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plane via the triangle of Petit, it is possible to block the group assignment. All patients received a standard-
sensory nerves of the anterior abdominal wall before ized general anesthetic. Standard monitoring, includ-
they pierce the musculature to innervate the abdomen. ing electrocardiogram, arterial blood pressure, arterial
We call this novel block the “transversus abdominis oxygen saturation, and end-tidal carbon dioxide
plane” (TAP) block. monitoring were used throughout, and patients were
Preliminary cadaveric studies, followed by volun- placed in the supine position. Anesthesia was induced
teer studies, have demonstrated the potential for the with IV fentanyl (1–1.5 g/kg to a maximum of 100
TAP block to produce a dermatomal sensory block of g) and propofol (2–3 mg/kg). All patients also re-
the lower six thoracic and upper lumbar abdominal ceived morphine 0.15 mg/kg, rectal diclofenac 1
afferents (6). In addition, we have demonstrated the mg/kg to a maximum of 100 mg and rectal acetamino-
analgesic potential of the TAP block in a series of phen 1 g immediately before surgical incision. Prophy-
patients undergoing radical prostatectomy (7). In this lactic antiemetics were not administered.
study, we evaluated the analgesic efficacy of TAP All patients randomized to undergo TAP block had
blockade for the first 24 postoperative hours, in pa- the block performed after induction of anesthesia, by one
tients undergoing large bowel resection via a midline of two investigators (JMcD, BO’D). The iliac crest was
abdominal wall incision. palpated from anterior to posterior until the latissimus
dorsi muscle could be felt (Fig. 2A). The triangle of Petit
METHODS was then located just anterior to the latissimus dorsi
After obtaining approval by the Hospital Ethics muscle. Using a blunt regional anesthesia needle (22G,
Committee, and written informed patient consent, we Plexufix威, B. Braun, Melsungen AG, Germany), the
studied 32 ASA physical status I–III patients sched- skin was pierced just cephalad to the iliac crest over
uled for large bowel resection via a midline abdominal the triangle of Petit (Fig. 2B). The needle was then
incision, in a prospective, randomized, double-blind, advanced at right angles to the skin, in a coronal
controlled clinical trial. Patients were excluded if there plane, until resistance was encountered. This resis-
was a history of relevant drug allergy, or if they were tance indicated that the needle tip was at the external
receiving medical therapies considered to result in oblique muscle. Gentle advancement of the needle
tolerance to opiates. After study entry, patients were resulted in a “pop” sensation as the needle entered the
also excluded if the surgery did not proceed to bowel plane between the external and internal oblique fascial
resection. layers. Further gentle advancement of the needle
Patients were randomized, by sealed envelopes, to resulted in a second pop, which indicated entry into
undergo TAP block (n ⫽ 16) or to receive standard the transversus abdominis fascial plane. After careful
care (n ⫽ 16). The patients, their anesthesiologists, and aspiration to exclude vascular puncture, 20 mL of 0.375%
the staff providing postoperative care were blinded to levobupivacaine solution (to a maximum dose of 1
Vol. 104, No. 1, January 2007 © 2007 International Anesthesia Research Society 195
Table 1. Baseline Patient Characteristics
Control TAP block
(n ⫽ 16) (n ⫽ 16)
Age (yr) 54.6 ⫾ 4.2 58.9 ⫾ 4.0
Sex ratio (M:F) 8:8 7:9
Weight (kg) 67.4 ⫾ 3.5 64.7 ⫾ 2.3
Height (m) 1.63 ⫾ 0.04 1.66 ⫾ 0.04
Duration of surgery (min) 163.6 ⫾ 8.5 170.4 ⫾ 17.8
Intraoperative morphine 0.15 ⫾ 0.0 0.15 ⫾ 0.0
(mg/kg)
Surgical procedure
Large bowel resection 14 10
Small bowel resection 1 2
Other procedure 1 4
Categorical variables as presented as number and proportion, and continuous variables are Figure 4. Mean postoperative verbal analog scale (VAS) pain
presented as mean ⫾ SEM.
scores on movement in each group over the first 24 postop-
TAP ⫽ tranversus abdominis plane block.
erative hours. *Indicates significantly (P ⬍ 0.05, t-test after
There were no significant differences between groups.
ANOVA) higher VAS score when compared with the trans-
versus abdominis plane (TAP) block group.
operative procedures performed (Table 1). In all pa- However, the decrease in PONV scores in the TAP
tients randomized to receive TAP block, the triangle of block group was modest (Table 3).
Petit was located easily on palpation, the transversus
abdominis neuro-fascial plane was localized after one
to two attempts, and the block performed without DISCUSSION
complication. The benefits of adequate postoperative analgesia
Patients undergoing TAP block had a longer time to are clear, and include a reduction in the postoperative
first request for morphine, and reduced overall mor- stress response (8), reduction in postoperative morbid-
phine requirements (Table 2). TAP block reduced cumu- ity (9), and in certain types of surgery, improved
lative postoperative morphine consumption (control surgical outcome (10). Effective pain control also fa-
versus TAP) at 4 h (29.2 ⫾ 2.5 mg vs 5.8 ⫾ 1.3 mg), 6 h cilitates rehabilitation and accelerates recovery from
(40.4 ⫾ 3.1 mg vs 7.8 ⫾ 1.6 mg) and at 24 h (Table 2). surgery (9,11). Other benefits of effective regional
Postoperative pain scores were reduced at all time points analgesic techniques include reduced pain intensity,
assessed after TAP block, both at rest (Fig. 3) and on decrease incidence of side effects from analgesics, and
movement (Fig. 4). Categorical pain scores were also improved patient comfort (11).
reduced in patients who received the TAP block, in the Direct blockade of the neural afferent supply of the
PACU and at 2, 4, and 6 h postoperatively (Table 2). abdominal wall, such as abdominal field blocks, ilio-
In patients who received the TAP block, postopera- inguinal, and hypogastric nerve blocks, have long
tive sedation scores were reduced at 4 and 6 h been recognized as capable of providing significant
postoperatively, but not at the other time points postoperative analgesia in patients undergoing ab-
assessed (Table 3). The incidence of postoperative dominal surgical procedures such as cesarean delivery
nausea and vomiting (PONV) was substantially re- (3) and inguinal herniorrhaphy (4). However, the lack
duced in patients in the TAP block group (Table 3). of clearly defined anatomic landmarks has meant that
Vol. 104, No. 1, January 2007 © 2007 International Anesthesia Research Society 197