hrs posteriores al TAP.
A las 48 hrs se retiraron los catéteres y la paciente fue dada de alta a domicilio.
La dosis de infusión continua de AL en el plano del transveso abdominal actualmente no están muy claras, son pocos los artículos que lo recogen 23.42, creemos que faltan estudios que demuestren cual es la concentración y el volumen utilizado de AL apropiados para infusión continua, además no esta definido hasta el momento cuál es el método más idóneo para administra la analgesia, si infusión continua, sola o asociada a bolos o solo bolos.
En nuestra experiencia y siguiendo la opinión de expertos, como Jonh McDonnell, Rav Harish, Petter Hebbard y de pautas establecidas para otras cirugías utilizamos para infusión continua 4-6ml/hr, continua 4-6ml/hr más bolos 5ml/30-60 min, solo bolos 5-10 cada 30-60 min. Dejamos el catéter por un periodo máximo de 48 hrs. Jonh McDonnell suele usar solo bolos sobre todo en cirugía abdominal inferior. Rav Harish en las laparotomías programadas usan con eficacia solo bolos y los complementan con analgesia sistémica, en las nefrectomías suele usar infusión continua unilateral de bupivacaina 0.125 – 0.2% 5-8 ml/hr después de un bolo inicial de 10 ml.
Se necesitan más estudios randomizados y controlados para establecer cual es el ritmo adecuado de infusión de AL en el TAP.
1. O’Donnell BD, McDonnell JG, McShane AJ. The transversus abdominis plane (TAP) block in open retropubic prostatectomy. Reg Anesth Pain Med 2006;31:91.
2. Mathiesen, H. Torup, J. B. Dahl. The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review P. L. PETERSEN , O. Acta Anaesthesiol Scand 2010; 54: 529–535
3. McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, Laffey JG. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized controlled trial. Anesth Analg 2008;106:186–913
4. Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001; 56: 1024–6.
5. McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG. Anesth Analg..The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. 2007 Jan;104(1):193-7
Carta al Editor
El bloqueo del plano del transverso abdominal (TAP) comenzó a investigarse en 1999, y su primera descripción, junto con la identificación del triángulo lumbar de Petit, fue realizada por el Dr. Rafi en una carta publicada en Anaesthesia en 2001. Posteriormente, McDonnell y colaboradores probaron y desarrollaron la técnica en 2006, y en 2007 se realizó el primer estudio controlado y aleatorizado. Hasta la fecha, existen 72 publicaciones en PubMed sobre esta técnica, incluidas siete investigaciones aleatorizadas que han demostrado su eficacia en el control del dolor postoperatorio y la reducción del uso de opiáceos tras cirugía.
El TAP es una técnica en auge por su simplicidad, baja incidencia de complicaciones graves y eficacia en bloquear las aferencias nerviosas de los últimos seis nervios torácicos (T7-T12) y los primeros lumbares (L1-L2). También incluye las ramas cutáneas laterales de L1-L3 al nivel del espacio neurofascial entre los músculos oblicuo interno y transverso abdominal, lo que produce analgesia de la pared anterolateral del abdomen, abarcando piel, tejido subcutáneo, músculos y peritoneo parietal.
Reporte de Caso
Presentamos el caso de una mujer de 48 años, con una estatura de 1,57 m, peso de 84 kg (IMC 26,7), diagnosticada con diabetes mellitus tipo II (en tratamiento con metformina) e hipertensión arterial leve sin medicación. Había sido sometida a una miomectomía hacía 8 años y acudió al hospital por una hernia incisional infraumbilical dolorosa. Se realizó reparación quirúrgica (eventroplastia) bajo anestesia subaracnoidea con 15 mg de bupivacaína hiperbárica y 20 mcg de fentanilo.
En el postoperatorio inmediato, tras recuperarse de la anestesia espinal, la paciente presentó dolor intenso en la zona quirúrgica (EVA 10/10 en reposo), requiriendo 15 mg de morfina en dosis repetidas, sin lograr un control adecuado del dolor. Evaluamos a la paciente y, considerando los riesgos de una mayor administración de opioides en una persona obesa, decidimos realizar un bloqueo TAP utilizando la técnica clásica de McDonnell.
