• Nerve blocks of the anterior abdominal wall
  Link:www.nysora.com/techniques/ultrasound-guided-techniques/3253-truncal-and-cutaneous-blocks.html?print
  
• The main nerve supply lies between the internal oblique and the transversus abdominis
• It contains anterior rami of T7 - L1 supplying the skin, peritoneum and muscles
• These pierce the posterior wall of the rectus sheath as cutaneous branches
• The iliohypogastric nerve originates from L1 nerve root and round between IO and TA and later pierces the IO to lie between IO and EO
• The ilioinguinal nerve also arises from L1 and is found inferior to the Iliohypogastric nerve. It runs in a deeper plane than the iliohypogastric nerve
• Rectus sheath block
  Link:www.youtube.com/results?search_query=rectus+sheath+block+ultrasound
  
• Blocks 9/10/11th nerves
• A point 2-3cm from midline slightly cephalad to the umbilicus and a 50mm needle directed posteriorly to feel a pop as the anterior sheath is punctured and advanced furthur until the firm resistance of the posterior wall is felt before LA is injected
• USS can be used for in-plane and out-of-plane views
• LA is injected between the rectus muscle and the posterior rectus sheath
• Complications
• Vessel damage
• Intra peritoneal injection
• Anatomical variations -> failure
• Bowel perforation
• Ilioinguinal and iliohypogastric nerve blocks
  Link:www.youtube.com/results?search_query=ilioinguinal+iliohypogastric+nerve+block+ultrasound
  
• Landmark technique 2cm medial and 2cm cephalad to the ASIS with 5-10 ml of local given with each pop. A fan-wise infiltration can catch some intercostal innervation
• Failure is due to positioning in the wrong fascial layer and may be improved with USS
• For hernias, ask the surgeon to infiltrate the sac as it is supplied by abdominal visceral nerves
• Too deep may block the femoral nerve
• Bowel perforation, failure and intraperitoneal administration are all possible
• TAP block
  Link:www.nysora.com/files/2013/pdf/(v12p28-33)TAPBlock.pdf
  
• Aims to block the nerves of the anterior abdominal wall before they pierce the musculature to innervate the abdomen
• Can be done by landmark or USS guided
• Aims to deliver LA between IO and TA which contains nerves from T7-L1
• Onset is slow - up to 60 mins
• Accessed via the angle of Petit bound by the iliac crest, posteriorly lat dorsi and anteriorly by EO
• Two pops are felt with 50mm needle
• USS can be used between the 12th rib and iliac crest in the MAL to identify the plane
• Good analgesia for up to 48hrs
• Complications
• Failure
• Intra vascular injection
• Bowel perforation
• Liver puncture
• Injection into peritoneal cavity
• Procedure
  Midline laparotomy
  Open appendix
  Open Chole
  Hysterectomy
  Open Inguinal hernia
  Open umbilical hernia
• Cutaneous nerve supply
  T6-12
  T10-11
  T6-9
  L1
  T12-L1
  T9-11
• Block
  Rectus sheath/TAP
  TAP
  TAP
  IL & IH, TAP
  IL & IH, TAP
  Rectus sheath block
• CEACCP
  Link:ceaccp.oxfordjournals.org/content/10/6/182.full.pdf
  
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  Link:www.google.co.uk/#q=rectus%20sheath%20block%20site%3Ayoutube.com
  
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  Link:www.google.co.uk/#q=ilioinguinal%20iliohypogastric%20nerve%20block%20site%3Ayoutube.com
  
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  Link:www.youtube.com/results?search_query=TAP+block+ultrasound