Intraoperative Ultrasonography Guidance Research Articles

Right hemihepatectomy preserving the fluorescently visible paracaval portion of the caudate lobe.

The paracaval portion (PC) of the caudate lobe is a small area of the liver located in front of the inferior vena cava. Conventional right hemihepatectomy (RH) along the Rex-Cantlie line involves resection of not only the anterior and posterior sections but also the PC behind the middle hepatic vein (MHV). However, to preserve the future liver remnant volume as much as possible, PC-preserving RH may be beneficial in selected patients. We injected an indocyanine green (ICG) solution in the PC portal branch under intraoperative ultrasonography (IOUS) guidance and performed an RH preserving the fluorescently visible PC in a patient with liver metastasis. The patient was a 47-year-old male with a 24 ×10 cm metastatic hepatic tumor from sigmoid colon cancer. CT volumetry revealed that the left hemiliver excluding the caudate lobe was 55%, and the caudate lobe was 5.3%. Before hepatic transection, the ICG solution was injected into the PC portal branch under IOUS guidance. During hepatic transection, the PC was identified as a fluorescent area behind the MHV using a near-infrared imaging system. Thus, the anatomical right-side boundary of the caudate lobe was clearly found. Following RH, the PC was preserved as a fluorescently visible area. The patient had an uneventful recovery. RH preserving the fluorescently visible PC of the liver is a feasible procedure.

Use of intraoperative ultrasonography in deciding the extent of surgical decompression for Chiari Malformation Type I

Introduction: The optimal surgical treatment for Chiari Malformation Type I continues to be controversial with procedures ranging from posterior fossa bone decompression alone to release or resection of the cerebellar tonsils. Intraoperative ultrasonography can be a useful tool in deciding the least invasive procedure so as to reduce the complications and improve the efficacy of the procedure. Methods: A retrospective study over a period of seven years of patients who underwent surgery for Chiari Malformation type I under the guidance of intraoperative ultrasonography was done. The patients underwent three types of surgery based on the adequacy of decompression seen as free flow of CSF through foramen of magendie and free movement of cerebellar tonsils on intraoperative ultrasonography placed over the duramater: Group 1: foramen magnum decompression alone, Group 2: foramen magnum decompression and lax duraplasty and Group 3: foramen magnum decompression with lax duraplasty and release or resection of cerebellar tonsils. Outcome of the types of surgery were determined by the clinical outcome at post-operative six months and two years. Result: A total of 10 patients: four males and six females were included in the study. The mean age of the population was 32.7 +/- 14.57 years with range of 42 years. There were three patients in group 1, two patients in group 2 and five patients in group 3. 100% of the patients in group 1, 50% of patients in group 2 and 60% of the patients in group 3 had improved outcome as evidenced by resolution of symptoms and resolution of syrinx at six months and one year postoperative period. Conclusion: Intraoperative ultrasonography is an effective tool in deciding the extent of surgical decompression for Chiari Malformation Type I. A larger multicentre study would help statistically validate the findings.

Comparison of sodium fluorescein and intraoperative ultrasonography in brain tumor resection

Various intraoperative neuroimaging modalities are available to the neurosurgeon during brain tumor surgery. There remains no consensus on which modalities are superior. This retrospective, single-center cohort study directly compares sodium fluorescein (SF) and intraoperative ultrasonography (IOUS) as intraoperative imaging modalities in a sample of patients with glioblastoma isocitrate dehydrogenase 1 wildtype (GBM). Adult patients with GBM who underwent surgical resection using SF or IOUS guidance between 2010 and 2020 were included. Primary outcomes included extent of resection (EOR), post-operative residual tumor volume, gross total resection (GTR) rate, false negative assessments, and the incidence of new post-operative neurologic deficits. Additionally, pre-and post-test probabilities were calculated to assess each modality’s ability to identify residual tumor. 98 patients met inclusion criteria (34 SF and 64 IOUS). Mean EOR was significantly higher for SF (94 ± 11 %) when compared to IOUS (87 ± 20 %; p = 0.032). Mean post-operative residual tumor was significantly higher for IOUS (197 ± 358 mm2) when compared to SF (81 ± 161mm2; p = 0.038). GTR was more frequent with SF (62 % vs 46 %, p = 0.12). False negative assessments for residual tumor were more common with IOUS (22 % vs 15 %, p = 0.53). One patient in each group suffered a new neurologic deficit post-operatively (p = 0.58). Sensitivity, specificity, positive predictive value, and negative predictive value were 62 %, 100 %, 100 %, and 81 % for SF and 59 %, 100 %, 100 %, and 67 % for IOUS, respectively. Taken together, SF may be superior to IOUS in maximizing EOR in patients with GBM, however, both modalities appear to have good efficacy.

