Ilioinguinal Nerve, Iliohypogastric Nerve, Inguinal Canal, TAP

Ilioinguinal Nerve, Iliohypogastric 

Nerve, Inguinal Canal & 

Transversus Abdominis Plane Block 

Palpation 

David Provenzano, M.D. 

Executive Director-IPDC 

Ohio Valley General Hospital 

Adjunct Assistant Professor 

Department of Pharmacology 

Duquesne University 

Nerve 

Stimulation 

• Interventional & Diagnostic 

Landmark Based Technique 

Failure rate � 45% 

Cases 

� 6 yrs. 

�SB & obstructive hematoma 

� 14 yr. � Colonic puncture 

� 40 yr. � Pelvic hematoma 

Pediatric population 

� Nerves � peritoneum 

�3.3 ± 1.3 mm 

� 50% only 2 muscle layers 

Ultrasound 

ASIS 

IPDC 

Frigon. Pediatric Anesthesia. 2006. 

Willschke. BJA. 2005. 

Ghani. J R Coll Surg Edinb. 2002. 

� Anatomy 

�Variable 

� Pathways 

� Innervation patterns 

Overview 

� Traditional Landmark Based 

�Limitations 

� Ultrasound-guided techniques 

� Future 

�Chronic pain treatment & diagnosis Rab. Plast Reconstr Surg. 2001. 

Ilioinguinal & Iliohypogastric 

Anatomy 

� Normal pattern of sensory distribution � 20% 

� Symmetrical patterns � 40% 

� Ilioinguinal nerve (L1) 

� Iliohypogastric nerve (T12-L1) 

� Anterior & lateral cutaneous branches 

� Three muscles of abdominal wall 

� External oblique � aponeurosis 

� Internal oblique 

� Transverse abdominis 

� Deep circumflex iliac artery (EIA) 

Schuenke. Thieme Atlas of Anatomy. 2010. 

Ferzli. Surg Clin N Am. 2008. 

Ilioinguinal and Iliohypogastric 

Ultrasound Technique: 

� ASIS � umbilicus 

� ASIS 

� Cranial & posterior 

� 90% TA-IO 

� TA – Nerves – IO 

� II medial & IH lateral 

� Deep circumflex iliac artery 

� Failure rates 20% to 30% 

IPDC 

IO 

EO 

TA 

ASIS 

Peng. RAPM. 2009. 

Eichenberger. BJA. 2006. 

Jamieson. Q Bull Northwest Univ Med Sch. 1952. 

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1

Ilioinguinal & Iliohypogastric 

Cadaver Anatomical Dissection Study 

� 10 embalmed cadavers (37) 

� 0.1 mL of dye 

� 95% success rate 

� Validated 

� BMI 20.6 kg/m 2 

� Location and size 

� NBD for II 6 mm* 

� Depth of nerves -1.2 cm 

� Median diameter – 2 to 3 mm 

IO 

EO 

TA 

Lateral 

IPDC 

Eichenberger. BJA. 2006. 

Landmark Based Technique 

� Blind technique 21 subjects 

� Mean age 72 (range 43-93) 

� Medial to the ASIS 

�Fascial click 

�EO-IO & IO-TA 

� Check needle position with ultrasound 

�Muscle layers and peritoneum visualized 

�Nerves not visualized 

� Only 57% positioned between IOM and TAM 

�43% found deep to TAM 

IPDC 

Genitofemoral Nerve 

Anatomy - Genital branch 

� Relation to spermatic cord 

�Ventral, dorsal, inferior location 

�Part of cremaster muscle 

� 116 dissections of GFN in IC 

�Only 3% outside of SC 

� 27 adult cadavers 

� 13% of cases GB and II unite 

�GB nerve varies considerably 

�3 pathways 

ASIS 

Peritoneum 

Randhawa. Can J Anesth. 2010. 


Liu. Eur J Surg. 2002. 

Akita. Anat Med Rad Surg Tech. 1998. 

ASIS 

Be Careful of the Vessel 

ASIS 

IPDC IPDC 


Anatomy 

� L1 & L2 

� Femoral branch 

�Sensory � thigh 

� Genital branch (mixed) 

�Women - round ligament 

�Labia majora 

�Mons pubis 

�Men - spermatic cord 

�Cremasteric muscles & scrotum Rab. Plast Reconstr Surg. 2001. 


