Subcostal TAP
Clinical Indications: upper abdominal surgeries (ie: cholecystectomies, PEG placement) where incision is above umbilicus up to costal margin of the ribs, chronic abdominal wall pain
Special Considerations: Subcostal TAPs Block allows for specific coverage of the upper abdominal wall. Target plane is superficial and typically is easy to access. It is important to look at the specific coverage that you will need to cover with incision and chose the appropriate truncal block.
Patient position: Supine
Dose: Please see Local Anesthetic dosing page for ASRA/ESRA suggested dosing guidelines
Technique: Probe – Linear ; Needle – in plane
Ultrasound probe placed parallel to costal margin of ribs, rectus muscle and transverse abdominis muscle identified. Skin prepared with antiseptic solution and lidocaine for skin numbing. Block needle advanced with in plane technique to fascial plane under rectus muscle. Aspiration and subsequent injection of local anesthetic with view of medication spreading between rectus abdominis and transverse abdominis muscle.
Coverage: T6-9 Anterior cutaneous branches of segmental thoracolumbar nerves
Potential Complications:
· Bleeding/infection at site of injection
· Damage to local nerves and tissues
· Intrabdominal injection
· Intravascular injection
Clinical Pearls:
· Shown to improve respiratory function after laparoscopic cholecystectomy and superior to posterior TAPs block for supraumbilical incisions
Patient Positioning & Dermatomal Coverage
Ultrasound Images
TAM: Transverse Abdominus Muscle
Subcostal TAP is a relatively newer block that is starting to be used in the pediatric population. First described by Hebbard et al (2) as having the potential to provide coverage for upper abdominal surgeries. Review of the subcostal TAP block by Soliz et al (5) reveals that in the adult population it is being proven to be a useful adjuvant in the multimodal approach to analgesia with upper abdominal cases or in conjunction with lateral TAP block. In practice, the block is fairly superficial making it easily visible, and can be done quickly in a supine patient. Subcostal TAP blocks are starting to be used in the pediatric population. A case report of 10 cases (6 of which had subcostal TAP performed) showed that neonates and infants provided improved analgesia in laparotomy cases with potential reduction in opioid use (1). In these cases, the goal fascial plane was identified with a SLA 25mm broadband linear ultrasound probe. The subcostal TAP was performed with 2-inch 19-gauge needle using 1 mL/kg of 0.25% levobupivacaine (or 0.5 mL/kg for bilateral TAP). The surgical procedures included from laparotomy for duodenal atresia, closure of gastroschisis, laparotomy for volvulus, cholangiogram, laparotomy for malrotation, and reversal of ileostomy. Data was collected intraoperatively looking at hemodynamic response to incision and opioid requirements, and postoperatively looking at Neonatal Infant Pain Scale (NIPS) and total analgesic requirements.
This fascial plane block may not be limited to acute pain. One case report, by Simpson et al, showed the effectiveness of the subcostal TAP block in treating anterior cutaneous nerve entrapment syndrome. This was a case of young patient who had chronic debilitating abdominal wall pain that was reduced to more reasonable levels with repeated subcostal taps blocks (4). This case followed a 13 year old female who had previously had laparotomy with Pfanensteil incision for an ovarian teratoma with subsequent diagnostic laparoscopies x2. She was initially treated with antineuropathic and analgesic medications. She was referred to a chronic pain service which diagnosed her with anterior cutaneous nerve entrapment syndrome (ACNES) based on exam. A multimodal pain treatment plan was enacted which again failed to improve her pain. The patient then underwent bilateral subcostal TAP blocks under general anesthesia using linear 13-6 MHz transducer, 22-gauge short bevel needle, and 20 mL 0.25% bupivacaine with 1:400,000 epinephrine on each side. After this approach, her pain scores were reduced from mean 8/10 to mean 4/10 for 1 week and her activity levels improved to near normal. This block was repeated in 6 weeks in a similar fashion with the addition of 20mg triamcinolone on each side. This provided reduction in pain and improvement in activity for about 1 month. Although with the second block the patient did note increased pain in the first 48 hours.
There is not a tremendous amount of literature on the utility of subcostal TAP blocks in the pediatric population. It has been proven to be effective in the adult population (2,5) and therefore more research may shed light on its effectiveness. Overall accurate planning with the surgical team on precise incision location and knowledge of the dermatomes with the subsequent blocks that can cover those areas gives the best chance of success for benefit from regional placement.
Jacobs A, Bergmans E, Arul GS et al. The transversus abdominis plane (TAP) block in neonates and infants – results of an audit. Pediatr Anesth 2011; 21: 1078– 1080.
Hebbard PD, Barrington MJ, Vasey C. Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique. Reg Anesth Pain Med. 2010 Sep-Oct;35(5):436-41
Nidhi Bhatia, Suman Arora, Wig Jyotsna, and Gurpreet Kaur. Comparison of posterior and subcostal approaches to ultrasound-guided transverse abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy, Journal of Clinical Anesthesia, Volume 26, Issue 4, 2014, Pages 294-299, ISSN 0952-8180
Simpson DM, Tyrrell J, De Ruiter J, Campbell FA. Use of ultrasound-guided subcostal transversus abdominis plane blocks in a pediatric patient with chronic abdominal wall pain. Paediatr Anaesth. 2011 Jan;21(1):88-90.
Soliz JM, Lipski I, Hancher-Hodges S, Speer BB, Popat K. Subcostal Transverse Abdominis Plane Block for Acute Pain Management: A Review. Anesth Pain Med. 2017;7(5):e12923. Published 2017 Oct 20.
Tsai HC, Yoshida T, Chuang TY, et al. Transversus Abdominis Plane Block: An Updated Review of Anatomy and Techniques. Biomed Res Int. 2017;2017:8284363.
