Fascia Lata

- The ilioinguinal and iliohypogastric nerve block,
is used for inguinal hernia repair,
and lower abdominal surgery.
This block is a field block,
where we put the local anesthestic within the plane,
between the transversis abdominis,
and the internal oblique muscle.
In order to find these landmarks,
we should position the patient properly,
we have the patient completely supine,
expose the iliac crest here
and the costal margin superiorly.
We use a linear probe for these blocks,
with a frequency of five to 10,
and have the frequency set
in the general or penetration mode.
Our initial probe placement is gonna be
just above the iliac crest.
I usually place the probe in this direction,
so we can see both the iliac crest caudally there,
and if I move slightly cranially,
you can see the three muscles of the abdominal wall.
Going from superior to inferior,
the first layer is Adipose Tissue,
the second layer is External Oblique,
the third layer is the Internal Oblique.
Now in some large patients, it's difficult to tell layers,
because their Adipose Tissue is quite significant.
So, a good clue is that, the Internal Oblique muscle layer
is going to be the thickest muscle layer.
Just as we see here.
The thin layer and the fourth layer down,
is a Transversus Abdominus muscle.
Below that is Bowel.
So that's very imporant to note,
that we are getting very close to Bowel,
and good needle visualization
is important for doing this block.
To actually do the block, I do turn my probe 90 degrees,
keeping those those planes on the picture.
And I still see the External Oblique, Internal Oblique,
and Transversus Abdominus deep.
My needle approach, is gonna be from anterior to posterior,
in this angle.
It's important to start several centimeters away
from the probe for this block, in order to see
the needle well.
If you start too close to the probe, such as here,
you'll have a sharper needle angle,
and you will not visualize your needle as well.
Flat needle angles, far away from the probe,
will allow you to visualize your needle.
Now I like to advance my needle in a shallow plane,
to view it first, and then advance it a little bit deeper.
I'm going to deposit local anesthetic
between 10 and 20 milliliters,
between the two deepest muscle layers,
the Internal Oblique, and the Transversus Abdominus.
In this image we can see the three layers of
the abdominal wall.
The External Oblique, the Internal Oblique
and the Transversus Abdominus.
Below the Transversus Abdominus is Bowel,
and you can see that moving.
So we wanna be very careful
not to advance our needle too deep.
Our goal is to inject between the Internal Oblique
and the Transversus Abdominus,
so we will carefully position our needle tip there,
and inject our local anesthetic.
For higher surgeries, you may want to perform
the same block higher.
Higher up, it's the same block,
using the same muscle planes, just given a different name.
Some people call this the Transversus Abdominus Plane Block,
or TAP Block.
Here now, we have moved just below the costal margin,
slightly cranially.
I will use the same needle position and advance it,
cranial to caudalal in this direction.
By moving higher up, we hope to get spread
a few dermatomes higher, potentially up to T7
with larger volumes.
The volumes I usually inject here are
10 to 20 milliliters on one side.
For bilateral blocks, for midline surgeries,
I'll stay on the same side, and just move my hands
over in this direction.
So I don't need to switch the machine to the other side.
I'll just lean over the patient,
get the same three muscle layers, and advance the needle
like this, in the middle of the probe,
just like previously.

Brightcove ID

5508104674001

https://youtube.com/watch?v=6E3ynIn6Ud4

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided TAP block.

