Which Fascial Plane Block Is Right for My Patient?

Valkyrie Blog Team
Aug 12
3 min read

Abdominal wall anatomy and nerve innervation

A Practical, Clinically Focused Blog Based on the 2026 Abdominal FPB Decision‑Making Algorithm

Abdominal surgery presents a unique challenge in regional anesthesia: pain patterns vary widely depending on incision location, tissue planes, and surgical approach. The 2026 Springer review, “Which fascial plane block is right for my patient? A practical decision‑making algorithm for abdominal surgery,” provides one of the first structured, evidence‑based tools to help clinicians select the most appropriate fascial plane block (FPB) for abdominal procedures.

This blog distills that review into a clear, clinician‑friendly format that explains what each block does, when to use it, and why it matters.

Why This Algorithm Matters

The review emphasizes that abdominal FPB selection has historically been inconsistent, relying heavily on clinician preference rather than structured decision‑making. The new algorithm changes that by offering a stepwise, anatomy‑driven approach that improves block reliability and aligns analgesia with surgical pain patterns.

The algorithm is built around three core principles:

Match the block to the incision location — because abdominal wall innervation is segmental and highly region‑specific.
Choose blocks based on expected pain depth — because superficial incisions require different coverage than deep visceral manipulation.
Use blocks with predictable spread patterns — because fascial plane blocks succeed when injectate follows the correct anatomical pathway.

The Abdominal FPB Decision Framework

The review organizes abdominal FPBs into functional categories based on their anatomical targets and expected spread

Select fascial plane blocks that have been shown to cover the abdominal wall.

Shown in the illustration is the largest potential area of analgesic coverage for each block, and interindividual variation (due to patient, performer, or other factors) should be expected.

Block	Best Use Cases	Why It Works	Limitations
TAP Block (Transversus Abdominis Plane)	• Lateral abdominal wall incisions • Laparoscopic trocar sites • ERAS protocols	• Covers T10–T12 dermatomes along the anterolateral abdominal wall • Trocar sites fall within TAP dermatomal spread • Provides consistent somatic analgesia without motor block	• No visceral analgesia - targets only somatic nerves between internal oblique & transversus abdominis
Rectus Sheath Block	• Midline incisions • Umbilical & periumbilical surgery	• Targets anterior cutaneous branches within posterior rectus sheath • Confined fascial compartment → predictable spread	• Narrow dermatomal range — only midline structures
QL Blocks (QL1, QL2, QL3)	• Broad abdominal & pelvic analgesia • Lower abdominal surgery	• Posterior/cranial spread reaches thoracolumbar nerves (T7–L1) • Deep variants may reach sympathetic fibers → potential visceral analgesia	• Highly variable spread due to anatomical differences
ESP Block (Erector Spinae Plane)	• Multilevel thoracoabdominal pain • Uncertain dermatomal coverage • Combined thoracic + abdominal pain	• Longitudinal spread along erector spinae fascia → wide multilevel coverage	• Less targeted than TAP/rectus; high-volume block
Ilioinguinal / Iliohypogastric Blocks	• Lower abdominal incisions • Inguinal hernia surgery • Pediatric abdominal surgery	• Directly anesthetizes nerves supplying inguinal & lower abdominal wall • Minimal motor involvement	• Narrow coverage — does not reach upper abdominal dermatomes

This structured approach ensures clinicians select the block that best matches the surgical pain pattern — improving analgesic reliability and reducing unnecessary motor involvement.

Clinical decision-making tool for selecting the most appropriate fascial plane block for patients undergoing abdominal surgery

The authors noted that prior to implementation, this decision-making tool was reviewed and iteratively revised by consultant anesthesiologists specializing in regional anesthesia and acute pain medicine as well as consultant surgeons involved in the procedures covered. An audit of eligible cases over a 3-month period in the year following implementation demonstrates 96% institutional adherence to the algorithm. Although the algorithm is focused on regional analgesic techniques, they emphasize that all patients should be provided multimodal analgesia in accordance with recent multi-society guidance and that this pathway is intended to serve the majority of patients undergoing abdominal surgery who can be expected to experience at least moderate postoperative pain. Patients who are at risk for higher levels of pain (e.g., known chronic pain or substance use disorders) may need more nuanced and personalized analgesic plans.

Conclusion

The FPB decision‑making algorithm gives clinicians a practical, evidence‑based way to choose the right block for the right patient. By aligning block selection with incision location, pain depth, and anatomical spread, clinicians can deliver more predictable analgesia, reduce opioid use, and improve ERAS outcomes.

This clinical decision-making tool complements existing guidelines and is designed for the general anesthesiologist. It simplifies the decision-making process for selecting an appropriate block and aims to increase access to regional analgesia for all patients who undergo abdominal surgery in alignment with the Plan A blocks framework.

See Valkyrie’s Torso Simulators in action and explore your options.

Resource Reference:

Which fascial plane block is right for my patient? A practical decision-making algorithm for abdominal surgery Ellile Sultan, Matthew A. Kosasih, Amit Pawa, Barbara Versyck and Edward R. Mariano