Traditional Technique-Genital Branch 

� Pubic tubercle & inguinal ligament 

� Point lateral to pubic tubercle 

� Below inguinal ligament 

� Field block - � volume LA 

IPDC 

� Concerns 

�Peritoneal cavity & abdominal viscera 

�Femoral artery 

PS 

PT PT 

�SC structures (testicular artery & vas deferens) 


5/18/2012 

2


Ultrasound-Guided Techniques 

� Limited publications 

� Described in review articles 

� Facilitation of PNS 

� Ultrasound-guided cryoablation 

�Case report-femoral branch 

�Diagnostic blind block 

�HF-LA � FA, FN & FV 


Ultrasound-Guided Technique 

� Above inguinal ligament 

� Locate rectus muscle medially 

� Inferior epigastric � EIA 

� Scan caudad & medial 

� Locate pubic tubercle 

� Medial � spermatic cord 

Campos. Pain Physician. 2009. 


Carayannopoulos. Neuromodulation. 2009 

Peng. Pain Physician. 2008. 

. 

Rectus Muscle 

Peritoneal Cavity 


Anatomy 

• Costal margin � iliac crest 

• T-L ventral rami (T7-L1) � skin, muscles, parietal peritoneum 

• Differentiate 

� Somatosensory vs. visceral 

• T6-T9 enter 

� TAP medial to anterior axillary line 

• 10 cadavers � 20 mL of blue dye 

� Mainly T10 (only 50% time )-L1 

IPDC 

� No cephalad spread past costal margin 

� � sensory blockade communication between branches 

• Subcostal TAP block 

I 

TA 

S 

Medial 

EO 

IPDC 

Tran. BJA. 2009. 



Cephalad 

� HF-LA 

� Nerve difficult to visualize � inguinal canal 

�Spermatic cord or round ligament 

� Transverse plane femoral artery 

� Rotate long axis � external iliac artery 

� Oval structure 

� Out of plane � deep to abdominal fascia 

�Injection inside and outside of SC 


IPDC 

Lateral 

Lateral 


Peng. Pain Physician. 2008. 


Traditional Technique 

� 2001 by Rafi 

� Triangle of Petit & double pop 

� Needle inserted perpendicular 

� 2 pops 

�External oblique fascia 

�IO-TA 

Jankovic. A & A. 2009. 

McDonnell. RAPM. 2007. 

Gray’s Anatomy. PDE. 

PT 

IPDC 

IPDC 

5/18/2012 

3



� HF-LA or LF-CA 

� Lateral decubitus position 

� Midaxillary line 

�IC � Costal margin 

� Avoid far medial 

�Only two muscle layers 

Lateral 

� Blunt 21-gauge 4 inch needle Gray’s Anatomy. PDE. 

Soliman. TRAPM. 2009. 

US-Guided & Postherniography Pain 

� Diagnosis & treatment 

� Previously no controlled studies published 

� Randomized, double-blind, crossover trial 

� 12 pts. & 12 controls 

� Analgesic & sensory effects 

� Premature discontinuation 

�11 nonresponders and 1 responder 

�No significant pain reduction 

�No consistent changes in neurophysiological 

assessments Bischoff. A&A. 2012. 

� Anatomy 

Conclusions 

�Sonoanatomy and relational anatomy 

� Limitations of landmark based techniques 

� US 

�Accuracy 

�Avoidance & earlier diagnosis 

] 

� Treatment of postherniorrhaphy groin pain 

�Efficacy of blocks for pain and diagnostic accuracy? 

�Additional cost of ultrasound 

�Genital branch of the GFN 

RM 

IPDC 


Traditional Technique - Complications 

� Anterior approach 

� 60 pts. � terminated early � 36 pts. 

� GA � TAP block � US � 76.4% 

IPDC 

23.6% 

* 

* 

EO 

36.1% 

IO 

TA 

Peritoneal Cavity 

* 

18% 

Reasons 

1. Sensory innervation complex 

� Branches IL,IH, and GFN 

� Numerous communicating branches 

2. More prominent role of GFN 

� Standardized technique 

� More proximal block 

3. Nerve branches dividing from IL/IH 

� Proximal to ASIS 

McDermott. BJA.2012. 