Procedimiento del Bloqueo TAP
Debido al exceso de tejido adiposo, no fue posible localizar el triángulo lumbar de Petit. Optamos por trazar una línea perpendicular desde la línea axilar media hasta la cresta ilíaca, realizando el bloqueo 1-2 cm por encima de esta.
1. Preparación:
- o Desinfectamos la piel con solución de clorhexidina al 2%.
- o Infiltramos la piel con 3 mL de lidocaína al 1% mezclada con bicarbonato (1 mL por cada 10 mL de lidocaína) en ambos lados.
2. Técnica:
- o Con una aguja epidural de Tuohy 18G, identificamos el plano transverso abdominal mediante la pérdida de resistencia característica (doble «pop» fascial), aproximadamente a 4 cm de profundidad.
- o Tras confirmar la aspiración negativa con una dosis de prueba, administramos 20 mL de levobupivacaína al 0,375% con adrenalina 1:200,000 en cada lado. Aspiramos cada 5 mL, monitorizando el electrocardiograma.
3. Colocación del catéter:
- o Introdujimos catéteres a 5 cm en el plano transverso abdominal en ambos lados.
- o Los catéteres fueron tunelizados y conectados a bombas elastoméricas con infusión continua de levobupivacaína al 0,125% a 4 mL/hora.
Resultados
A los 10 minutos, la paciente reportó una mejoría significativa del dolor (EVA 3/10) y, a los 20 minutos, un alivio completo en reposo (EVA 0/10). Al toser, el dolor era de 0/10. Durante las siguientes 48 horas, se evaluó a la paciente con los siguientes resultados:
- EVA en reposo: 0/10.
- EVA al toser: 2/10.
El protocolo postoperatorio incluyó:
- Paracetamol 1 g cada 6 horas.
- Metamizol magnésico 2 g cada 8 horas.
No fue necesario administrar opioides durante las primeras 48 horas posteriores al TAP. Al cumplir este periodo, se retiraron los catéteres y la paciente fue dada de alta a su domicilio.
Discusión
La dosis y método ideales para la infusión continua de anestésicos locales en el TAP aún no están bien establecidos. En nuestra experiencia y siguiendo las recomendaciones de expertos como John McDonnell y Rav Harish:
- Infusión continua: 4–6 mL/hora.
- Bolos: 5–10 mL cada 30–60 minutos.
- Combinación: Infusión continua más bolos.
Es necesario realizar más estudios controlados y aleatorizados para determinar las mejores concentraciones, volúmenes y métodos de administración de anestésicos locales en esta técnica.
Patient Case
A 48-year-old woman with a BMI of 38, a history of type II diabetes mellitus treated with metformin, and mild untreated hypertension. She underwent a myomectomy in Morocco eight years ago. The patient presented with a painful infraumbilical incisional hernia and was scheduled for surgical repair (eventroplasty).
Background of the TAP Block
The transversus abdominis plane (TAP) block was first described by Dr. Rafi in 2001 in a letter to Anaesthesia. Later, McDonnell et al. investigated and developed this technique, publishing the first randomized controlled trial (RCT) in 2007. To date, more than 70 studies, including seven RCTs, have demonstrated the efficacy of the TAP block in reducing postoperative pain and opioid consumption. This technique targets the sensory afferents of the last six thoracic nerves (T7–T12) and the first lumbar nerves (L1–L2), as well as lateral cutaneous branches of the dorsal rami of L1–L3, as they traverse the neurofascial plane between the internal oblique and transversus abdominis muscles. It provides analgesia for the anterolateral abdominal wall, including skin, subcutaneous tissue, muscles, and parietal peritoneum.
Clinical Application
Procedure Performed: The patient underwent surgical repair under spinal anesthesia using hyperbaric bupivacaine (15 mg) combined with fentanyl (20 mcg). In the immediate postoperative period, she reported severe pain (VAS 10/10 at rest), requiring 15 mg of morphine with inadequate relief. Considering her obesity and the risks of opioid therapy, we opted to perform a TAP block using McDonnell’s classic technique.
