Morison's Pouch Research Articles

Robotic Excision of Morrison's Pouch and Full-Thickness Diaphragmatic Endometriosis

Robotic Excision of Morrison's Pouch and Full-Thickness Diaphragmatic Endometriosis

Involvement of Morrison's Pouch in Right Upper Quadrant Endometriosis

Involvement of Morrison's Pouch in Right Upper Quadrant Endometriosis

Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery.

Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.

Giant Pseudocyst of the Pancreas: A Rare Case Report

A Pancreatic Pseudocyst (PP) is a fluid-filled collection often found near the pancreas. It is characterised by its contained structure and homogeneous fluid composition, with little to no necrotic tissue. Individuals with a history of chronic pancreatitis, and to a lesser extent acute pancreatitis, may exhibit non specific symptoms. To minimise related morbidity and mortality, any potential complications must be identified. The authors present a case of a rare giant PP in a 28-year-old man who presented with abdominal pain and distention, severe backache, fever, frequent vomiting, loss of appetite, weight loss, and firm, sticky stools. Initially measuring 25×19.2×11.2 cm on a Computed Tomography (CT) scan, this PP was unusually large for its type. Due to the patient’s condition not being suitable, a direct cystojejunostomy was performed. Three drains were placed: an anastomotic drain near the anastomosis site, a Morrison’s drain in the Morrison pouch, and a pelvic drain. Later, a complication arose in the form of a faecal fistula, which was managed conservatively with a suction drain. The patient’s only primary complaint was non specific stomach pain, despite the size of the pseudocyst. Therefore, individuals with a history of chronic alcoholism and symptoms such as abdominal pain and distension should be evaluated for PP. A CT scan is recommended to investigate this condition, despite its rarity.

Supragastric lesser sac: an insidious site for surgical exploration during the debulking surgery in advanced ovarian cancer.

Metastases in the supragastric lesser sac (SGLS) are not only occult but are also barriers to complete resection of ovarian cancer. We describe a cohort of patients with SGLS disease undergoing debulking surgery. We identified all patients who underwent evaluation and eventual resection of SGLS disease as part of cytoreductive surgery for stage IIIC-IVB high-grade epithelial ovarian cancer at our institution from January 2018 to August 2022. Thirty-three of 286 patients (11.5%) underwent resection of SGLS disease. Metastases in the SGLS were identified by preoperative imaging in 4 of 33 patients (12.1%). The median peritoneal cancer index score was 22 (range, 9-33). Through surgical exploration, metastases were frequently seen in the right diaphragm (100%), hepatorenal recess (97%), lesser omentum (81.8%), left diaphragm (78.8%), supracolic omentum (75.8%), anterior transverse mesocolon (72.7%), splenic hilum (63.6%), ligamentum teres hepatis (60.6%), and gallbladder fossa (51.5%). The lesser omentum was normal in 6 of 33 (18.2%) patients, despite metastases within the SGLS. A total of 54.5% of patients underwent complex surgery (surgical complexity scores; median, 8; range, 3-14). Complete resections were achieved in 19 (57.6%) patients. No complications were related to the resection of SGLS disease. The median length of progression-free survival was 24.8 months (95% confidence interval=16.6-32.9). Metastases to the SGLS are not uncommon in advanced ovarian cancer, particularly those with widely disseminated disease. Disease in this recess is rarely identified by preoperative imaging and deserves systematic surgical exploration to attain complete cytoreduction.

334 Novel Application of Artificial Intelligence in Ultrasound of Solid Organ Adjacent Morison's Pouch by Object Segmentation

334 Novel Application of Artificial Intelligence in Ultrasound of Solid Organ Adjacent Morison's Pouch by Object Segmentation

Investigating the Skill Development of Medical Students in Focused Assessment With Sonography for Trauma (FAST) Ultrasound: A Comparative Analysis Across Different Stages of Medical Training.

