Acta Anaesthesiol Scand 2010; 54: 529–535
Printed in Singapore. All rights reserved
The transversus abdominis plane block: a valuable option
for postoperative analgesia? A topical review
P. L. PETERSEN1, O. MATHIESEN2, H. TORUP3 and J. B. DAHL4
1
Department of Anaesthesia, Copenhagen University Hospital, Glostrup, Denmark, 2Section of Acute Pain Management and Palliative
Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 3Department of Anaesthesia, Copenhagen University
Hospital, Herlev, Denmark and 4Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet,
Copenhagen, Denmark
The transversus abdominis plane (TAP) block is a newly de-
scribed peripheral block involving the nerves of the anterior
abdominal wall. The block has been developed for post-operative
pain control after gynaecologic and abdominal surgery. The
initial technique described the lumbar triangle of Petit as the
landmark used to access the TAP in order to facilitate the
deposition of local anaesthetic solution in the neurovascular
plane. Other techniques include ultrasound-guided access to
the neurovascular plane via the mid-axillary line between the
iliac crest and the costal margin, and a subcostal access termed
the ‘oblique subcostal’ access. A systematic search of the litera-
ture identified a total of seven randomized clinical trials inves-
tigating the effect of TAP block on post-operative pain, including
a total of 364 patients, of whom 180 received TAP blockade. The
surgical procedures included large bowel resection with a mid-
T HE use of peripheral nerve blocks has become
increasingly popular in the last two decades.
With the use of anatomical landmark-based techni-
ques, peripheral nerve stimulators or ultrasound-
guided techniques, novel types of nerve blocks have
been made possible with both new indications as well
as a lower risk of complications for the patient.1,2
The transversus abdominis plane (TAP) block
is a newly developed block involving the nerves
of the anterior abdominal wall.2–4 Initial studies
describe a blockade of these nerves accessed in the
neurofascial plane between the internal oblique
and the transversus abdominis muscles through a
well-defined entrance at the triangle of Petit.3,4
Recent published clinical trials involving patients
undergoing both major abdominal4 as well as
gynaecological surgery5,6 have demonstrated pro-
mising results with this technique as part of a
multimodal post-operative pain treatment.
This review presents a brief summary of the
methods used for the TAP block. Clinical studies
r 2010 The Authors
Journal compilation r 2010 The Acta Anaesthesiologica Scandinavica Foundation
ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/j.1399-6576.2010.02215.x
Review Article
line abdominal incision, caesarean delivery via the Pfannenstiel
incision, abdominal hysterectomy via a transverse lower abdom-
inal wall incision, open appendectomy and laparoscopic chole-
cystectomy. Overall, the results are encouraging and most studies
have demonstrated clinically significant reductions of post-op-
erative opioid requirements and pain, as well as some effects on
opioid-related side effects (sedation and post-operative nausea
and vomiting). Further studies are warranted to support the
findings of the primary published trials and to establish general
recommendations for the use of a TAP block.
Accepted for publication 6 January 2010
r 2010 The Authors
Journal compilation r 2010 The Acta Anaesthesiologica Scandinavica Foundation
of the effect of the TAP block on post-operative
pain were systematically searched and reviewed.
Suggestions for future assessment and use of the
TAP block are discussed.
Techniques for TAP block
The TAP block was first described in 2001 in a letter
by Dr Rafi,3 and was further developed and tested
by McDonnell et al.4,6–8 In this block, the lumbar
triangle of Petit is used as a landmark for injecting
local anaesthetic into the neurovascular plane of
the abdominal wall, located between the internal
oblique and the transversus abdominis muscles.
Nerves supplying the anterior abdominal wall are
derived from T6 to L1 and pass through this plane
before supplying the anterior abdominal wall.8,9 In
addition, anatomical dissections have demon-
strated that in this plane, the T6–L1 communicate
closely and branch widely with neighbouring seg-
mental nerves.9
529
P. L. Petersen et al.
Fig. 1. Anatomical landmarks defining the lumbar triangle of
Petit, an access point used for performing the transversus abdo-
minis plane block with the blind technique. With insertion of a
blunt needle a double ‘pop’ sensation indicates penetration of the
fascia of the external and internal oblique muscles before entering
the transversus abdominis fascial plane.
The triangle of Petit is located with the iliac crest
forming the base, the external oblique muscle as
the anterior border and the latissimus dorsi muscle
as the posterior border of the triangle. The floor
of the triangle is made up of fascial extensions
of both the external and the internal oblique
muscles (Fig. 1). In the triangle of Petit, a blunt
regional anaesthesia needle is inserted perpen-
dicular to the skin just cephalad to the iliac crest
and behind the mid-axillary line, and the transver-
sus abdominis fascial plane is localized with a
two-‘pop’ sensation (or loss of resistance) modus.