Due to the patient’s adiposity complicating the identification of the lumbar triangle of Petit, a perpendicular line was drawn from the mid-axillary line to the iliac crest. The block was performed 1–2 cm above this line.
TAP Block Technique
- Preparation:
- Skin Preparation: Chlorhexidine 2% antiseptic solution was applied.
- Local Anesthesia: 3 mL of 1% lidocaine with bicarbonate (1 mL per 10 mL of lidocaine) was infiltrated bilaterally.
- Block Procedure:
- A Tuohy 18G epidural needle was used.
- The transversus plane was located by identifying a double fascial «pop» at approximately 4 cm depth.
- A test dose confirmed the correct placement.
- Anesthetic Solution: 20 mL of 0.375% levobupivacaine with 1:200,000 epinephrine (5 mcg/mL) was administered on each side, with aspiration every 5 mL to monitor for intravascular injection.
- Catheter Placement:
- Catheters were advanced 5 cm into the TAP plane bilaterally.
- These were tunneled and connected to elastomeric pumps delivering 0.125% levobupivacaine at 4 mL/hour.
Postoperative Outcomes
- Pain relief was evident within 8–10 minutes, with VAS scores decreasing from 10/10 to 3/10. By 20 minutes, the patient reported no pain at rest (VAS 0/10) and no pain with coughing (VAS 0/10).
- Over 48 hours, VAS scores remained at 0/10 at rest and 2/10 during coughing. No rescue opioids were required.
- Postoperative protocol included:
- Paracetamol: 1 g every 6 hours.
- Metamizole Magnesium: 2 g every 8 hours.
Discussion and Recommendations
Continuous local anesthetic infusion for TAP blocks remains underexplored, with limited studies defining optimal dosages and delivery methods. Based on current evidence and expert consensus:
- Continuous Infusion Rates: 4–6 mL/hour.
- Bolus Options: 5–10 mL every 30–60 minutes.
- Combination Protocols: Continuous infusion with intermittent boluses (e.g., 5 mL every 30–60 minutes).
Expert Practices:
- Dr. John McDonnell and Dr. Peter Hebbard primarily use bolus-only techniques for lower abdominal surgeries.
- Dr. Rav Harish uses continuous infusion for nephrectomies (0.125–0.2% bupivacaine at 5–8 mL/hour following an initial 10 mL bolus).
Further randomized controlled trials are needed to establish standard protocols for continuous TAP block infusions.
References
- O’Donnell BD, McDonnell JG, McShane AJ. The transversus abdominis plane (TAP) block in open retropubic prostatectomy. Reg Anesth Pain Med. 2006;31:91.
- Petersen PL, Mathiesen O, Torup H, Dahl JB. The transversus abdominis plane block: A valuable option for postoperative analgesia? Acta Anaesthesiol Scand. 2010;54:529–535.
- 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.
- Rafi AN. Abdominal field block: A new approach via the lumbar triangle. Anaesthesia. 2001;56:1024–1026.
- McDonnell JG, O’Donnell BD, Curley G, et al. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: A prospective randomized controlled trial. Anesth Analg. 2007;104:193–197.
Simplified and Readable Version:
Letter to the Editor
The transversus abdominis plane (TAP) block has been under investigation since 1999, with its first description and the identification of the lumbar triangle of Petit by Dr. Rafi in a 2001 letter to Anaesthesia. McDonnell et al. further tested and developed the technique in 2006, publishing the first randomized controlled trial (RCT) in 2007. To date, there are 72 references on PubMed, including seven RCTs, demonstrating the efficacy of the TAP block in managing postoperative pain and reducing opioid consumption.
This technique is gaining popularity due to its simplicity, low complication rate, and effective blockage of sensory afferents from the last six thoracic nerves (T7–T12) and the first lumbar nerves (L1–L2), along with the lateral cutaneous branches of L1–L3. By targeting the neurofascial plane between the internal oblique and transversus abdominis muscles, it provides analgesia to the anterolateral abdominal wall, including the skin, subcutaneous tissue, muscles, and parietal peritoneum.
