<p begin="00:00:13.744" end="00:00:16.595" style="s2">- The ilioinguinal and<br />iliohypogastric nerve block,</p>
<p begin="00:00:16.595" end="00:00:18.527" style="s2">is used for inguinal hernia repair,</p>
<p begin="00:00:18.527" end="00:00:21.642" style="s2">and lower abdominal surgery.</p>
<p begin="00:00:21.642" end="00:00:23.317" style="s2">This block is a field block,</p>
<p begin="00:00:23.317" end="00:00:26.278" style="s2">where we put the local<br />anesthestic within the plane,</p>
<p begin="00:00:26.278" end="00:00:28.342" style="s2">between the transversis abdominis,</p>
<p begin="00:00:28.342" end="00:00:31.009" style="s2">and the internal oblique muscle.</p>
<p begin="00:00:31.960" end="00:00:34.656" style="s2">In order to find these landmarks,</p>
<p begin="00:00:34.656" end="00:00:37.313" style="s2">we should position the patient properly,</p>
<p begin="00:00:37.313" end="00:00:39.489" style="s2">we have the patient completely supine,</p>
<p begin="00:00:39.489" end="00:00:42.095" style="s2">expose the iliac crest here</p>
<p begin="00:00:42.095" end="00:00:44.845" style="s2">and the costal margin superiorly.</p>
<p begin="00:00:46.396" end="00:00:49.263" style="s2">We use a linear probe for these blocks,</p>
<p begin="00:00:49.263" end="00:00:52.492" style="s2">with a frequency of five to 10,</p>
<p begin="00:00:52.492" end="00:00:54.372" style="s2">and have the frequency set</p>
<p begin="00:00:54.372" end="00:00:57.642" style="s2">in the general or penetration mode.</p>
<p begin="00:00:57.642" end="00:01:00.687" style="s2">Our initial probe placement is gonna be</p>
<p begin="00:01:00.687" end="00:01:03.280" style="s2">just above the iliac crest.</p>
<p begin="00:01:03.280" end="00:01:07.465" style="s2">I usually place the<br />probe in this direction,</p>
<p begin="00:01:07.465" end="00:01:11.632" style="s2">so we can see both the<br />iliac crest caudally there,</p>
<p begin="00:01:12.799" end="00:01:15.173" style="s2">and if I move slightly cranially,</p>
<p begin="00:01:15.173" end="00:01:19.143" style="s2">you can see the three muscles<br />of the abdominal wall.</p>
<p begin="00:01:19.143" end="00:01:22.504" style="s2">Going from superior to inferior,</p>
<p begin="00:01:22.504" end="00:01:24.909" style="s2">the first layer is Adipose Tissue,</p>
<p begin="00:01:24.909" end="00:01:27.841" style="s2">the second layer is External Oblique,</p>
<p begin="00:01:27.841" end="00:01:31.174" style="s2">the third layer is the Internal Oblique.</p>
<p begin="00:01:32.382" end="00:01:35.622" style="s2">Now in some large patients,<br />it's difficult to tell layers,</p>
<p begin="00:01:35.622" end="00:01:40.043" style="s2">because their Adipose<br />Tissue is quite significant.</p>
<p begin="00:01:40.043" end="00:01:43.660" style="s2">So, a good clue is that, the<br />Internal Oblique muscle layer</p>
<p begin="00:01:43.660" end="00:01:46.631" style="s2">is going to be the thickest muscle layer.</p>
<p begin="00:01:46.631" end="00:01:48.593" style="s2">Just as we see here.</p>
<p begin="00:01:48.593" end="00:01:50.898" style="s2">The thin layer and the fourth layer down,</p>
<p begin="00:01:50.898" end="00:01:53.794" style="s2">is a Transversus Abdominus muscle.</p>
<p begin="00:01:53.794" end="00:01:55.461" style="s2">Below that is Bowel.</p>
<p begin="00:01:56.422" end="00:01:57.674" style="s2">So that's very imporant to note,</p>
<p begin="00:01:57.674" end="00:02:00.733" style="s2">that we are getting very close to Bowel,</p>
<p begin="00:02:00.733" end="00:02:03.281" style="s2">and good needle visualization</p>
<p begin="00:02:03.281" end="00:02:05.686" style="s2">is important for doing this block.</p>
<p begin="00:02:05.686" end="00:02:10.343" style="s2">To actually do the block, I<br />do turn my probe 90 degrees,</p>
<p begin="00:02:10.343" end="00:02:13.667" style="s2">keeping those those planes on the picture.</p>
<p begin="00:02:13.667" end="00:02:17.265" style="s2">And I still see the External<br />Oblique, Internal Oblique,</p>
<p begin="00:02:17.265" end="00:02:20.190" style="s2">and Transversus Abdominus deep.</p>
<p begin="00:02:20.190" end="00:02:23.571" style="s2">My needle approach, is gonna<br />be from anterior to posterior,</p>
<p begin="00:02:23.571" end="00:02:25.075" style="s2">in this angle.</p>
<p begin="00:02:25.075" end="00:02:27.719" style="s2">It's important to start<br />several centimeters away</p>