The first ‘pop’ indicates penetration of the fascia
of the external oblique muscle and the second
‘pop’ indicates penetration of the internal oblique
muscle and thereby entering the transversus abdo-
minis fascial plane.4 In this neurovascular plane,
a local anaesthetic solution can be injected, thus
blocking the sensory nerves before innervating the
different muscles of the anterior abdominal wall. In
volunteers, injection of 20 ml of lidocaine 5 mg/ml
produced a sensory block extending from T7 to
L1.8 The TAP block may be performed unilater-
ally but sufficient analgesia after a midline abdom-
inal surgery requires a bilaterally performed
TAP blockade.
This ‘blind’ TAP block technique is described as
easy to perform and with few complications.3–6,10
However, the triangle of Petit may be difficult to
palpate in obese patients3,7 and one case of acci-
dental liver trauma has been described in a patient
530
Fig. 2. Cross-section of the abdominal wall demonstrating the
location of the transversus abdominis fascial plane. EO, external
oblique muscle; IO, internal oblique muscle; TA, transversus
abdominis muscle.
scheduled for a total abdominal hysterectomy. This
patient had an enlarged liver and was of a small
stature, and the importance of palpating the edge
of the lever before performing the TAP block was
pointed out.11
Ultrasound-guided access to the neurovascular
plane was initially presented in a letter by Heb-
bard.12 The ultrasound probe is positioned on the
abdominal wall in the mid-axillary line between
the iliac crest and the costal margin, and carefully
moved postero-laterally for optimal identification
of the transversus abdominis fascial plane (Fig. 2).
A needle is inserted anterior and inline with the
probe and followed visually until correct position-
ing of the local anaesthetic. Recently, a subcostal
access termed ‘oblique subcostal’ has also been
described by the same author,13 in which the probe
is positioned directly parallel to the costal margin
and the needle is introduced near the xiphoid
process. It is suggested that this access may be
used for optimizing analgesia of the supraumbilical
abdominal area.
A variant ultrasound-guided access to the TAP
block has also been described for children using a
hockey stick probe initially placed just lateral to the
umbilicus. When sliding laterally, the muscle layers
of the abdominal wall can be identified and local
anaesthesia can be deposited close to the origin of
the thoracolumbar roots.14

Clinical studies with a TAP block on
post-operative pain
Literature search and quality assessment
Randomized, blinded, controlled trials of TAP block
for acute post-operative pain relief were systemati-
cally sought using the PubMed (http://www.ncbi.
nlm.nih.gov/pubmed/) database without language
restriction. Free text combinations of the following
search terms: ‘transversus abdominis plane block’,
‘post-operative pain’ and ‘post-operative analgesia’
were used. The last search was performed on De-
cember 2009. Reference lists of retrieved manuscripts
were searched for additional papers.
Study quality (randomization/allocation con-
cealment; details of the blinding process; and
description of withdrawal and dropouts) was eval-
uated using the three-item (1–5) Oxford Quality
Scale.15 Study validity was evaluated using the
five-item (1–16) Oxford Pain Validity Scale.16 Each
identified study was read and scored by two of the
authors (P. L. P. and O. M.). In case of disagreement
between the authors, a consensus was reached by
involving a third author (J. B. D.).
Clinical studies
A total of seven randomized, double-blinded clinical
trials with a TAP block on post-operative pain were
identified.4–6,17–20 These studies included a total of
364 patients, of whom 180 received TAP blockade
(Table 1). Quality scores (median 5, range 2–5) and
validity scores (median 14, range 2–15) of the studies
were generally high (Table 1). Three of the seven
studies were from the same group of investigators.4–6
The surgical procedures included large bowel
resection with a midline abdominal incision,4 a
cesarean delivery via the Pfannenstiel inci-
sion,6,19,20 abdominal hysterectomy via a transverse
lower abdominal wall incision,5 open appendect-
omy18 and laparoscopic cholecystectomy with all
four ports of the procedure described as inserted
below the umbilicus17 (Table 1).
In four of the studies,4,5,17,18 patients received a
general anaesthesia and in three studies spinal
anaesthesia was performed.6,19 In four of the seven
studies,4–6,19 a multimodal post-operative analgesic
regimen was used including paracetamol 1 g every
6 h and NSAID, either diclofenac 100 mg every 16–
18 h or ibuprofen 400 mg every 8 h, in combination
with PCA-morphine. In the appendectomy study,18
patients received a multimodal post-operative an-
algesic regimen with paracetamol 1 g every 6 h,
TAP block for post-operative analgesia
diclofenac 50 mg as required and PCA-morphine.
