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Coeliac Plexus Block
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab.
DCA, Dip. Software statistics
Ph D physiology.
Mahatma gandhi medical college and research
institute, puducherry, India
Definition- what is this coeliac
plexus ??
• A complex network of nerve fibres
• The coeliac plexus is the largest of the autonomic
plexuses and is located in the abdomen surrounding
the coeliac and superior mesenteric arteries
Introduction
• The coeliac plexus contains visceral afferent
and efferent fibers derived from T5 to T12 by
means of the greater, lesser, and least
splanchnic nerves.
• The plexus has no somatic fibers and is
composed of a number of ganglia and nerve
fibers.
• It innervates most of the abdominal viscera.
Coeliac plexus
HISTORY
1914 – KAPPIS
– first block in lateral
position
1920 – WELDING – anterior approach.
1927 – LABAT
– now followed retrocrural
approach in prone position.
1982 – SINGLERS – CT guided transcrural
approach
1983– ISCHIA
– posterior transaortic
approach
Indications:
• Abdominal pain associated with
malignancy.
• ( Local anaesth. Or neurolysis)
• Nonmalignant abdominal pain ( neurolysis
controversial).
Is it worth ??
• In carefully selected patients with
pancreatic cancer,
• provide partial to complete pain relief for
90% patients for up to 3 months and 7090% up until end of life.
• Pain relief for all types of upper GI cancer
has been reported to be between 70 and
97%.
Indications
• can be combined with an intercostal
block to provide anaesthesia for intraabdominal surgery.
• Because it results in blockade of the
autonomic nervous system, may help
reduce stress and endocrine responses to
surgery.
Anatomy
• The coeliac plexus -- solar plexus.
• main junction for autonomic nerves supplying the
upper abdominal organs (liver, gall bladder,
spleen, stomach, pancreas, kidneys, small bowel,
and 2/3 of the large bowel).
• The celiac plexus proper consists of the celiac
ganglia with a network of interconnecting fibers.
.
Anatomy
• Sympathetic-supply:
Greater splanchnic nerve (T5/6 to T9/10)
Lesser splanchnic nerve (T10/11)
Least splanchnic nerve (T11/12)
The upper abdominal organs receive their
parasympathetic supply from the left and right
vagal trunks, which pass through the coeliac plexus
but do not connect there
Anatomy
• L1 vertebra. – posterior
• The vena cava lies anteriorly to the right, and on
the left anteriorly is the aorta., with the
pancreas anterior.
• The kidneys lie laterally
• The number of ganglia varies from one to five,
and each ganglion is 0.5 to 4.5 cm in diameter.
Left-sided ganglia are usually lower than those
on the right.
Coeliac plexus
Technique
• prone position and a pillow beneath the
abdomen
• intravenous sedation, local anaesthetic
infiltration of the superficial layers
• Iv fluids
• Needle entry – below tip of twelfth rib
Technique
Technique
• L1 spinous process(A)
• inferior edge of the 12th rib at a point 78cm lateral of the midline(points B and C).
Connect these points to form a triangle, the
base of which is passing over the inferior
edge of the L1 spinous process
Technique
• Aseptic preparation of the skin,
• infiltrate the skin and muscle with local
• use a 12-18 cm long ,20-22 gauge needle and
introduce(the left side needle first) at a 45degree
angle relative to the sagittal plane
• The direction is towards the L1 spine and proceeds
to hit on the L1 vertebral body.
• (more superficial bony contact may be the L1
transverse process)
Finger as control
Technique
• The needle contacts the L1 vertebral body at a
depth of. 7-10 cm.
• A skin marker is placed on the needle.
• The needle is then withdrawn
• re introduced laterally until it just slips from the
lateral border of the vertebral body Slowly advance
the needle further, feeling for the transmitted
pulsations of the aorta and stop advancing once
pulsations are felt.
• On the right side advance further 1 cm.
Points A,B,C and 2 needles
Fluroscopy
CT guided
Other techniques
Paramedian approach: Needle is inserted
caudad to 12 th spinous process at a point 3
cm lateral to the midline in a plane
perpendicular to the skin
Anterior approach: Through the anterior
abdominal wall under fluoroscopic and
ultrasound guidance.
USG guided anterior approach
Newer approaches
• “transdiscal percutaneous approach of
splanchnic nerves”,
• which is carried out under
• CT control, improves accuracy, reduces
complications
Surgical approach
Transgastric approach
Endoscopic Ultrasound
Drugs
• Agents used for blockade are 0.5% bupivacaine
with adrenaline1:200000 around 30ml, 15 ml on
either side with or without dexa for chronic pain
• Neurolytic blockade is indicated in abdominal
malignancies where alcohol 50-100% or 10%
phenol is used.
• The pain on injection of alcohol can be minimised
with combination of bupivacaine 1:1 ratio
How to know it works ??
• The signs of successful block is
• hypotension
• patient may feel an urge to empty bowel.
Contraindications
• Bleeding disorders and infection
• Aortic aneurysm
• Non autonomic pain
Complications
• Severe hypotension may result, even after
unilateral block.
• Bleeding due to aorta or inferior vena cava injury
by the needle.
• Intravascular injection (should be prevented by
checking the needle position with radio-opaque
dye).
• Upper abdominal organ puncture with
abscess/cyst formation.
Complications
• Paraplegia from injecting phenol into the arteries
that supply the spinal cord (prevented by checking
the needle position with radio-opaque dye).
• Sexual dysfunction (injected solution spreads to
the sympathetic chain bilaterally).
Intramuscular injection into the psoas muscle.
• Lumbar nerve root irritation (injected solution
tracks backwards towards the lumbar plexus).
Complications
• More from neuro lytic blocks
Thank you all