<p begin="00:02:27.719" end="00:02:30.682" style="s2">from the probe for this<br />block, in order to see</p>
<p begin="00:02:30.682" end="00:02:32.352" style="s2">the needle well.</p>
<p begin="00:02:32.352" end="00:02:35.014" style="s2">If you start too close to<br />the probe, such as here,</p>
<p begin="00:02:35.014" end="00:02:37.104" style="s2">you'll have a sharper needle angle,</p>
<p begin="00:02:37.104" end="00:02:40.065" style="s2">and you will not visualize<br />your needle as well.</p>
<p begin="00:02:40.065" end="00:02:42.292" style="s2">Flat needle angles, far<br />away from the probe,</p>
<p begin="00:02:42.292" end="00:02:44.955" style="s2">will allow you to visualize your needle.</p>
<p begin="00:02:44.955" end="00:02:47.756" style="s2">Now I like to advance my<br />needle in a shallow plane,</p>
<p begin="00:02:47.756" end="00:02:52.452" style="s2">to view it first, and then<br />advance it a little bit deeper.</p>
<p begin="00:02:52.452" end="00:02:55.083" style="s2">I'm going to deposit local anesthetic</p>
<p begin="00:02:55.083" end="00:02:57.937" style="s2">between 10 and 20 milliliters,</p>
<p begin="00:02:57.937" end="00:03:01.036" style="s2">between the two deepest muscle layers,</p>
<p begin="00:03:01.036" end="00:03:05.203" style="s2">the Internal Oblique, and<br />the Transversus Abdominus.</p>
<p begin="00:03:08.327" end="00:03:10.930" style="s2">In this image we can<br />see the three layers of</p>
<p begin="00:03:10.930" end="00:03:12.552" style="s2">the abdominal wall.</p>
<p begin="00:03:12.552" end="00:03:15.221" style="s2">The External Oblique, the Internal Oblique</p>
<p begin="00:03:15.221" end="00:03:17.721" style="s2">and the Transversus Abdominus.</p>
<p begin="00:03:18.608" end="00:03:21.405" style="s2">Below the Transversus Abdominus is Bowel,</p>
<p begin="00:03:21.405" end="00:03:23.321" style="s2">and you can see that moving.</p>
<p begin="00:03:23.321" end="00:03:24.894" style="s2">So we wanna be very careful</p>
<p begin="00:03:24.894" end="00:03:28.494" style="s2">not to advance our needle too deep.</p>
<p begin="00:03:28.494" end="00:03:31.289" style="s2">Our goal is to inject<br />between the Internal Oblique</p>
<p begin="00:03:31.289" end="00:03:33.286" style="s2">and the Transversus Abdominus,</p>
<p begin="00:03:33.286" end="00:03:36.553" style="s2">so we will carefully position<br />our needle tip there,</p>
<p begin="00:03:36.553" end="00:03:39.220" style="s2">and inject our local anesthetic.</p>
<p begin="00:03:54.065" end="00:03:56.584" style="s2">For higher surgeries,<br />you may want to perform</p>
<p begin="00:03:56.584" end="00:03:58.834" style="s2">the same block higher.</p>
<p begin="00:03:58.834" end="00:04:00.954" style="s2">Higher up, it's the same block,</p>
<p begin="00:04:00.954" end="00:04:04.774" style="s2">using the same muscle planes,<br />just given a different name.</p>
<p begin="00:04:04.774" end="00:04:08.029" style="s2">Some people call this the<br />Transversus Abdominus Plane Block,</p>
<p begin="00:04:08.029" end="00:04:09.845" style="s2">or TAP Block.</p>
<p begin="00:04:09.845" end="00:04:13.241" style="s2">Here now, we have moved just<br />below the costal margin,</p>
<p begin="00:04:13.241" end="00:04:14.934" style="s2">slightly cranially.</p>
<p begin="00:04:14.934" end="00:04:19.692" style="s2">I will use the same needle<br />position and advance it,</p>
<p begin="00:04:19.692" end="00:04:22.111" style="s2">cranial to caudalal in this direction.</p>
<p begin="00:04:22.111" end="00:04:24.387" style="s2">By moving higher up, we hope to get spread</p>
<p begin="00:04:24.387" end="00:04:28.502" style="s2">a few dermatomes higher,<br />potentially up to T7</p>
<p begin="00:04:28.502" end="00:04:30.489" style="s2">with larger volumes.</p>
<p begin="00:04:30.489" end="00:04:32.961" style="s2">The volumes I usually inject here are</p>
<p begin="00:04:32.961" end="00:04:36.483" style="s2">10 to 20 milliliters on one side.</p>
<p begin="00:04:36.483" end="00:04:39.948" style="s2">For bilateral blocks,<br />for midline surgeries,</p>
<p begin="00:04:39.948" end="00:04:43.284" style="s2">I'll stay on the same side,<br />and just move my hands</p>
<p begin="00:04:43.284" end="00:04:45.201" style="s2">over in this direction.</p>
<p begin="00:04:47.080" end="00:04:49.641" style="s2">So I don't need to switch the<br />machine to the other side.</p>