How to: Femoral Nerve Block

Read more about How to: Femoral Nerve Block

/sites/default/files/ST_Femoral_Nerve_EDU00167.jpg

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

The femoral nerve block is used
for many different surgeries.
The femoral nerve block can be used for knee surgery,
hip surgery, femur surgery,
or even medial ankle surgery to get the saphenous nerve.
To perform the femoral nerve block,
there's a few key positioning tips.
We want to put the patient completely supine.
Many of our patients are larger and have larger abdomens,
so putting the patient supine allows us to get
high enough in the femoral region.
Also, if their adipose tissue hangs over the femoral region,
we want to put tape here and tape their abdomen away
out of the way, so you can put your probe
comfortably in the femoral region.
To do an ultrasound guided femoral nerve block,
we use a linear high frequency probe.
To start the femoral nerve block,
we usually put the probe right in the femoral crease.
On our screen now, we see several important features.
From medial to lateral, we see the Iliacus muscle,
we see the nerve sitting right on the Iliacus muscle,
and we also see the femoral artery,
and then to the right we see the femoral vein.
There are a few fascia coverings in this area
that are important.
The Facia Iliaca runs above the femoral nerve
and below the artery.
The Fascia Lata runs above all of this,
above the artery and vein as well.
Now for the femoral nerve, we want to see a hyperechoic
or bright nerve sitting on the Iliacus muscle.
The true femoral nerve is a wide, flat nerve
laying directly on the muscle.
If you inject above the Facia Iliaca,
this will create a barrier to your nerve
and allow a block that is not complete.
So as we move up and down the leg,
we're gonna see some key that will help you find
the femoral nerve in all patients.
More medially, you see the pulsating femoral artery,
and medial to that you see the femoral vein.
Here the vein collapses with pressure.
Now some keys to find the femoral nerve
in every patient are as follows.
If the probe is placed too cranially,
your femoral artery and vein and nerve
drop deep on the screen.
The femoral vein, artery, and nerve
are too deep, then you need to move the probe caudally.
If you probe is placed too distally,
that femoral artery is going to split
into two femoral arteries.
Here you can see a pulsating Profunda femoral deep
as well as a true femoral artery superficial.
Now I'm gonna put some color flow on that,
and you can see a pulsating artery deeper,
and a superficial femoral artery as well.
Now the vein is on the left,
represented in red in this picture.
As we move cranially, those two arteries come together.
When we look laterally from there,
the nerve has also come together from
many branches, forming one femoral nerve.
This way we can see the femoral nerve the best
when the artery also comes together as well.
Now our needle approach to the femoral nerve
is going to be from lateral to medial.
Typically, we use a 10-centimeter needle
because we use these in-plane approaches
to the femoral nerve.
I like to put my target on the further side of the screen
so I can see my needle coming in from the lateral side.
So I'll put my first injection lateral to the nerve
just above the Iliacus muscle
to ensure injection below the Fascia Iliaca
but not within the Iliacus muscle.
By using typical volume, such as 20 to 30 milliliters,
we'll get spread above the nerve
or below the nerve, without poking into
the nerve, and damaging the nerve.
In this femoral nerve block, you can see a single
injection needle being advanced lateral to the nerve
which is lying right on the Iliacus muscle.
You can see the pulsating femoral artery medially,
and the local anesthetic now spreading over
the wide, flat femoral nerve.
Our needle tracks in with the local anesthetic
so we can get local anesthetic spreading
all the way medial around the femoral nerve here.

Brightcove ID

5765925239001

https://youtube.com/watch?v=Z-O_EaAE_rg

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

3D How To: Ultrasound Guided TAP Block

Read more about 3D How To: Ultrasound Guided TAP Block

/sites/default/files/Ilioinquinal_Iliohypogastric_edu00498_thumnail.jpg

3D animation demonstrating an ultrasound guided Ilioinguinal and Iliohypogastric nerve blocks.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound guided ilioinguinal
and iliohypogastric nerve block.
The target depth is approximately three centimeters
in an 80 kilogram adult.
The patient is positioned in a supine position.
The transducer is placed over the bony prominence
of the anterior superior iliac spine
with the orientation marker directed to the patient's right.
The transducer is rotated slightly counterclockwise
so one side rests on the anterior superior iliac spine
and the other side points at the umbilicus.
The medial side of the transducer is slowly swept superiorly
and inferiorly while maintaining the bony iliac crest
in the lateral part of the ultrasound image.
The structures of the anterior abdominal wall
should be identified from superficial to deep,
including adipose tissue, external oblique muscle,
internal oblique muscle,
and the transversus abdominis muscle.
A fourth muscle, the iliacus, may occasionally
be visualized underneath the transversus abdominis.
The nerves are located between the internal oblique
and the transversus abdominis muscle layers.
They may appear only as hyperechoic thickness
between these two muscles or as dark hypoechoic
oval structures with the bright hyperechoic covering.
The nerves are very closely related to the iliac crest.
The needle is advanced using an in-plane
or out-of-plane technique.
If using an in-plane technique,
the needle is positioned one to two centimeters
medial to the transducer and advanced under the transducer.
The end point for the needle is
between internal oblique and transversus abdominis.
The local anesthetic is injected incrementally
close to the nerves.

Brightcove ID

5508136009001

https://youtube.com/watch?v=uurxBFRT_EE

3D How To: Femoral Nerve Block

Read more about 3D How To: Femoral Nerve Block

/sites/default/files/Femoral_edu00499_thumbnail.jpg

3D animation demonstrating an ultrasound guided femoral nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided femoral nerve block.
The target depth is approximately one to three centimeters
in an 80 kilogram adult.
The patient is placed in a supine position.
The transducer is placed just superior
to the inguinal skin crease
with the orientation marker directed to the patient's right.
The common femoral artery is seen
as a round, pulsatile structure.
The transducer should be moved laterally
one to two centimeters to identify the femoral nerve.
The nerve lies deep to the fascia iliaca
and appears as an oblong, bright hyperechoic structure
lying on the iliacus muscle.
It may contain dark hyperechoic circles
that represent the nerve fascicles.
The nerve always lies deep to the fascia iliaca
and should not be confused
with the bright hyperechoic tissue lying above the fascia,
which is lymphatic tissue.
The needle is advanced using an in-plane technique.
The needle is positioned one to two centimeters lateral
to the transducer and advanced under the transducer.
The initial end point for the needle
is just lateral to the nerve and deep to the fascia iliaca.
The local anesthetic is injected incrementally,
close to the nerve.
For a successful block, a spread of local
should be observed behind the femoral artery.
If local anesthetic is identified anterior to the artery,
then the needle is superficial to the fascia iliaca
and the needle needs to be repositioned deeper.

Brightcove ID

5508117977001

https://youtube.com/watch?v=pCkjioc-EmQ

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