Focused assessment with sonography for trauma (FAST) ultrasound (US) is a valuable medical examination used in trauma settings, particularly for rapid responses to events such as natural disasters. Although the efficacy and benefits of FAST in patient care have been extensively studied, there is limited research on training medical students in FAST. Previous studies have found that medical students can proficiently perform a FAST US after two days of training. However, these studies exclusively included first-year medical students without considering variations in their medical knowledge. Particularly, the advantage of medical students having US experience before undergoing FAST training has not been previously examined. Assess the performance and knowledge acquisition of medical students with and without prior US experience after completing a FAST training course. The study included a total of 71 students, consisting of 33 males and 38 females, who were between the ages of 18 and 31, with an average age of 24.6 and a standard deviation of 2.4. The inclusion criteria targeted first- and second-year medical school students who participated on a volunteer basis. Students were divided into two groups: group A, consisting of those without prior USexperience, and group B, made up of those who had previous US experience. All students completed a pre-training survey to share their comfort and confidence in US use and knowledge. A baseline FAST exam was conducted to establish initial performance. A comprehensive three-hour training session was then provided. Post-training, students performed another FAST exam to assess improvement, followed by a post-training survey to evaluate comfort and confidence. Medical students who had prior experience in the US (group B) performed significantly better (p<0.01) in both the pre- and post-training FAST exams when compared to students without previous US experience. Specifically, in locating the liver, right kidney, hepatorenal recess, and left kidney, as well as detecting fluid accumulation when in a supine position. Additionally, medical students with prior US experience (group B) exhibited higher baseline confidence (p<0.005-p<0.01) in their ability to perform a FAST exam, as indicated by the results of the pre-testing survey. Previous experience with USsignificantly boosted confidence and knowledge gains following FAST training. This emphasizes the value of including US training in medical school programs after earlier exposure, offering evident benefits. The study reveals the unexplored benefit of having prior US experience for medical students undergoing FAST training, thus addressing a previously unexplored area in current research. The conclusions stress the necessity of integrating US training into medical school curricula after initial exposure. This understanding can direct medical educators in refining the education process, enabling students to be better equipped for real-world medical situations involving FAST.

Trauma by Couch: A Case Report of a Massive Traumatic Retroperitoneal Hematoma.

Trauma, retroperitoneal hemorrhage, ultrasound, FAST, computed tomography, hepatorenal recess, Morrison's pouch.

Use of Automated Machine Learning for Classifying Hemoperitoneum on Ultrasonographic Images of Morrison's Pouch: A Multicenter Retrospective Study.

This study evaluated automated machine learning (AutoML) in classifying the presence or absence of hemoperitoneum in ultrasonography (USG) images of Morrison's pouch. In this multicenter, retrospective study, 864 trauma patients from trauma and emergency medical centers in South Korea were included. In all, 2200 USG images (1100 hemoperitoneum and 1100 normal) were collected. Of these, 1800 images were used for training and 200 were used for the internal validation of AutoML. External validation was performed using 100 hemoperitoneum images and 100 normal images collected separately from a trauma center that were not included in the training and internal validation sets. Google's open-source AutoML was used to train the algorithm in classifying hemoperitoneum in USG images, followed by internal and external validation. In the internal validation, the sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve were 95%, 99%, and 0.97, respectively. In the external validation, the sensitivity, specificity, and AUROC were 94%, 99%, and 0.97, respectively. The performances of AutoML in the internal and external validation were not statistically different (p = 0.78). A publicly available, general-purpose AutoML can accurately classify the presence or absence of hemoperitoneum in USG images of the Morrison's pouch of real-world trauma patients.

Radical surgery for stage IV gallbladder cancers: Treatment strategies in patients with limited metastatic burden.

The present study looked at the role of radical surgery in gallbladder cancers (GBC) with limited metastatic disease. The retrospective observational study was conducted to screen the database from 1st January 2010 to 31st December 2019. Patients of GBC found to have low-volume metastatic disease upon surgical exploration were included. Of the 1,040 patients operated for GBC, 234 patients had low-volume metastatic disease (microscopic disease in station 16b1 node or N2 disease isolated port-site metastases, or low burden peritoneal disease with deposits less than 1 cm, in adjacent omentum or adjacent diaphragm or Morrison's pouch or a solitary discontinuous liver metastasis in adjacent liver parenchyma) detected intraoperative. Of these, 62 patients underwent radical surgery for R-0 metastatic disease followed by systemic therapy, while the remaining 172 patients did not undergo radical surgery and were given palliative systemic chemotherapy. Patients who underwent radical surgery had significantly superior overall survival (19 months versus 12 months, p < 0.01) and superior progression-free survival (10 months versus 5 months, p < 0.01) when compared to the rest. This difference in survival was more significant amongst patients when operated on after neoadjuvant chemotherapy. Regression analysis showed that a sub-group of patients with incidental GBC with limited metastases showed more favorable outcomes with radical surgery. Authors suggest a possible role for radical treatment of advanced GBC with a limited metastatic burden. Neoadjuvant chemotherapy can be used for preferentially selecting patients of favorable disease biology for curative treatment.

Morrison's Pouch: Anatomy and Radiological Appearance of Pathological Processes.