Simultaneous Sigmoid Colectomy, Bilobar Liver Resection and Lung Metastasectomy via a Transdiaphragmatic Approach for Stage IV Colonic Adenocarcinoma

Current evidence supports the curative resection of colorectal cancer and synchronous liver and lung metastases in selected patients.1,2 This video shows simultaneous left colectomy, bilobar liver resection, and lung metastasectomy via a transdiaphragmatic approach for stage IV colorectal cancer.3 PATIENT: A 57-year-old man with a stage IV colonic adenocarcinoma was considered for simultaneous resection of primary, liver, and lung metastases without thoracic incision. The tumor mutational status was KRAS, NRAS, and BRAF wild-type, and the patient underwent preoperative chemotherapy. After performing a midline laparotomy, atypical liver resection of segments 8/4a was performed under the guidance of intraoperative ultrasonography and intermittent Pringle maneuver using the two-surgeon's technique. A small capsular lesion in segment 3 also was intraoperatively detected and resected. Lung metastasectomy of the right lower lobe was performed via a transdiaphragmatic approach using an endoscopic stapler. Sigmoid colectomy with transanal circular-stapled anastomosis was performed. Duration of surgery and blood loss were 358min and 400ml, respectively. Histopathological examination showed metastatic colonic adenocarcinoma with negative surgical margins and final stage was T3N2aM1b. The patient was discharged on postoperative day 6without complication. He was alive and free of disease at 90-day follow-up. Simultaneous colon, liver, and lung resection via a transdiaphragmatic approach is a feasible and safe surgical strategy in selected patients with peripheral lung metastases and favorable tumor biology.4 This surgical strategy avoids thoracic incision, multiple operations, and may reduce the healthcare costs and the recovery time to early implement postoperative therapy.

1147: The role of ultrasound in the management of third stage of second trimester delivery

The use of intraoperative sonographic guidance for second trimester elective dilation and curettage (D & E) procedure reduces the incidence of uterine perforation. Nevertheless, the role of intraoperative sonographic guidance during curettage procedure following second trimester medical induction has not been evaluated. We aim to evaluate the effect of intraoperative sonographic guidance during curettage procedure following second trimester uterine evacuation. A retrospective cohort study performed in a Gynecology department at a tertiary university-affiliated medical center including patients undergoing second trimester medical induction up to 23 6/7 weeks estimated gestational age who underwent uterine curettage after delivery of the fetus. Women undergoing curettage procedure under continuous ultrasound guidance were compared with those undergoing curettage without ultrasound guidance One hundred ninety four patients underwent a curettage without intraoperative sonographic guidance, while 79 underwent the procedure utilizing intraoperative sonographic guidance. The overall rate of composite adverse outcome was higher among those undergoing curettage under intraoperative sonographic guidance as compared with no sonographic guidance (39.2% vs. 20.6%, P=0.002). Placental morbidity (12.6% vs. 5.6%, P=0.04) and infectious complications (7.5% vs. 2.5%. P=0.05) were more frequent among those undergoing curettage using intraoperative sonographic guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with an adverse outcome (P=0.001). Procedure time was longer when ultrasound guidance was used; 9:52 min. vs. 6:58 min. (P< 0.001). Intraoperative ultrasonography guidance during curettage after second trimester uterine evacuation is associated with a higher complication rate than no guidance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1262 The Role of Ultrasound in the Management of Third Stage of Second Trimester Delivery: A Retrospective Cohort Study

Study Objective The use of intraoperative sonographic guidance for second trimester elective dilation and curettage (D & E) procedure reduces the incidence of uterine perforation. Nevertheless, the role of intraoperative sonographic guidance during curettage procedure following second trimester medical induction has not been evaluated. We aim to evaluate the effect of intraoperative sonographic guidance during curettage procedure following second trimester uterine evacuation. Design A retrospective cohort study. Setting A Gynecology department at a tertiary university‐affiliated medical center. Patients or Participants Patients undergoing second trimester medical induction up to 23 6/7 weeks estimated gestational age who underwent uterine curettage after delivery of the fetus. Interventions Women undergoing curettage procedure under continuous ultrasound guidance were compared with those undergoing curettage without ultrasound guidance. Measurements and Main Results One hundred ninety four patients underwent a curettage without intraoperative sonographic guidance, while 79 underwent the procedure utilizing intraoperative sonographic guidance. The overall rate of composite adverse outcome was higher among those undergoing curettage under intraoperative sonographic guidance as compared with no sonographic guidance (39.2% vs. 20.6%, P=0.002). Placental morbidity (12.6% vs. 5.6%, P=0.04) and infectious complications (7.5% vs. 2.5%. P=0.05) were more frequent among those undergoing curettage using intraoperative sonographic guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with an adverse outcome (P=0.001). Procedure time was longer when ultrasound guidance was used; 9:52 min. vs. 6:58 min. (P Conclusion Intraoperative ultrasonography guidance during curettage after second trimester uterine evacuation is associated with a higher complication rate than no guidance.