In one of the cesarean delivery studies,20 a multi-
modal analgesic regimen including paracetamol 1 g
every 6 h, diclofenac 50 mg every 8 h and intrathe-
cal opioids (fentanyl 10 mg and morphine 100 mg)
was used in combination with i.v. morphine 2 mg
on request. In the last study, only PCA-morphine
was administered17 (Table 1). No prophylactic anti-
emetic drug was used in any of the studies.
In three studies, the TAP block was performed
bilaterally after induction of anaesthesia, using the
blind technique via the triangle of Petite as described
under methods.4–6 In the remaining studies, an
ultrasound-guided TAP block was performed.17–20
In the studies, 15 or 20 ml of either levobupivacaine,
bupivacaine or ropivacaine in different concentra-
tions was injected (see Table 1 for details). In six
studies, the TAP block was performed bilaterally,
whereas in the appendectomy study, injection was
unilateral. In four of the studies,5,6,19,20 saline 0.9%
was injected as a placebo in the control group,
whereas in the remaining studies,4,17,18 no placebo
infiltration was performed.
In all but one study,20 24-h post-operative PCA-
morphine consumption was significantly reduced
with the TAP block, ranging from 33% to 74%,
compared with the control groups (Fig. 3). A metaa-
nalysis showed a significant reduction in 24 h mor-
phine consumption [WMD: 22 mg, 95% confidence
interval (CI): 31 to 13 mg], favouring the TAP
block treatment. A subgroup analysis revealed a
difference between the outcome for the landmark-
based technique (WMD: 38 mg, CI: 61 to
16 mg) and the ultrasound-guided technique
(WMD: 11 mg, CI: 19 to 2 mg) (Fig. 4). Three
studies5,6,20 investigated for an extended 48 h analgesic
effect of the TAP block. Two5,6 of the studies reported
on a reduced 48 h analgesic requirement, favouring
the TAP block treatment. Although the morphine-
sparing effect was mainly evident for the first 12 h, a
significant opioid-sparing effect was demonstrated in
most of the 12-h time intervals in the studies.
Pain scores, both at rest and during mobilization,
were significantly reduced with the TAP block in the
early post-operative period (0–6 h) in four studies
(bowel resection,4 abdominal hysterectomy,5 caesar-
ean section6 and appendectomy18). After appendect-
omy,18 bowel surgery4 and abdominal hysterectomy,5
pain scores were also reduced after 24 h. Further-
more, in the abdominal hysterectomy study, reduced
pain scores, both at rest and during mobilization,
were reported for up to 48 h post-operatively. In
two studies (caesarean section19,20), pain scores
531
 Table 1

532
Randomized-controlled studies of a TAP block in post-operative pain.
References Surgical n active/ TAP block Intra-operative Post-operative Effect on Effect on pain Effect on Effect on PONV Oxford Oxford
procedure control procedure anaesthetic analgesics analgesic sedation Quality Validity
requirements Score Score
(0–5) (1–16)
McDonnell Large bowel 16/16 20 ml General Paracetamol PCA-morphine VAS reduced at Sedation scores Incidence of 5 12
P. L. Petersen et al.

et al.4 resection levobupivacaine anaesthesia 1 g/6 h, reduced from rest and during reduced at 4 PONV reduced.
3.75 mg/ml with propofol diclofenac 80 mg to mobilization at and 6 h post-op PONV scores
bilateral. LOR- and fentanyl 100 mg/18 h, 22 mg/24 h 0–24 h post-op modestly
technique via the and PCA- reduced
triangle of Petit morphine
McDonnell Caesarean 25/25 1.5 mg/kg Spinal Paracetamol PCA-morphine VAS reduced at Incidence of No significant 5 14
et al.6 delivery ropivacaine anaesthesia 1 g/6 h, reduced from 52 rest (2, 4, 6, 12 sedation difference
7.5 mg/ml with diclofenac to 14 mg/24 h and and 48 h post- reduced.