Morrison's pouch is the intraperitoneal space in the supramesocolic compartment located between the right liver lobe and right kidney. Pathological conditions that can involve this peritoneal space include fluid collections, infectious or inflammatory processes, and neoplasms. Frequent involvement by disease entities can be attributed to its dependent location, communication with the inframesocolic compartment, close proximity to the adjacent organs and peritoneal fluid dynamics. Knowledge of the appearance of pathological entities on various imaging modalities helps the radiologist in making the correct diagnosis.

OGBN P21 A complex case of gallbladder and CBD stones treated with Laparoscopic Cholecystectomy and Trans-Cystic lithotripsy using SpyGlass™ Discover post failed ERCP

Abstract Background Laparoscopic Cholecystectomy and bile duct exploration remain the gold standard treatment for gallstone disease associated with bile duct stones. However, interval two session management with ERCP followed by Laparoscopic Cholecystectomy should be avoided. It exposes patients to preventable risk of perforation, bleeding, and pancreatitis, especially if the patient is fit and keen for surgery. Trans-Cystic bile duct exploration (TC BDE) appears to have less morbidity than Trans- Ductal bile duct exploration (TD BDE). However, large bile duct stones remain the main challenge for Trans-Cystic approach along with distorted anatomy. Methods We present a 48-year-old female with symptomatic gallstone disease and a complex past surgical history. Results Trial of ERCP failed despite Needle-knife papillotomy due to large mobile and hard papilla. Unfortunately, the patient suffered post ECRP pancreatitis that was complicated by an abdominal collection around the head of the pancreas. The collection required radiologic drainage through the anterior abdominal wall, 13 days post-pancreatitis. The patient recovered well and was listed for a Laparoscopic Cholecystectomy and bile duct exploration with high risk of conversion to open, 6 weeks after discharge. The operation was challenging due to presence of adhesions and shrunken gallbladder (Nassar grade IV). Trans-Cystic BDE was performed using basket inside catheter (BIC) technique. SpyGlass™ Discover choledochoscopy showed a clear distal CBD and a large 12mm stone in the common hepatic duct. The stone was hard and required a high setting of lithotripsy (30, Max). The stone was fragmented successfully, and all fragments extracted using baskets. The cystic duct was closed by suturing using 3.0 Vicryl and two Robinson abdominal drains were left in the abdomen; one in Morrison's pouch and one in the sub-diaphragmatic space. The patient had an uncomplicated post-operative recovery and was discharged home after 5 days. Follow-up 8 months later was satisfactory. Conclusions Trans-Cystic bile duct exploration has become increasingly safe and feasible even for large bile duct stones using new technology. ERCP should be avoided in young fit patients, especially females due to the higher risk of post-ERCP pancreatitis.

Don't Forget to Look Up: Operating in the Upper Abdomen

<h3>Study Objective</h3> To illustrate strategies to improve efficiency and ergonomics when operating in the upper abdomen. <h3>Design</h3> A stepwise demonstration of our operating room modifications when operating in the upper abdomen with narrated video footage. <h3>Setting</h3> Given the marked improvement in laparoscopic technology, gynecologic surgeons feel comfortable operating in the pelvis for a variety of gynecologic pathologies. When pathology is found outside of the pelvis, however, gynecologic surgeons find operating in the upper abdomen challenging. Operating in the upper abdomen is difficult given the loss of ergonomics and the impression of operating backwards. It is prudent for minimally invasive gynecologic surgeons to master operating in the upper abdomen given the variety of pathologies a gynecologist can encounter outside of the pelvis. We aim to describe our operating room modifications that help simulate operating in the upper abdomen as if one was operating in the pelvic cavity. <h3>Patients or Participants</h3> A compilation of various patient procedures showcasing upper abdominal surgery including resection of pericardial endometriosis, Morrison's pouch endometriosis and a para-aortic lymphadenectomy. <h3>Interventions</h3> The patients elected to undergo laparoscopic surgery for their individualized evaluation and treatment plan. If the surgery is a combined procedure, after completion of the pelvic phase, the operating room must be modified to proceed with the upper abdomen. Strategies to improve efficiency and ergonomics when operating in the upper abdomen include: •Switching monitors to the patients' shoulders bilaterally •Changing surgeon location to the right side of the patient •Changing port configuration •30-degree camera selection <h3>Measurements and Main Results</h3> All patients recovered well without any postoperative complications. <h3>Conclusion</h3> Although gynecologic surgeons have the skills and adequate knowledge of anatomy to operate in the upper abdomen, some lack the ability to adapt their surgical set up to operate outside the pelvis. Gynecologists should familiarize themselves with strategies and techniques to be able to confidently operate in the upper abdomen.

