Hernia

- The Sciatic Nerve Block can be used for surgery of the
leg, knee, foot and ankle.
To do the Sciatic Nerve Block,
you can block it at the Popliteal region
or you can block it higher.
Some benefits of blocking it higher
are to be above the tourniquet,
so you don't have to worry so much about nerve ischemia.
You may also get the Posterior Femoral Cutaneous nerve
of the thigh, which comes off very high on the Sciatic nerve
and it's also medial to the Sciatic nerve, as well high up.
This way, you can cover any kind of pain of incision
in the upper thigh area.
To position patients for Subgluteal Sciatic Nerve Block,
we position the patient lateral.
This way, the patient is comfortable,
they can be well-sedated and you can place a probe
on the posterior side of the leg and advance the needle
from lateral to medial.
The probe we use for a Sciatic Nerve Block
is a curvilinear low-frequency probe.
The reason we use this probe is because
it penetrates deeper and this is useful in larger patients.
So some of the landmarks we use
for the Subgluteal Sciatic Nerve Block
are the Greater Trochanter laterally,
the Ischial Tuberosity medially, and
directly in between these two is where we place the probe
The initial view we see is the Greater Trochanter
on the left side of the screen.
On the right side of the screen,
we see the Ischial Tuberosity.
There is a large muscle, the Gluteus Maximus
at the superficial level of the screen.
Underneath the Gluteus Maximus is a hyperechoic nerve,
the Sciatic Nerve.
Between the two bony landmarks is the Quadratus Femoris.
So on this level, the nerve is sandwiched between
the Gluteus Maximus and the Quadratus Femoris.
The nerve here can appear wide, flat or triangular.
It is not a circular structure like some people imagine.
Needle approaches for the Sciatic Nerve Block,
whether is be here, at the Mid-Femoral region,
or higher up at the Subgluteal region,
are performed from a lateral-to-medial approach.
The lateral-to-medial approach usually starts
three to four centimeters away from the probe in this angle.
Now, higher up we'll use the same needle approach.
We can see the triangular Sciatic Nerve here,
and we'll start the needle angle about here.
Now you typically put my nerve
on the distal side of the screen from where my needle
is entering, in order to see the needle better
and travelling across the screen to the nerve.
Typical volumes are 20 to 30 milliliters
of local anesthetic.
Because this nerve is so deep in some people,
some anesthesiologists like to approach this nerve
from an Out-of-Plane needle angle.
And Out-of-Plane needle angle would be in this direction
into the Sciatic Nerve.
Other people like to turn this probe in a longitudinal
direction and see the nerve in long axis.
So here we are turning the probe in the long axis
and following that nerve in the longitudinal pattern here.
So now we see the Sciatic Nerve going down the leg.
The needle approach in this orientation would be in
this angle in plane of the ultrasound beam
down to the Sciatic nerve.
- (Dr. Auyong) Here you can see the Greater Trochanter
on the left side of the screen, the Ischial Tuberosity
on the right side of the screen, the Gluteus Maximus
superficial and a 21 gauge needle
advancing to the Sciatic Nerve.
The Sciatic Nerve is below the Gluteus Maximus
and above the Quadratus Femoris.
Our needle is advancing above the Sciatic Nerve
to attempt to get local anesthetic to spread
to the medial side of the nerve.
Which would be more likely to get the larger
Tibial component, as well as the posterior femoral
cutaneous nerve of the thigh.
Now you can see the nerve, which very hyperechoic,
below the local anesthetic.

Brightcove ID

5508120191001

https://youtube.com/watch?v=IL4qqETpb0k

Body

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

How To Perform A TAP Block With Ultrasound

Read more about How To Perform A TAP Block With Ultrasound

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

Clinical Specialties

Anesthesiology (Regional)

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How To Videos

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- 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.

Tap Muscles with Linear Transducer

Read more about Tap Muscles with Linear Transducer

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Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Media Library Tag

Transadominis Procedure

Transversus Abdominis Muscles

Umbilicus

X-Porte

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: Gluteal Sciatic Nerve Block

Read more about 3D How To: Gluteal Sciatic Nerve Block

/sites/default/files/GlutealSciatic_edu00500_thumbnail.jpg

3D animation demonstrating an ultrasound guided Gluteal Sciatic nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A curved array transducer
with a nerve exam type is used to perform
a ultrasound guided sciatic nerve block.
The target depth is approximately four to six centimeters
in an 80 kilogram adult.
The patient is positioned in a lateral decubitus position
with the hip and knee flexed.
The transducer is placed between the greater trochanter
and the ischial tuberosity in a transverse position
just proximal to the gluteal fold
with the orientation marker directed laterally.
The bony landmarks will appear
as bright hyperechoic crescents with posterior shadowing.
There are several layers of tissue
between the bony landmarks, which should be identified
from superficial to deep, including adipose tissue,
the gluteus maximus muscle and quadratus femoris muscle.
The sciatic nerve lies deep to the gluteus maximus
and superficial to the quadratus femoris muscle.
It appears as a bright hyperechoic oval
or triangular shaped density.
The transducer should be moved slightly cranially
or caudally from the initial position
by slightly rocking the transducer
so the beam is perpendicular to the nerve
for the best echo reflection if it is difficult to identify.
When the transducer is moved distally in the thigh,
the sciatic nerve becomes more oval in shape
and is found more superficially between the biceps femoris
and abductor magnus muscles.
The needle is advanced using an in plane technique.
The needle is positioned one to two centimeters lateral
to the transducer and advanced slowly under the transducer.
The initial end point for the needle
is just lateral and deep to the nerve.
The local anesthetic is injected incrementally
close to the nerve.
For a successful block, a spread of locals
should be observed around the medial side
or tibial component of the nerve.

Brightcove ID

5508134308001

https://youtube.com/watch?v=xvAY_bu_S7A

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S Series: Sciatic Nerve Gluteal Level

S Series: Sciatic Nerve Gluteal Level

How to: Subgluteal Sciatic Nerve Block

How to: Subgluteal Sciatic Nerve Block

How To Perform A TAP Block With Ultrasound

How To Perform A TAP Block With Ultrasound

Tap Muscles with Linear Transducer

Tap Muscles with Linear Transducer

3D How To: Ultrasound Guided TAP Block

3D How To: Ultrasound Guided TAP Block

3D How To: Gluteal Sciatic Nerve Block

3D How To: Gluteal Sciatic Nerve Block

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