okay now we're going to do a tap block since this lady is having a mommy makeover consisting of breast augmentation with a silicone gel implant and an abdominoplasty so if we look at the musculature of the anterior abdominal wall this would be the lateral border of the rectus that's the plica semilunaris and then these three muscles start to separate where we want to go is in the space between the tap plane which is between the transversalis and the internal oblique and the internal obliques always the largest of the three muscles so there's my view i've got a nice view of all three muscles and for this we're going to use a mixture of 20 cc's of saline 20 ccs of marcain half percent and 20 cc's of x braille so now i'm just following the needle down and there i popped in give me a test dose and there's the space between the two okay switch over to the rope pivot cane expert i mean ex-braille marking okay and there's this the muscles kind of separating right there that's perfect that's exactly what you want to say they're just separating away and that you can see the transverse house being pushed down and the internal dominant oblique being pushed upward and the x braille marking mixture just separating the two so we're going to put easy it's going in easy we put 15 cc's of that on each side okay that's one side so now we're going to do a tap block on the opposite side so again i've got this is in pettit's triangle between the costal margin and the anterior superior iliac spine it's usually just uh in front of the line of the anterior axillary line or wherever the muscles look like they're the most separated just above the umbilicus is usually where this is going in so i'm going to go in perpendicular to the skin i'm going to find the needle and i'm already through the internal because she's so thin see i'm pushing on the that that little plane i think i'm in give me a test dose perfect okay switch over and they're usually they're not that fast but you know 10 seconds is pretty fast but usually it's about 35 40 seconds to do and there you can see it's splitting and separating the muscles and the patients get such good pain relief from this and we reserve because it's a 60cc mixture so i'll reserve 10 cc's five from each side to directly infiltrate the area where we close the diastasis above the umbilicus and with that they get really good pain relief they're in the pacu for an hour where they used to be in there for three and four hours with a mommy maker and you can see here that here's the fluid you can see the internal oblique being pushed upward and the transversal is being pushed downward and that's it thank you very much