Laparoscopic Repair of Post-Coital Vaginal Perforation Communicating with the Abdominal Cavity

<h3>Study Objective</h3> The objective of this video is to describe an approach to the work-up and surgical management of postcoital vaginal laceration communicating with the abdominal cavity. <h3>Design</h3> N/A. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> The patient is an 18 y/o G0 who presented 12 hours after intercourse with heavy vaginal bleeding, diffuse abdominal pain, and multiple syncopal episodes. Initial exam was notable for hypotension, diffuse abdominal pain with involuntary guarding, and copious vaginal bleeding from the vagina of unclear origin. <h3>Interventions</h3> A bedside FAST scan demonstrated free fluid in Morrison's pouch. CT scan demonstrated multiple foci of air in the pelvis consistent with vaginal perforation. The patient was taken to the OR for laparoscopic repair of a 4cm full-thickness vaginal perforation communicating with the abdominal cavity, where 300cc of hemoperitoneum was evacuated from the abdominal cavity. An air leak test was performed at the end of the case to ensure no injury to the sigmoid colon. <h3>Measurements and Main Results</h3> The patient received was discharged on POD#1 in stable condition. <h3>Conclusion</h3> Vaginal perforation communicating with the abdominal cavity is a rare complication of intercourse that can have a delayed presentation and occur with hemorrhagic shock. FAST scan can be employed at the bedside to rapidly identify massive hemoperitoneum. Though prior case reports have mainly reported an open repair, a laparoscopic approach is a safe and effective method to repair vaginal defects communicating with the abdominal cavity. Finally, given the high rate of traumatic rectovaginal fistula reported in this population, surgeons should consider the use of an intraoperative air-leak test to confirm colorectal integrity after the repair.

S3361 Liposarcoma Masquerading as IgG4-Related Disease

Introduction: IgG4-related disease (IGRD) is characterized by lymphoplasmacytic tissue infiltration by IgG4-positive plasma cells and small lymphocytes and is known to involve multiple organs, sometimes simultaneously.1 Retroperitoneal involvement is common with IGRD, often presenting as mass-like lesions and fibrosing disease such as retroperitoneal fibrosis2 and sclerosing mesenteritis3. While there is no established association, very few cases have been reported in literature about strong IgG4 positivity and sarcomas.3,4 Investigation usually warrants biopsy, as imaging studies and serologies cannot differentiate between IGRDs and sarcomas. We present a case of an aggressive liposarcoma mimicking IGRD. Case Description/Methods: A 40-year-old female presented with right upper quadrant (RUQ) pain for 3 months. Patient was hemodynamically stable with physical exam demonstrating fullness and tenderness in RUQ. CT abdomen revealed a 12.9x11.8x8.7 cm heterogenous macro-lobulated mass located below the inferior hepatic border in the retroperitoneal space and hepatorenal recess (Figure A). CT guided biopsy of the mass revealed increased IgG4-positive cells identified by immunohistochemical studies, however, FISH MDM2 amplification studies were inconclusive. Patient’s serum IgG4 levels were elevated, and she was started on prednisone therapy. At 2 month follow-up, the patient’s serum IgG4 levels had decreased but upon physical examination, the mass had increased in size and was firmer. Decision was made to repeat CT-guided biopsy, wherein MDM2 amplification studies revealed that the mass was consistent with well-differentiated liposarcoma (Figure B). She underwent liposarcoma resection, lymph node dissection, and right nephrectomy (adherent to the mass). Histopathologic analysis revealed a final diagnosis of stage I well-differentiated liposarcoma. Patient now follows for surveillance of her liposarcoma. Discussion: IGRD and liposarcoma can have common initial presentations and at times overlapping serological markers such as IgG4 levels, which necessitates histopathologic analysis for confirmation of the disease. In addition, raised IgG4 levels are not specific and can be elevated in infections and autoimmune conditions5. Our case emphasizes the importance of considering liposarcomas in retroperitoneal masses with elevated IgG4 levels, as they can mimic IGRD. A repeat biopsy should be considered if the initial diagnosis is doubtful, or patient responds poorly to corticosteroids.Figure 1.: A) Coronal view of the CT scan showing a macrolobulated heterogenous mass measuring 10.6x10.5x14.1cm, B) MDM2 expression of mass using FISH.

