The patient is placed in the lateral position with the side to be anaesthetized turned upwards.

A curved array transducer (6-2 MHz) is placed in the transverse plane at the abdominal flank immediately cranial to the iliac crest.

Surgical anaesthesia for hip surgery in combination with a sacral plexus block as an alternative to general or spinal anaesthesia

Postoperative analgesia after major hip surgery

Combined analgesia of the femoral, obturator and lateral femoral cutaneous nerves

The transversalis fascia (TF) covers the deep surface of the transverse abdominis muscle (TAM), the quadratus lumborum muscle QLM) and the psoas major muscle (PMM). Anteriorly it covers the deep surface of the rectus abdominis muscle. It is covered by the peritoneum.

The layers of the abdominal wall from the outside are: external oblique muscle (EOM), internal oblique muscle (IOM) and TAM.

The latissimus dorsi muscle (LDM) and the erector spinae muscle (ESM) are superficial to the QL muscle.

The pleura is visible as a hyperechoic line with “pleura sliding” in synchrony with respiration. This is different from the rib that has an anechoic acoustic shadow and no lung sliding.

The needle is advanced with real-time in-plane technique and aims at the triangular thoracic paravertebral space underneath the internal intercostal membrane and the needle tip should be placed right next to the anechoic acoustic shadow of the transverse process. A “pop” is often felt when the needle tip penetrates the internal intercostal membrane.

After assuring negative aspiration for blood 15-20 mL of local anaesthetic is injected. The TPS is seen to expand and push the pleura downwards. The local anaesthetic should be injected into the anterior part of the TPS anterior to the endothoracic fascia. This assures that the local anaesthetic spreads longitudinally inside the TPS and that sympathectomy is produced.

Analgesia of abdominal visceral and somatic pain.

The subcostal nerve (T12), ilioinguinal nerve (L1) and iliohypogastric nerve (L1) run across the anterior side of the quadratus lumborum (QL) muscle between the QL muscle and the transversalis fascia (TF).

The subcostal, ilioinguinal and iliohypogastric nerves are sandwiched between the QL muscle and the psoas major muscle (PMM).

– informed consent

– monitoring

– intravenous access (and maybe sedation)

– sitting position, relaxed and slumped

– demarcate landmarks

– infiltrate with local anaesthetics

The thoracic paravertebral space is located where the intercostal muscles meet the transverse processes.

Technique 1:
– inject 15-20 mL of local anaesthetic at the midpoint of the desired level
– expect blockade of 4-5 dermatomes

Technique 2:
– extend blockade by 4-5 injections of 4-5 mL

Levels:
– simple mastectomy T3-T4
– open cholecystectomy T6-T7