Comparison of intraoperative ultrasonography guidance with an open surgical method for venous port catheter placement in chemotherapy.

OBJECTIVE:One of the leading venous access methods in chemotherapy is the use of a venous port catheter (VPC). An open surgical or ultrasound-guided technique can be performed. In our study, the VPC placement via both of these techniques was compared.METHODS:A total of 180 consecutive patients who underwent the VPC placement procedure either via the open or ultrasound-guided methods in two centers between January 2014 and January 2016 were included in the study. Patients’ data were reviewed retrospectively. Groups were compared in terms of intervention-related complication rates, a total procedure time, and the requirement of control imaging with ionizing radiation.RESULTS:The mean total procedure time was significantly shorter (19.5±4.6 min, 46.7±19.6 min, p<0.001) in the ultrasound-guided group than the open method. The rate of catheter malposition was significantly less in the ultrasound-guided group than in the open group (p<0.001). The need for per-operative imaging with ionizing radiation and the need of reversion in the preferred technique were not observed in the ultrasound-guided group, whereas in the open group, they were observed in 90 (100%) and 6 (6.7%) patients, respectively (p<0.001, p=0.01).CONCLUSION:Intraoperative ultrasound guidance for the VPC placement shortens the processing time and eliminates the need for routine imaging methods that require the use of ionizing radiation. In accordance with the current guidelines recommendations, intraoperative ultrasonography should be preferred as much as possible during the VPC placement. However, the need for the surgical teams in centers to maintain the necessary educational processes for both techniques should not be overlooked.

Clinical value of preventative surgical resection in the treatment of extra-hepatic portal vein aneurysm

Objective To investigate the clinical value of preventative surgical resection in the treatment of extra-hepatic portal vein aneurysm. Methods The method of retrospective descriptive study was conducted. The clinical data of 1 patient with extra-hepatic portal vein aneurysm who was admitted to the Guangzhou General Hospital of Guangzhou Military Command of PLA in May 2014 were collected. The patient suffered from dull pain in his epigastrium, with no obvious causative factors. The patient recieved abdominal B-ultrasound, CT scans abdominal and superior mesenteric artery, angiographies after admission in May 2014, and was diagnosed as with extra-hepatic portal vein aneurysm. The preventative surgical resection was selected according to the patient′s individual health status. Extra-hepatic portal vein aneurysm resection was conducted under the guidance of intraoperative ultrasonography after abdominal exploration. A double-cavity drainage tube was placed in the venturis hole when portal vein aneurysm was dissected and removed. Then the abdomen was closed. The patient received regular perioperative management. The operation time, volume of intraoperative blood loss, time for diet recovery, time of drainage tube removal, postoperative complications, results of laboratory tests, results of imaging findings, healing of incision, time of postoperative discharge from hospital, results of pathologic examination and follow-up were observed. Follow-up using outpatient examination or telephone interview was performed to detect the inspect status of portal vein and inspect recurrence of portal vein aneurysm by abdominal B-ultrasound and CT examinations till December 2014. Results The patient underwent successful extra-hepatic portal vein aneurysm resection. The operation time was 85 minutes and the volume of intraoperative blood loss was around 150 mL. The patient gradually returned to normal diet and self-care ability at postoperative day 3, and the abdominal drainage tube was removed at postoperative day 3. No postoperative complications including hemorrhage, portal vein thrombosis and dysfunction of liver were detected after operation. There were normal levels of blood routine and blood biochemical test. Postoperative B-ultrasound examination showed smooth blood flow in portal vein and the abdominal blood vessel CT angiography presented clear image of the portal vein, with smooth blood flow and normal lumen. The surgical incision recovered very well and the patient was discharged from hospital at postoperative day 9. Results of postopeartive pathologic examination showed that there were cystic-like tissues with simple squamous epithelium cells on the interior, the wall of which consisted of smooth muscle was in accordance of the structure of vein. The patient didn′t receive any other special treatment or take medicines postoperatively. The patient had good physical health and can take care of himself during six-month follow-up, without narrow portal vein, recurrence of portal vein aneurysm and other complications. Conclusion Preventative surgical resection is safe and feasible for extra-hepatic portal vein aneurysm, with a good efficacy. Key words: Portal vein aneurysm, extra-hepatic; Surgical procedures, operative; Preventability; Portal vein aneurysm resection