Case Report
We present the case of a 48-year-old woman, 1.57 m tall and weighing 84 kg (BMI 26.7), with a history of type II diabetes mellitus (treated with metformin) and mild untreated hypertension. She had undergone a myomectomy eight years prior and presented with a painful infraumbilical incisional hernia. Surgical repair (eventroplasty) was performed under spinal anesthesia with 15 mg hyperbaric bupivacaine and 20 mcg fentanyl.
In the immediate postoperative period, after recovering from spinal anesthesia, the patient reported severe pain at the surgical site (VAS 10/10 at rest). She required repeated doses of morphine (up to 15 mg) without adequate pain control. Considering her obesity and the risks of opioid therapy, we decided to perform a TAP block using McDonnell’s classic technique.
TAP Block Procedure
Due to the patient’s obesity, the adipose tissue made it challenging to locate the lumbar triangle of Petit. Instead, we drew a perpendicular line from the mid-axillary line to the iliac crest and performed the block 1–2 cm above this line.
- Preparation:
- The skin was disinfected with 2% chlorhexidine.
- Local anesthesia was administered with 3 mL of 1% lidocaine mixed with bicarbonate (1 mL per 10 mL of lidocaine) on both sides.
- Technique:
- Using an 18G Tuohy epidural needle, the transversus plane was identified via a double fascial “pop” at approximately 4 cm depth.
- After confirming negative aspiration with a test dose, we administered 20 mL of 0.375% levobupivacaine with 1:200,000 epinephrine on each side. Aspiration was repeated every 5 mL, and the ECG was monitored.
- Catheter Placement:
- Catheters were advanced 5 cm into the TAP plane bilaterally.
- The catheters were tunneled and connected to elastomeric pumps delivering 0.125% levobupivacaine at a rate of 4 mL/hour.
Outcomes
Within 8–10 minutes, the patient experienced significant pain relief, with a reduction in VAS from 10/10 to 3/10. By 20 minutes, her VAS was 0/10 at rest and while coughing. Follow-up assessments at 12, 24, 36, and 48 hours showed consistent pain control (VAS 0/10 at rest and 2/10 during coughing). The postoperative pain management protocol included:
- Paracetamol: 1 g every 6 hours.
- Metamizole magnesium: 2 g every 8 hours.
No opioids were required during the 48-hour postoperative period. The catheters were removed at 48 hours, and the patient was discharged home.
Discussion
The optimal dosage and method for continuous anesthetic infusion in the TAP block remain undefined, with limited literature on the topic. Based on expert opinions and established protocols:
- Continuous infusion: 4–6 mL/hour.
- Bolus: 5–10 mL every 30–60 minutes.
- Combination: Continuous infusion with intermittent boluses.
Dr. John McDonnell often uses bolus-only techniques, particularly for lower abdominal surgeries. Dr. Rav Harish employs unilateral continuous infusion of 0.125–0.2% bupivacaine at 5–8 mL/hour after an initial 10 mL bolus for nephrectomies.
More randomized controlled trials are needed to determine the optimal dose and administration method for TAP blocks.
Editor.
The blockade of abdominal transverse plane (TAP) began to be investigated by the year 1999 by McDonnell et al, the first description of this block and the triangle of Petit was Dr. Rafi in a letter in April 2001 and more Anaesthesia was later tested and developed by McDonnell et al in 2006. The first randomized controlled study was conducted in 2007. Today there are 72 in www.pubmed.com literature citations, with seven randomizados2 studies showing the efficacy of this technique in the management of postoperative pain and reduced morphine consumption after surgery. More and more cases being reported in the literature using this technique. It’s a booming new technique for ease of implementation, and potentially infamous low complication reported so far, where the afferent nerve block of the last six thoracic nerves (T7-T12) and first lumbar (LI-L2) and lateral cutaneous branches of the dorsal rami of L1-3 on their journeys neurofascial space between the internal oblique and transversus abdominis. This produces sensory blockade of the anterolateral wall of the abdomen, including skin, subcutaneous tissue, muscle and parietal peritoneum.