<p begin="00:04:49.641" end="00:04:52.169" style="s2">I'll just lean over the patient,</p>
<p begin="00:04:52.169" end="00:04:55.364" style="s2">get the same three muscle<br />layers, and advance the needle</p>
<p begin="00:04:55.364" end="00:04:57.537" style="s2">like this, in the middle of the probe,</p>
<p begin="00:04:57.537" end="00:04:59.287" style="s2">just like previously.</p>

<p begin="00:00:07.549" end="00:00:09.196" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.196" end="00:00:11.475" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.475" end="00:00:13.828" style="s2">an ultrasound guided ilioinguinal</p>
<p begin="00:00:13.828" end="00:00:16.351" style="s2">and iliohypogastric nerve block.</p>
<p begin="00:00:16.351" end="00:00:19.067" style="s2">The target depth is<br />approximately three centimeters</p>
<p begin="00:00:19.067" end="00:00:21.384" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:21.384" end="00:00:24.528" style="s2">The patient is positioned<br />in a supine position.</p>
<p begin="00:00:24.528" end="00:00:27.639" style="s2">The transducer is placed<br />over the bony prominence</p>
<p begin="00:00:27.639" end="00:00:30.408" style="s2">of the anterior superior iliac spine</p>
<p begin="00:00:30.408" end="00:00:33.991" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:33.991" end="00:00:37.495" style="s2">The transducer is rotated<br />slightly counterclockwise</p>
<p begin="00:00:37.495" end="00:00:41.199" style="s2">so one side rests on the<br />anterior superior iliac spine</p>
<p begin="00:00:41.199" end="00:00:43.968" style="s2">and the other side<br />points at the umbilicus.</p>
<p begin="00:00:43.968" end="00:00:47.696" style="s2">The medial side of the transducer<br />is slowly swept superiorly</p>
<p begin="00:00:47.696" end="00:00:51.231" style="s2">and inferiorly while<br />maintaining the bony iliac crest</p>
<p begin="00:00:51.231" end="00:00:53.956" style="s2">in the lateral part of<br />the ultrasound image.</p>
<p begin="00:00:53.956" end="00:00:56.495" style="s2">The structures of the<br />anterior abdominal wall</p>
<p begin="00:00:56.495" end="00:00:59.425" style="s2">should be identified<br />from superficial to deep,</p>
<p begin="00:00:59.425" end="00:01:03.104" style="s2">including adipose tissue,<br />external oblique muscle,</p>
<p begin="00:01:03.104" end="00:01:04.727" style="s2">internal oblique muscle,</p>
<p begin="00:01:04.727" end="00:01:07.759" style="s2">and the transversus abdominis muscle.</p>
<p begin="00:01:07.759" end="00:01:10.688" style="s2">A fourth muscle, the<br />iliacus, may occasionally</p>
<p begin="00:01:10.688" end="00:01:14.527" style="s2">be visualized underneath<br />the transversus abdominis.</p>
<p begin="00:01:14.527" end="00:01:17.271" style="s2">The nerves are located<br />between the internal oblique</p>
<p begin="00:01:17.271" end="00:01:20.056" style="s2">and the transversus<br />abdominis muscle layers.</p>
<p begin="00:01:20.056" end="00:01:22.816" style="s2">They may appear only as<br />hyperechoic thickness</p>
<p begin="00:01:22.816" end="00:01:25.738" style="s2">between these two muscles<br />or as dark hypoechoic</p>
<p begin="00:01:25.738" end="00:01:29.166" style="s2">oval structures with the<br />bright hyperechoic covering.</p>
<p begin="00:01:29.166" end="00:01:32.752" style="s2">The nerves are very closely<br />related to the iliac crest.</p>
<p begin="00:01:32.752" end="00:01:35.150" style="s2">The needle is advanced using an in-plane</p>
<p begin="00:01:35.150" end="00:01:37.031" style="s2">or out-of-plane technique.</p>
<p begin="00:01:37.031" end="00:01:39.007" style="s2">If using an in-plane technique,</p>
<p begin="00:01:39.007" end="00:01:41.607" style="s2">the needle is positioned<br />one to two centimeters</p>
<p begin="00:01:41.607" end="00:01:45.855" style="s2">medial to the transducer and<br />advanced under the transducer.</p>
<p begin="00:01:45.855" end="00:01:47.343" style="s2">The end point for the needle is</p>
<p begin="00:01:47.343" end="00:01:50.999" style="s2">between internal oblique<br />and transversus abdominis.</p>
<p begin="00:01:50.999" end="00:01:53.689" style="s2">The local anesthetic is<br />injected incrementally</p>
<p begin="00:01:53.689" end="00:01:55.439" style="s2">close to the nerves.</p>