Percutaneous Tenolig® repair under intra-operative ultrasonography guidance in acute Achilles tendon rupture

BackgroundAcute Achilles tendon rupture can be treated conservatively or surgically. Open surgery restores tendon continuity but carries a risk of skin complications. Tenolig® is a device designed for the percutaneous biological treatment of acute Achilles tendon rupture. Earlier studies found high rates of recurrent tears and nerve injury after Tenolig® repair. HypothesisWe hypothesised that intra-operative ultrasonography during Tenolig® repair would decrease the post-operative complication rate and improve functional outcomes. Materials and methodsWe studied 75 consecutive patients with a mean age of 39.9 years. The injury was sports-related in 82.8% of cases. Mean distance from the calcaneal tendon attachment to the tear was 5cm and mean time from injury to repair was 4.2 days. All patients underwent Tenolig® repair under ultrasound guidance followed by early rehabilitation therapy with partial weight bearing started after 3 weeks. ResultsMean follow-up was 20.7 months and no patient was lost to follow-up. A single patient (1.3%) experienced rerupture and none had permanent sural nerve damage. Mean time to sports resumption was 8.6 months, with two-thirds of patients returning to their previous level of sporting activities. The mean AOFAS functional score was 95 and the mean ATRS score was 91.3. DiscussionOur experience suggests that intra-operative ultrasonography, a non-invasive, widely available, and accurate tool, provided improved control of Tenolig® suture position. Ultrasonography provided valuable guidance during this demanding procedure and allowed the very early initiation of rehabilitation therapy. Another crucial factor is patient education about the physical therapy programme. Attention to this point allowed us to obtain robust and reliable functional outcomes in a population predominantly composed of athletes. Level of evidenceLevel IV.

Intraoperative ultrasonography is useful in surgical management of neck metastases in differentiated thyroid cancers.

Differentiated thyroid carcinomas are the most common malignancies of endocrine organs. Metastases to cervical lymph nodes occur in 20-50% of cases. Recurrence and survival rates are closely related to the type of surgery performed. High-resolution ultrasonography (USG) is a sensitive imaging method used to detect occult lymph node metastases in patients with thyroid cancer. We evaluated how intraoperative USG affected surgical success. This was a retrospective study comparing two groups of patients with thyroid carcinoma who underwent cervical lymph node dissection. A total of 101 patients (33 males and 68 females) were included. Group 1 included 53 patients who underwent surgery with intraoperative USG guidance. Group 2 included 48 patients who underwent surgery without the use of USG. All patients were followed up (mean 23 months; range 5-44 months) with thyroglobulin measurements and USG evaluations. Group 1 (intraoperative USG) had a residual/recurrent tumor rate of 1.9% (1/53 patients). Group 2 had a residual/recurrent tumor rate of 12.5% (6/48 patients). A statistically significant difference appeared between the residual/recurrent tumor rates in Groups 1 and 2 (p<0.05). In addition to its classical use in diagnosis and follow-up, intraoperative use of high-resolution USG can improve surgical success and may decrease the number of residual/recurrent tumors encountered during follow-up.

Application of Hepatic Segmental Staining in Anatomic S8 Segmentectomy Under Intra-Operative Ultrasonography

Objective The purpose of this study was to investigate the clinical value of hepatic segmental staining under intra-operative ultrasonography guidance in anatomic segment 8 (S8) segmentectomy. Method This was a retrospective study of 31 patients with hepatocellular carcinoma (HCC) whose lesions were located in S8. Under intra-operative ultrasonography guidance, the hepatic portal vein branch of S8 was dyed and then the resection line was marked with an electric knife on the stained area of the liver surface, in preparation for the anatomic S8 segmentectomy. The liver section exposed the right hepatic vein, the middle hepatic vein trunk side wall and the hepatic pedicle of S8. Results The average operation time of 31 cases of anatomic S8 segmentectomy was (230±76) min, the average surgical blood loss was (305±235) ml, the incidence of post-operative complications was 26% (8/31), average post-operative hospitalization time was (13±3) d, with a 1-year recurrence rate of 19% (6/31) and a 1-year survival rate of 94% (29/31). Conclusion Under the guidance of intra-operative ultrasonography, hepatic segmental staining can improve the precision of an anatomic S8 segmentectomy, maximally reducing the post-operative complications and improving the safety of liver resection.