bilateral. LOR- bupivacaine 100 mg/18 h from 67 to 15 mg/ op) and during Sedation
technique via the and fentanyl and PCA- 48 h mobilization scores reduced
triangle of Petit morphine (2, 4 and 6 h at 6 h post-op
post-op)
Carney Total abdominal 24/26 1.5 mg/kg General Paracetamol PCA-morphine VAS reduced Incidence of No significant 5 14
et al.5 hysterectomy ropivacaine anaesthesia 1 g/6 h, reduced from at rest (4–36 h sedation difference
7.5 mg/ml with propofol diclofenac 40 to 21 mg/24 h post-op) and reduced
bilateral. LOR- and fentanyl 100 mg/16 h, and from 55 to during
technique via the and PCA- 27 mg/48 h mobilization
triangle of Petit morphine (2–48 h post-op)
El-Dawlatly Laparoscopic 21/21 15 ml General PCA-morphine PCA-morphine No data No data No data 2 2
et al.17 cholecystectomy bupivacaine anaesthesia reduced from
5 mg/ml bilateral. with 23 to 11 mg/24 h
UL-guided sevoflurane
technique and sufentanil
Niraj Open 24/23 20 ml General Paracetamol PCA-morphine VAS reduced No data Reduced at 5 13
et al.18 appendectomy bupivacaine anaesthesia 1 g/6 h, reduced from at 30 min and 30 min post-op
5 mg/ml with isoflurane diclofenac 50 to 28 mg/24 h at 24 h post-op
unilateral. 50 mg (pn) and at rest and on
UL-guided PCA-morphine coughing
technique
Belavy Caesarean 23/24 20 ml Spinal Paracetamol PCA-morphine No significant No significant Use of anti- 5 14
et al.19 delivery ropivacaine anaesthesia 1 g/6 h, reduced from difference difference emetic reduced.
5 mg/ml bilateral. with ibuprofen 36 to 24 mg/24 h Nausea and
UL-guided bupivacaine 400 mg  3, vomiting: No
technique and fentanyl and PCA- significant
morphine differences
Costello Caesarean 47/49 20 ml Spinal Paracetamol No significant No significant No data No data 5 15
et al.20 delivery ropivacaine anaesthesia 1 g/6 h, difference difference
0.375% bilateral. with diclofenac
UL guided bupivacaine, 50 mg/8 h and
technique morphine and morphine on
fentanyl request

LOR, loss of resistance; PCA, patient-controlled analgesia; UL, ultrasound; VAS, visual analogue scale; post-op, post-operatively.

were not reduced, and in the remaining study,17 no
pain scores were recorded.
Five4–6,18,19 of the seven studies reported on
PONV and four studies on sedation.4–6,19 One
study18 reported that the incidence and severity of
PONV were reduced at 30 min post-operatively with
the TAP block, and in another study,4 the incidence
of PONV was reduced, although the reduction in the
nausea scores was modest. Sedation was reduced
with the TAP block in three of four studies.4–6,19
None of the studies investigated the distribution
of the TAP block by sensory testing. One study
Fig. 3. Percentage reduction in 24-hour morphine consumption
with transversus abdominis plane block compared with control
group (*Po0.05).
Fig. 4. Meta-analysis demonstrating the 24-hour cumulative morphine consumption (mg) in patients receiving the transversus abdominis
plane (TAP) block compared with control groups. For both the landmark based as well as the ultrasound-guided technique a significant
reduction in morphine consumption is demonstrated, favouring TAP blockade. CI, confidence interval; SD, standard deviation.
TAP block for post-operative analgesia
reported on an allergic reaction in a patient follow-
ing injection of the local anaesthetic. No other
incidences of complications or failures were re-
ported with the block procedure.
Discussion
Based on the results from trials included in this
review, it appears that the transversus abdominis
plane block has the potential to become a new and
important tool in post-operative pain management
for patients undergoing surgery involving the ante-
rior abdominal wall. The TAP block was reported
to be effective in six of seven trials with regard
to reduced post-operative opioid consumption.
Furthermore, four of six trials also demonstrated
reduced pain scores, both at rest and during mo-
bilization, favouring TAP block treatment.
For patients undergoing colonic surgery in
which epidural analgesia is currently the gold
standard for post-operative pain treatment, the
TAP block may offer a new alternative and without
the unwanted motor blockade often accompanied
by an effective epidural analgesia. Also, patients
with coagulation disorders that preclude the use of
a central neuraxial block might be amenable to an
efficient alternative for post-operative pain treat-
ment with the TAP block.
As only seven studies have been published so far,
however, general recommendations for the use of
533
P. L. Petersen et al.
TAP block may seem premature.21 The results from
primary published studies, of which three studies
are from the same group of authors, have to be
confirmed in future studies. The number of patients
included in the studies is rather small, thus masking
both potential rare complications with the TAP
block, but also a possible reduced incidence of
side-effects. The present studies indicate that pa-
tients may suffer less from PONV and sedation with
the TAP block. The evidence so far, however, is
weak, and it is prudent that future trials also focus
on this potential advantage of the new block.