4. Central sensitization & central pain processing 

Placebo response in patients (5/12) 

� Importance of controlled blocks 

Select References 

1. Rab M, Ebmer And J, Dellon AL: Anatomic variability of the ilioinguinal and genitofemoral nerve: 

implications for the treatment of groin pain. Plast Reconstr Surg 2001; 108: 1618-23 

2. Ferzli GS, Edwards E, Al-Khoury G, Hardin R: Postherniorrhaphy groin pain and how to avoid it. Surg Clin 

North Am 2008; 88: 203,16, x-xi 

3. Frigon C, Mai R, Valois-Gomez T, Desparmet J: Bowel hematoma following an iliohypogastric-ilioinguinal 

nerve block. Paediatr Anaesth 2006; 16: 993-6 

4. Ghani KR, McMillan R, Paterson-Brown S: Transient femoral nerve palsy following ilio-inguinal nerve 

blockade for day case inguinal hernia repair. J R Coll Surg Edinb 2002; 47: 626-9 

5. Eichenberger U, Greher M, Kirchmair L, Curatolo M, Moriggl B: Ultrasound-guided blocks of the 

ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical 

dissection. Br J Anaesth 2006; 97: 238-43 

6. Peng PW, Narouze S: Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, 

sonoanatomy, and procedures: part I: nonaxial structures. Reg Anesth Pain Med 2009; 34: 458-74 

7. Jamieson RW, Swigart LL, Anson BJ: Points of parietal perforation of the ilioinguinal and iliohypogastric 

nerves in relation to optimal sites for local anaesthesia. Q Bull Northwest Univ Med Sch 1952; 26: 22-6 

8. Randhawa K, Soumian S, Kyi M, Khaira H: Sonographic assessment of the conventional 'blind' ilioinguinal 

block. Can J Anaesth 2010; 57: 94-5 

9. Liu WC, Chen TH, Shyu JF, Chen CH, Shih C, Wang JJ, Kung SP, Lui WY, Wu CW, Liu JC: Applied 

anatomy of the genital branch of the genitofemoral nerve in open inguinal herniorrhaphy. Eur J Surg 2002; 168: 

145-9 

5/18/2012 

4

Select References 

10. Akita K, Niga S, Yamato Y, Muneta T, Sato T: Anatomic basis of chronic groin pain with special reference 

to sports hernia. Surg Radiol Anat 1999; 21: 1-5 

11. Bischoff JM, Koscielniak-Nielsen ZJ, Kehlet H, Werner MU: Ultrasound-Guided 

Ilioinguinal/Iliohypogastric Nerve Blocks for Persistent Inguinal Postherniorrhaphy Pain: A Randomized, 

Double-Blind, Placebo-Controlled, Crossover Trial. Anesth Analg 2012 

12. Campos NA, Chiles JH, Plunkett AR: Ultrasound-guided cryoablation of genitofemoral nerve for chronic 

inguinal pain. Pain Physician 2009; 12: 997-1000 

13. Jankovic ZB, du Feu FM, McConnell P: An anatomical study of the transversus abdominis plane block: 

location of the lumbar triangle of Petit and adjacent nerves. Anesth Analg 2009; 109: 981-5 

14. McDonnell JG, O'Donnell BD, Farrell T, Gough N, Tuite D, Power C, Laffey JG: Transversus abdominis 

plane block: a cadaveric and radiological evaluation. Reg Anesth Pain Med 2007; 32: 399-404 

15. Peng PW, Tumber PS: Ultrasound-guided interventional procedures for patients with chronic pelvic pain - a 

description of techniques and review of literature. Pain Physician 2008; 11: 215-24 

16. Tran TM, Ivanusic JJ, Hebbard P, Barrington MJ: Determination of spread of injectate after ultrasoundguided 

transversus abdominis plane block: a cadaveric study. Br J Anaesth 2009; 102: 123-7 

17. Willschke H, Marhofer P, Bosenberg A, Johnston S, Wanzel O, Cox SG, Sitzwohl C, Kapral S: 

Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth 2005; 95: 226-30 

Thank You 

davidprovenzano@hotmail.com 

5/18/2012 

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Ilioinguinal Nerve, Iliohypogastric Nerve, Inguinal Canal, TAP

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