Is intraoperative ultrasound required in cervical spinal tumors ? a prospective study

To determine the role of intraoperative ultrasonography (IOUSG) in the surgical management of patients with intradural spinal tumors. Twenty-six patients with intradural spinal cord tumors were surgically treated under intraoperative ultrasonographic guidance between January 2007 and May 2011. Guidance with IOUSG was used in 26 patients, of which 14 fourteen had extramedullary and 12 had intramedullary tumors. Intraoperative ultrasound assistance was used to localize each tumor exactly before opening the dura. The extent of tumor resection was verified using axial and sagittal sonographic views. The extent of tumor resection achieved with IOUSG guidance was assessed on postoperative early control MRI sections. Total tumor resection was achieved in 22 (84%) of 26 cases. All of the residual tumors were typically intramedullary and infiltrative. The sensitivity of IOUSG for the determination of the extent of resection was found to be 92%. Ultrasonography was found to be effective in identification of tumor boundaries and protection of spinal cord vessels. The average time spent for IOUSG assessment was 7 minutes. Intraoperative ultrasonography is practical, reliable and highly sensitive for spinal cord surgery. It not only enhances surgical orientation, but also reduces morbidity and helps to resect the tumor completely.

Optimising surgical accuracy in palpable breast cancer with intra-operative breast ultrasound – Feasibility and surgeons’ learning curve

AimsTo evaluate if intra-operative guidance with ultrasonography (US) could improve surgical accuracy of palpable breast cancer excision, and to evaluate the performance of surgeons during training for US-guided excision. Materials and methodsThirty female patients undergoing breast-conserving surgery for palpable T1–T2 invasive breast cancer were recruited. Three individual breast surgeons, assisted by US, targeted and excised the tumours. The main objective was to obtain adequate resection margins with optimal resection volumes. The specimen volume, tumour diameter and histological margin status were recorded. The specimen volume was divided by the optimal resection volume, defined as the spherical tumour volume plus a 1.0-cm margin. The resulting calculated resection ratio (CRR) indicated the amount of excess tissue resected. ResultsAll tumours were correctly identified during surgery, 29 of 30 tumours (96.7%) were removed with adequately negative margins, and one tumour was removed with focally positive margins. The median CRR was 1.0 (range, 0.4–2.8), implying optimal excision volume. For all breast surgeons, CRR improved during the training period. By the 8th procedure, all surgeons showed proficiency in performing intra-operative breast US. ConclusionSurgeons can easily learn the skills needed to perform intra-operative US for palpable breast tumour excision. The technique is non-invasive, simple, safe and effective for obtaining adequate resection margins. Within the first two cases, resections reached optimal volumes, thereby, presumably resulting in improved cosmetic outcomes. In a multicentre, randomised, clinical trial, intra-operative US guidance for palpable breast tumours will be evaluated for oncological and cosmetic outcomes.

“Radical but Conservative” Is the Main Goal for Ultrasonography-Guided Liver Resection: Prospective Validation of this Approach

Despite higher blood loss, morbidity, and mortality, rate of major resection is still high in most surgical institutions because of fear of incomplete tumor removal. To verify whether intraoperative ultrasonography (IOUS) minimizes the rate of major hepatectomies while maintaining treatment radicality, we have prospectively validated our policy, based on extensive use of IOUS resection guidance. Ninety-three consecutive patients with liver tumors were prospectively enrolled. There were 61 men and 32 women with a mean age of 65.6 years. Fifty-nine patients had hepatocellular carcinoma and 34 had colorectal cancer liver metastases. Surgical strategy was based on the relationship between the tumor and intrahepatic vascular structures at IOUS. Rates of major and minor resection, mortality, morbidity, and rate of local recurrences were evaluated. There was no hospital mortality; major morbidity occurred in 2.2% of patients and minor complications in 17%. Six (6.5%) patients required blood transfusion. Major resections (two or more segments) were accomplished in 14 patients (15%), and 5 (5.4%) patients had more than three segments removed. Major vascular invasion was present in 16 patients (17%), and contact without infiltration with major vessels was present in another 16; part of the wall of the inferior vena cava was resected in 1 patient. Surgical clearance was achieved in all patients without local recurrence at a mean followup of 18 months (median 13, range 6 to 52 months). This study shows that liver operations performed under IOUS guidance are safe and radical and reduce need for major hepatectomies.