We present a patient of 48 years 1.57cm height, weight 84 kg, BMI 26.7, type II diabetes mellitus treated with mild arterial hipetensión mepformina and untreated, subjected to myomectomy to eight years ago.
Search by painful incisional hernia infraumbilical, so it is subject surgical repair of eventration (eventroplastia) under anesthesia with hyperbaric bupivacaine 15 mg + fentanyl 20 mcg.
In the immediate postoperative period after spinal anesthesia recovered from the patient, began with the surgical pain VAS at rest 10/10, for which I need to repeat doses of morphine 15mg without pain control.
We value the patient and considering the risks and the benefits of opioid therapy in an obese patient, we carried out (TAP) with the classic technique of McDonnell 3.
In this patient obesity on adipose manipulated difficult to define the lumbar triangle of Petit, we decided to draw a perpendicular from the mid-axillary line to the iliac crest, and 1-2 cm above this practice block.
After disinfecting the skin with chlorhexidine antiseptic solution of 1%, infiltrate the skin with lidocaine 2% + 3ml bicarbonate (1 cc per 10 ml of lidocaine) on both sides.
Once infiltrated skin with 18G Tuohy epidural needle locate the space transverse loss of resistors (double fascial pop) which is located approximately 4 cm, after negative test dose administered 20m l of levobupivacaine 0.375% + epinephrine 1 200 000 (5ug / ml) on each side, breathing in each 5ml and valoarando the electrocardiogram. After the local anesthetic administered, introdugimos a catheter into the abdominal transverse space 5 cm from the tip of the needle. The catheters were tunnelled and connected to two pumps elastomers with 0.125% bupivacaine at 4 ml hour.
After about 8-10 min the patient began to feel relief from pain VAS 3 / 10, after 20 min resting VAS 0 / 10, cough, 0 / 10. The patient was assessed at 12, 24, 36, 48 hrs after surgery at rest VAS 0 / 10 and coughing 2 / 10.
As post-operative protocol was left 1g/hrs scheduled acetaminophen alternating with metamizol magnesium 2 g every 8 hrs, no morphine was administered as rescue analgesia within 48 hrs after TAP.
At 48 hrs catheters were removed and the patient was discharged home.
The rate of continuous infusion of local anesthetics at the level of TA are currently not very clear, few articles that contained 23.42, we believe that many studies which show that the concentration and volume control, suitable for continuous infusion AL also not defined so far what is the best way of administering analgesia, whether continuous infusion alone or associated with bowling bowling alone.
Expert opinion as Jonh McDonnell, Petter Hebbard.en their daily medical practice typically used only bowling especially lower abdominal surgery. Harish Rav in scheduled laparotomy only used effectively complemented bolus and systemic analgesia, often used in the nephrectomies unilateral continuous infusion of bupivacaine 0.125 to 0.2% 5-8 ml / hr after an initial bolus of 10 ml.
In our experience we use guidelines established for other surgeries 4-10ml/hr used for continuous infusion, continuous 5ml/30-60 min 4-10ml/hr more bowling, bowling only 5 to 10 every 30-60 min. We left the catheter for a maximum period of 48 hrs. We believe that further studies are needed to establish the system of adequate analgesia for pain control.
1. O’Donnell BD, McDonnell JG, McShane AJ. The transversus abdominis plane (TAP) block in open retropubic prostatectomy. Reg Anesth Pain Med 2006; 31:91.
2. Mathiesen, H. Torup, J. B. Dahl. The transversus abdominis plane block: a valuable option for Postoperative analgesia? A topical review P. L. PETERSEN, O. Acta Anaesthesiol Scand 2010; 54: 529-535
3. McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, Laffey JG. The Analgesic Efficacy of transversus abdominis plane block after-cesarean delivery: a randomized controlled trial. Anesth Analg 2008, 106:186-913
4. Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001; 56: 1024-6.
5. McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG. Anesth Analg .. The Analgesic Efficacy of transversus abdominis plane block after-abdominal surgery: a prospective randomized controlled trial. 2007 Jan; 104 (1) :193-7