Ultrasound can be used widely by surgeons during operations. It has several uses including acquiring new diagnostic information, confirming completion of operations, and guiding surgical procedures. Intraoperative ultrasound is performed using contact, probe-standoff, or compression scanning techniques. It is useful for examining organs like the liver and bile ducts. Laparoscopic ultrasound overcomes some disadvantages of laparoscopy and can also be used to guide procedures. Focused assessment with sonography for trauma (FAST) allows rapid identification of free fluid in trauma patients.

1. Dr. Priyadarshan Konar
Post Graduate Trainee (1st year)
Department of Surgery
IMS & SUM Hospital
Bhubaneswar 17.02.2017
ULTRASOUND FOR
SURGEONS

2. *Ultrasound is sound waves with frequencies which are
higher than those audible to humans (>20,000 Hz)
*English-born physicist John Wild first used ultrasound to
assess the thickness of bowel tissue in 1949; he has been
described as the "father of medical ultrasound".
*Ultrasound was first used for clinical purposes in 1956 in
Glasgow by obstetrician Ian Donald and engineer Tom
Brown.

3. Ultrasound can be used by surgeons widely during
various types of operations. On the basis of it’s use, it
can be divided in 2 categories -

4. 1) ACUISITION OF NEW DIAGNOSTIC INFORMATION
NOT OTHERWISE AVAILABLE
2) COMPLEMENT TO OR REPLACEMENT FOR
CONVENTIONAL OPERATIVE RADIOGRAPHY
3) CONFIRMATION OF COMPLETION OF OPERATION
4) GUIDANCE OF SURGICAL PROCEDURES

5. Similar to those of IOUS during laparotomy. There are 2
major situations in which LUS is performed..
1) EXAMINATION OF THE BILE DUCT DURING
LAPAROSCOPIC CHOLECYSTECTOMY
2) STAGING & DETERMINATION OF RESECTABILITY
DURING LAPAROSCOPIC EXPLORATION FOR
ABDOMINAL MALIGNANCIES

6. Ultrasound scanning is a two steps procedure..
A. Probe Placement
B. Probe Movement

7. intraoperative ultrasound probe placement, including..
A. Contact Scanning
B. Probe-Standoff Scanning
C. Compression Scanning
Probe Placement

8. A.Contact Scanning:
 Probe is placed in direct
contact with the tissue.
 Used for examination of
the interior of the liver,
kidney or pancreas.

9. B. Probe-Standoff Scanning:
 Used for examination of
Extrahepatic biliary ducts.
 Acoustic coupling is obtained
between the tissue and the
probe by filling the operative
field with saline until the
transducer surface is
immersed beneath the
solution.

10. C. Compression Scanning:
 This technique helps to eliminate air between target
organ and transducer.
 Especially effective when air in the duodenum
obscures the distal common bile duct.

11. Probe Movement
Second step in
ultrasound scanning.
Longitudinal,
Transverse and at times
Oblique views of a
lesion or organ is
important.

12. There are 3 basic scanning maneuvers of the probe:
1. Sliding: The probe slides across the surface of the
organ, while the probe-to-surface geometry is
maintained.
2. Rotating: Probe is turned along the direction of the
sound beam, either clockwise or anticlockwise.
3. Angulating (Rocking / Tilting): Probe's head remains
relatively stationary while the shaft is moved to
different angles.

13. INTRAOPERATIVE
ULTRASOUND
SCANNING OF
THE SPECIFIC
ORGANS

14. Best scanned with side viewing flat T-shaped probe.
In majority of cases liver is visualized by scanning from
the anterior or diaphragmatic surface.
Scanning from the inferior surface done for examination
of Posterior surface of Right lobe & Caudate lobe.
Intrahepatic vessels are scanned using Sliding, Rotating
and at times minimal Angulating maneuvers.

15. Probe placed on the liver
surface and contact
scanning is performed.
*Sliding
*Rotating
*Angulating
-maneuvers should
be appropriately used.
Intraoperative ultrasound scanning
of liver
Combination of ‘Angulating’ maneuver with partial
probe Standoff tecgnique.

16.  Left: IOUS showing the left portal vein and the caudate lobe in
transverse views.
 Right: IOUS of 3 hepatic veins. The RHV, LHV & MHV are coming
to the Vena Cava.

17. IOUS is particularly important to determine the final
resectability of liver tumors. This was a metastatic liver
tumor from a left colon cancer. The tumor (T) was
located in in segment 4 to 8 and it was invading the
Middle Hepatic Vein (MHV) & Vena Cava (VC). These
IOUS findings suggest that Surgical resection was
impossible with negative margin.

18. Best scanned with end-viewing cylindrical probe.
Supraduodenal portion viewed longitudinally
Retroduodenal & intrapancreatic portion scanned
through the duodenum – occasionaly with gentle
compression.
When examined
transversely, displays
PV & HA in transverse
sections.
Appearance of portal
triad described as
‘Mickey Mouse’ view.