The optimal procedure-specific volumes and
concentrations of injected local anaesthetic in
the TAP block have to be established in future
trials. Also, further safety data are warranted
including serum concentrations of local anaes-
thetics after administration.
The analgesic duration of a single administration
should be assessed, and continuous techniques
should be further studied. The differential effects
of the block on different surgical procedures
should be investigated and compared. It is not
clear whether the ultrasound-guided TAP block,
as described by Hebbard,12 is sufficient for surgical
procedures located at both the supra- and the
infraumbilical level, or whether upper abdominal
procedures need an additional TAP block, e.g. the
‘oblique subcostal’ block,13 to be efficient.
In the present studies, both the original blind
technique and the ultrasound-guided access were
described as easy to perform and with few com-
plications. However, recent reviews1,22 conclude
that ultrasound guidance reduces the block time
and the number of attempts, and decreases the
block onset time. Another advantage of using an
ultrasound-guided technique is that accidental
puncture of the internal gastro-intestinal organs
reported with the TAP block11 may be avoided.
Furthermore, the position of the lumbar triangle of
Petit was investigated in a cadaver study,23 demon-
strating that the triangle was more posteriorly
located than described in the literature, and with
a relatively small and varying size and shape. In
addition, the relevant nerves of the anterior ab-
dominal wall did not always enter the transversus
abdominis plane at the point of the lumbar triangle
of Petit, thus supporting an ultrasound-guided
TAP block access in the mid-axillary line.23
Interestingly, our subgroup meta-analysis demon-
strated a relatively large difference in morphine
sparing between the two TAP-block techniques. It
may be speculated whether this difference is related
534
to the anatomical injection sites used for the two
techniques, as the Triangle of Petit is located more
posterior than the site used in the ultrasound-guided
technique. However, it is also possible that the
difference in the outcome of the techniques simply
reflects a procedure-specific difference in post-op-
erative pain and morphine consumption related to
the surgical procedures included in the trials.
The results from two of three of the caesarean
delivery studies6,19 and also from the abdominal
hysterectomy study5 are remarkable as a relatively
large reduction in morphine consumption is demon-
strated with the TAP block. However, post-operative
pain in these patients can be considered a combina-
tion of both somatic (the abdominal wall incision)
and visceral pain (internal organs) and the TAP
block is not known to block visceral afferents. There-
fore, other mechanisms of action with the TAP block
have to be considered. In a newly published study,24
serum concentrations of lidocaine were investigated
after a 2  20 ml TAP block with lidocaine 10 mg/ml,
demonstrating serum concentrations within or just
above the therapeutic range for the anti-arrhythmic
effect of lidocaine. Therefore, the authors suggested
that the analgesic effect in part might be caused by a
systemic rather than a local analgesic effect of the
local anaesthetic, thus warranting further studies to
examine this question.
One study did not find any significant advantage
from the use of TAP blockade for patients under-
going a caesaren section.20 The basic multimodal
analgesic regimen in this study included use of
intrathecal morphine, a treatment well known for
its analgesic efficacy,25 but with significant side
effects. Thus, pain scores and morphine consump-
tion in the control group of this study were low,
thereby making it difficult to demonstrate an an-
algesic improvement from the TAP blockade.
In most of the trials published so far, both pain
scores and opioid consumption were reduced. This
was achieved with a TAP block added to a basic
analgesic regimen consisting of paracetamol and
NSAIDs, indicating that the block may be an im-
portant part of a multimodal analgesic regimen.
Likewise, four cases of laparoscopic appendectomy
were reported in a recent letter.26 In these cases, all
patients received a TAP block in combination with
paracetamol and NSAID, and none of the patients
required supplemental opioid for the first 12 h post-
operatively. Two of the four patients did not con-
sume any opioids at all.26 It is therefore possible that
the TAP block may confer special advantages in
procedures with small to moderate surgical trauma

and pain, as in e.g. day case surgery, in which the
TAP block has the potential to minimize pain and
opioid usage, thereby promoting fast recovery and
discharge.
Conclusion
Post-operative pain treatment with a TAP block is a
promising new technique, demonstrating both a
substantial reduction in morphine consumption as
well as improved pain scores in surgery involving
the anterior abdominal wall. Before the TAP block
is implemented in routine clinical practice, how-
ever, further studies are warranted in order to
support the findings of the primary published
trials and to establish general recommendations
for the use of a TAP block, especially as part of a
multimodal post-operative analgesic regimen.
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Address:
Pernille L Petersen
Department of Anaesthesia
Copenhagen University Hospital
Ndr. Ringvej, DK-2600 Glostrup
Denmark
e-mail: pernille.lykke.petersen@dadlnet.dk
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