Intraoperative ultrasonography guidance is accurate and efficient according to results in 100 breast cancer patients

Background The frequency of nonpalpable breast cancer has doubled in the last 10 years. Surgical use of high quality portable ultrasound units has made it possible to evaluate the time-saving method of intraoperative ultrasonography localization. Methods Ultrasonography localization in the operating room immediately prior to definitive surgery was performed by the surgeon. All tissue underwent specimen mammography and ink orientation. The presence of negative margins, the closest margins, the need for reexcision, and the cosmetic result were examined for each patient. Results Ultrasonography correctly localized all breast cancers at surgery (100% sensitivity). Negative margins for invasive carcinoma were found in 90% of patients. Negative margins were at least 10 mm in 27%, at least 5 mm in 62%, and at least 1 mm in 90%. Positive margins were due to the presence of noncalcified ductal carcinoma in-situ (4 of 10) or multifocal invasive disease (6 of 10) noted at final histology. Reexcisions were performed in 9% of patients. Conclusions Surgical use of intraoperative ultrasonography for localization of breast cancer is accurate and efficient. Ultrasonography localization is easier on the patient, is time and cost efficient, and convenient to schedule. Surgeons should embrace this new skill and utilize this tool whenever a nonpalpable breast cancer can be seen with ultrasonography.

Impact of intraoperative ultrasonography on surgery for cystic lesions of the pancreas.

The impact of intraoperative ultrasonography (IUS) on surgery for cystic lesions of the pancreas (CLPs) has not been fully clarified. Twenty patients with CLPs, including 5 pseudocysts and 15 true cysts, were scanned intraoperatively to evaluate the utility and practicality of IUS for CLPs. In four of the five patients with pseudocysts and two with retention cysts, the operative procedures were performed under IUS guidance. In one with a pseudocyst, IUS showed that the cyst did not involve the pancreas, and subsequently cystectomy without pancreatic resection was necessary. In one of the two patients with mucin-producing cystadenocarcinomas, IUS demonstrated a skip lesion in the duct of the pancreatic tail, which contributed to changing the operative procedure from pancreatoduodenectomy to total pancreatectomy; in the other, IUS showed that the lesion was localized in the body of the pancreas, and subsequently segmental pancreatectomy was carried out instead of scheduled pancreatoduodenectomy or distal pancreatectomy. Thus in these three patients the operative procedures were changed in light of the IUS findings. In the remaining 11, although IUS visualized CLPs clearly, it added no new information relevant to the operations. We conclude that IUS contributes to performing surgery for certain types of CLP, such as pseudocysts with severe inflammation, retention cysts with nonpalpable or invisible small cysts, mucin-producing cystadenocarcinomas, and possibly other lesions.

Hepatic Segrnentectomy on Primary Liver Cancer with Situs Inversus Totalis

We present the first case treated by hepatic segmentectomy in a 69-year-old woman with primary liver cancer and situs inversus totalis. The situs inversus did not cause any technical problems during the operation, which was conducted under guidance of intraoperative ultrasonography.

Intraoperative ultrasonography in surgery for chronic pancreatitis.

We report our experience with intraoperative ultrasonography in 49 patients undergoing surgery for chronic pancreatitis. Among drainage procedures, there were 14 laterolateral pancreaticojejunostomies, 15 pseudocystojejunostomies, and 2 pseudocystoduodenostomies. Under the guidance of intraoperative ultrasonography, left sided partial resection of the pancreas was performed in 7 patients, whereas a Whipple-type procedure was necessary in 6 cases. All preoperatively diagnosed pseudocysts, abscess formations, and dilated pancreatic ductal systems could be easily localized with the assistance of intraoperative ultrasound. Additionally to diagnoses already made preoperatively, intraoperative ultrasonography revealed a second, smaller pseudocyst in one patient and pancreaticolithiasis in another case. However, significant assistance and comfort to the operating surgeon was provided in all cases by intraoperative ultrasound imaging. This technique, which is cost effective and minimally invasive, proved to be extremely helpful in localizing pancreatic fluid collections and the course of the pancreatic duct. It facilitates the operation by reducing tissue traumatization and operative time. In experienced hands, intraoperative ultrasonography is a reliable method and a useful adjunct to the surgeon.