19. IOUS showing resectable Cholangiocarcinoma.
Left: Longitudinal view of BD, showing the
junction of the BD with CD. Tumor is situated in
that area.
Right: Transverse view of the same tumour. No
invasion of tumor in the PV.

20. ①SAFETY
②REPEATABILITY
③SPEED
④HIGH ACCURACY
⑤MORE IMAGING INFORMATION
⑥WIDER APPLICABILITY
⑦PROCEDURE GUIDANCE CAPABILITY

21. 1. Detectability of small lesions
2. Delineation of ductal and tubular structures
3. Displays smaller field of vision than operative
radiography
4. Diagnosis and localisation of fistulas are limited
5. Special transducers are required, which are small
and easily maneuverable
6. High cost
7. Operator dependency

22. LAPARPSCOPIC
ULTRASOUND
SCANNING OF
THE SPECIFIC
ORGANS

23. LUS scanning for each organ depends on the type of
probes used & the location of trocar insertion sites.
Sub xiphoid port is commonly used for introduction of
probe into the peritoneal cavity.
Showing different types of LUS probe used & on the right side showing a
flexible LUS probe

24.  LUS scanning of the extrahepatic
bile duct using rigid end-viewing LUS
probe.
 Can view both Transverse &
Longitudinal sections only by rotating
the probe.

25. ①Main advantage is the capability of compensating
for the disadvantages of laparoscopy.
②Overall, the the advantages of LUS are basically
the same as those of IOUS

26. 1. Difficult scanning techniques due to limited access
2. Information and diagnostic accuracy may not be as
accurate as by IOUS
3. Time duration is longer
4. As well as learning curve is also longer
5. More costly
6. Limited availability
7. Organ injuries due to probe manipulation
8. Contamination due to disruption of sterile cover

27. INTRAOPERATIVE
& LAPARPSCOPIC
ULTRASOUND
GUIDED
PROCEDURES

28. IOUS /LUS can guide various operative procedures.
Surgical procedures guided / manipulated by IOUS /
LUS can be divided into 2 categories -
A.Ultrasound-Guided Needle, Cannula,
or Ablation Probe Placement
A.Ultrasound-Guided Tissue Dissection

29. Ultrasound-Guided Needle, Cannula, or Ablation
Probe Placement
 IOUS/LUS-guided needle placement helps in various
procedures, like
- biopsy of tumors (especially nonpalpable).
- fluid aspiration of cystic lesion.
- injection of contrast / other agents.
- catheter introduction into the ducts / lesions.
 Ablation cannula introduction under IOUS/LUS
guidance is performed for Thermal ablation or
Cryoablation.

30. Ultrasound-Guided Tissue Dissection
 Can assist incision / resection of solid organ such as
liver, pancreas and other intra/retro peritoneal
organs.
 Various pancreatic surgeries, abdominal abscess
drain, foreign body extraction from different
organs/tissues performed.
 Used most frequently in hepatic resections including
lobectomy, segmentectomy, subsegmentectomy &
other non anatomical resections.

31. ENDOSCOPIC & ENDORECTAL
ULTRASOUND
 Endoscopic Ultrasound (EUS) is a technically
demanding procedure.
 Major advantage is that the probe is directly on or very
close to the organ of interest – allows higher frequency
with better resolution.
 7 – 12 MHz transducer is used.
 Presently EUS is mostly used for pancreatic diseases
– helps determining the resectability.
 EUS guided celiac ganglion block is used to palliate
pain from pancreatic origin.

32.  Endorectal/Anorectal ultrasound has also an
advantage of the use of high frequency (7-12 MHz)
probe directly on the pathology in the rectum /anus.
 Rigid straight probe is frequently used.
 Can determine the depth of tumor penetration in
and outside the rectal wall & presence of metastatic
lymph nodes. Thereby, helps in T & N-staging.
 Surveillance of anastomosis and operative site .
 Helps determining the plan of surgery.

33. FAST
 Focussed Assessment with Sonography for Trauma
 With this technique it is possible to identify the
presence of intraperitoneal or pericardial free fluid.
In the context of traumatic injury, this fluid will
usually be due to bleeding
 Four areas are examined
a. Perihepatic space (Morison’s pouch / hepatorenal
recess)
b. Perisplenic space
c. Pericardium
d. Pelvis
 Extended FAST- examination of both lungs

34. 1) Perihepatic
2) Perisplenic
3) Pelvic
4) Pericardium

35. Showing different FAST images

36.  FAST is less invasive
 No exposure to radiation
 It is cheaper, but achieves similar accuracy
 It makes emergency care faster and better
 Helps determining the plan of surgery.
Advantages of FAST:

37. CONCLUSION
Ultrasonography provides various diagnostic
information.
Can guide / assist various surgical procedures in
real time.
Newer USG technologies such as Ultrsound
Contrast Enhancement, 3D Ultrasound, and high-
intensity focused Ultrasound.

38. Thank you