Tele‐Ultrasound: Virtual Hands‐on Medical Education for Novice Users Utilizing FAST &amp; Carpal Tunnel Models, Pilot Study

Ultrasound (US) training is an emerging tool, utilized to enhance anatomy education in medical schools with preliminary incorporation into non‐medical anatomy courses. The need for distanced, virtual, education has always been present with an exponential increase in demand due to COVID‐19. Recent developments in point‐of‐care‐ultrasound (POCUS) have enabled relay of remote imaging and communication, Tele‐US. This pilot study aims to assess whether the integration of virtual self‐paced modules and virtually guided (VG) ultrasound sessions, utilizing the Butterfly iQ (BiQ) US device, is as effective as in‐person (IP) learning for novice users.Study sessions included three, 30‐minute modules: Introduction, Carpal Tunnel (CPL‐T), Focused assessment with sonography in trauma (FAST). Live hands‐on active learning sessions utilized CPL‐T and FAST modules where groups of 2‐3 participants performed peer‐peer scanning. Hands‐on guidance was given to IP groups, whereas VG groups received guidance through the BiQ Tele‐guidance software (TGS). The TGS provides remote video conferencing, real‐time imaging relay for simultaneous viewing by the operator and educator, educators ability to remotely change settings, and the integration of augmented reality to provide visual cues to the operator on screen. Seven first‐year medical students were invited to participate in the IRB‐exempt pilot study. Pre‐ and Post‐study online surveys were used to collect data on previous US training utilizing multiple choice questions and self‐perception of confidence levels US skill and usefulness of the BiQ US system. Perceptions were assessed utilizing a 5‐point Likert scale (1= strongly disagree/not useful/extremely difficult, 5= strongly agree/extremely useful/extremely easy). Additionally, a 20‐point assessment was administered IP by staff to participants in a random order on 4 key anatomical regions; median nerve, radial artery, hepatorenal recess, and thorax to assess participant US skill levels at the end of the live session. Feedback provided to participants after the assessment period was completed for all participants.Two‐way t‐tests were used to assess post‐study ratings and assessment scores. Pre‐ and post‐study survey response rates were 100% (3 IP, 4 VG) with roughly equal gender distribution. Comparison of post assessment survey did not show a significant difference (SD) in self confidence levels (P&gt;0.05) between the groups across all 5 prompts: ease of CPL‐T/ FAST, usefulness of BiQ, confidence in displaying CPL‐T/FAST. Further, a SD in scores during the live session assessment was not observed (IP average= 15.5 ±0.71, VG average= 12.3 ±2.9; P=0.1). Detailed analysis was not performed due to the limited sample size of the pilot study.Perceived confidence and assessment scores do not differ when comparing traditional POCUS to Tele‐US using BiQ for novice users, suggesting that medical students can demonstrate equal competency levels when undergoing distanced US education as IP courses. Yet, further testing is required to expand the sample size and test in‐group variances.

Increasing incidence and severity of post-hepatectomy adhesion around the liver may be influenced by the hepatectomy-related operative procedures

BackgroundThe incidence of postoperative adhesions is directly correlated with the difficulty level of repeat hepatectomies. However, the incidence, location, and severity of postoperative adhesions in relation to hepatectomy-related operative procedures are yet unclear. MethodsFirst hepatectomy-induced hard dense adhesions were evaluated from the surgical records and/or videos of 168 patients who underwent second hepatectomies. ResultsThe incidence of postoperative hard dense adhesions around the liver was significantly associated with locations, such as the hepatic cut surface, dissected areas around the liver, and peri-incision peritoneum, and hepatectomy-related operative procedures, such as Pringle maneuver and cholecystectomy. The incidence of hard dense adhesions after dissection was higher around the right liver than in the left infraphrenic space. Further, the incidence of hard dense adhesions around the hepatoduodenal ligament or Morison pouch was greater than 30% even in patients who did not undergo Pringle maneuver, cholecystectomy, or hepatorenal ligament dissection. Although the incidence of hard dense adhesions of the peritoneum around the incision was higher after open hepatectomy than after laparoscopic hepatectomy, adhesion barrier use reduced the incidence of such adhesions in patients after open hepatectomy. ConclusionHepatectomy-related operative procedures such as peri-hepatic dissection, Pringle maneuver and cholecystectomy are directly associated with postoperative hard dense adhesions. However, the incidence of postoperative hard dense adhesions around the hepatoduodenal ligament and Morison pouch was high even when the above-mentioned operative procedures were not performed. These findings may help inform clinical decisions regarding the indications and sites for adhesion barrier use during hepatectomies.

Focused Assessment with Sonography for Trauma

The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients. This review contains 10 figures, 7 tables, 8 videos and 58 references Keywords: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

Focused Assessment with Sonography for Trauma

The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients. This review contains 10 figures, 7 tables, 8 videos and 58 references Keywords: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

Focused Assessment with Sonography for Trauma

The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients. This review contains 10 figures, 7 tables, 8 videos and 58 references Keywords: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography