Ultrasound Identification Research Articles

Robotic distal pancreatectomy with selective closure of pancreatic duct: surgical outcomes.

Pancreatic fistula is the main post-operative complication of distal pancreatectomy associated with other further complications, such as intra-abdominal abscesses, wound infection, sepsis, electrolyte imbalance, malabsorption and hemorrhage. Surgeons have tried various techniques to close the stump of the remaining pancreas, but the controversy regarding the impact of stapler closure and suture closure of the pancreatic stump is far from resolved. In this study, we reported our technique and results of robotic assisted distal pancreatectomy with ultrasound identification and consequent selective closure of pancreatic duct. Twenty-one patients underwent consecutive robotic-assisted distal pancreatectomy were included in our study. We describe our technique and analyzed the operative and peri-operative data including mean operative time, intra-operative bleeding, blood transfusions necessity, conversion rate, mortality and morbidity rate, pancreatic fistula rate and grade, time of refeeding and canalization, length of hospital stay and readmission. Median operative time was 260min. No conversion occurred. Estimated blood loss was 100mL (range 50-200). No blood transfusions were performed. Mortality rate was 0%. One (5%) patient had a major complication, while 9 (43%) patients had minor complications (grade I). Three (14%) patients developed pancreatic fistula (grade B), while two (10%) patients had a biochemical leak. No late pancreatic fistula and re-operation occurred. The refeeding was started at second day (range 1^-6^) and the median canalization time was 4days (range 2-7). The median hospital stay was 6days (range 3-25) with a readmission rate of 0%. Robotic distal pancreatectomy can be considered safe and feasible. Our technique is easily reproducible, with good surgical results.

EP09.17: Prenatal ultrasound identification of an occipital encephalocele with an underlying duplication of chromosome 7q36.3 including the sonic hedgehog gene

EP09.17: Prenatal ultrasound identification of an occipital encephalocele with an underlying duplication of chromosome 7q36.3 including the sonic hedgehog gene

209 Point-of-Care Ultrasound Use Changes Care When Utilized by Flight Medics

Point-of-care ultrasound (POCUS) has become a widely used tool in emergency medicine. With it, one can quickly diagnose a wide range of pathologies very quickly. In the most acutely ill, quickly identifying pericardial effusion with tamponade, pneumothorax, or hemoperitoneum can allow for life-saving changes in care. Each of those pathologies can be identified quickly with ultrasound. While now commonplace in emergency departments, the benefits of POCUS are just beginning to be realized in out-of-hospital settings. This is a retrospective study of POCUS use by flight nurses and paramedics after training in identification of pericardial effusion with tamponade, pneumothorax, and hemoperitoneum. The study aims to evaluate feasibility of implementing POCUS with a group of flight nurses and paramedics, and to evaluate adequacy of image acquisition and interpretation. In 2017, the flight nurses and paramedics of Lifelink III were trained by emergency physicians in ultrasound identification of pericardial effusion with tamponade, pneumothorax, and hemoperitoneum. This included bilateral lung, cardiac, and right-upper-quadrant (RUQ) abdominal windows. Qpath E was utilized for quality assurance review by ultrasound-trained emergency physicians. Retrospective chart review of cases in which ultrasound was utilized by the flight personnel was performed for cases between 10/1/2017 and 5/15/2018. Adequacy of images for interpretation, correctness of interpretation, and changes in management were assessed. During the study period, 96 ultrasound exams were submitted and evaluated for quality assurance. Images were adequate for evaluation in 86/96 (89.6%) of studies. Ultrasound was used to confirm return of spontaneous circulation in 2 cases of cardiac arrest, and for pulse checks on another cardiac arrest. Two trauma cases had a unilateral lack of lung sliding resulting in out-of-hospital decompression. Peritoneal fluid was seen in a trauma case, which resulted in tranexamic acid and blood being given. The findings of this study suggest that training flight nurses and paramedics in POCUS can be done successfully. POCUS use by such providers can lead to earlier diagnosis of dangerous pathologies and changes in care as a result of such diagnoses being made.

Use of Intraoperative Duplex Ultrasound and Resistance Index Reduces Complications in Living Renal Donor Transplantation

BackgroundThe treatment of choice in end-stage renal disease is transplantation. Hemodynamic disturbances can evoke graft loss, while early ultrasound identification of vascular problems improves outcome. The aim of this study was to identify differences in postoperative complications with and without systematic intraoperative Doppler ultrasound use. MethodsThe primary outcome was the postoperative rate of complications and the secondary aim was to find a predictive resistance index cut-off value, which would show where surgical reintervention was necessary. Over a 10-year period, 108 renal transplants were performed from living donors at our institution. In group 1 (n = 67), intraoperative duplex ultrasound and intraparenchymatous resistance index measurements assessed patients, while in group 2 (n = 41), no ultrasound was performed. ResultsThere were no intergroup differences in the overall postoperative complication rate or in benefit to graft or patient survival with Doppler use. However, significantly more vascular complications (10% vs 0%, P = .02) and more acute rejections (37% vs 10%) occurred in group 2 than in group 1. Therefore, an intraoperative cut-off value of the resistance index 0.5 was proposed to justify immediate surgical revision. ConclusionsThis is the first report demonstrating benefits of systematic intraoperative Doppler ultrasound on postoperative complications in renal transplantation from living donors. Our results support surgical revision with a resistance index <0.5.

Closed Treatment of Shoulder Dislocation in Children With Birth Brachial Plexus Injuries

There is no financial information to disclose. With earlier recognition of shoulder dysplasia, is there a role for intervention with closed shoulder reduction and botulinum toxin injections to improve shoulder dysplasia or prevent future open procedures? Early ultrasound identification and closed treatment of glenohumeral dysplasia in patients with birth brachial plexus injuries (BBPI) and shoulder subluxation can prevent worsening deformity and decrease the need for open shoulder reduction. 26 consecutive patients with BBPI who underwent closed shoulder reductions with or without botulinum toxin injections at a mean age of 6.5 months (range 3–19 months) were followed to failure of treatment (n = 18) or to an average follow-up of 40 months (range 12–66 months). All children included in the study were identified clinically by loss of passive external rotation (PER) with imaging confirming shoulder dislocation (Figure 23-1). All children were treated with closed reduction of the glenohumeral joint under general anesthesia and were casted in maximum shoulder external rotation (ER) (Figure 23-2). Treatment outcomes were assessed by changes in ER and ultrasound measurements of humeral head coverage (HHC) and alpha angle. Descriptive and comparative statistics were performed for all patients with available follow-up for preoperative versus postoperative AMS shoulder ER, PER, ultrasound percent HHC, and alpha angle for initial postoperative values (average 11 weeks). For patients undergoing open reduction, subgroup analysis was performed. Final outcome measures for patients not requiring subsequent open reduction were compared with preoperative measures for AMS and shoulder position. Active Movement Scale shoulder external rotation score improved by 0.7 posttreatment. Passive external rotation increased by 42° (P < .001). Humeral head coverage improved by 39% (P < .001). Alpha angle improved by –41° (P < .001). 18 patients (69%) required an open reduction and tendon transfer of the affected shoulder at an average of 13.4 months (range 1–47 months) after the index procedure. 7 patients (27%) did not require further open shoulder reduction. Of these 7 patients, 2 needed repeated botulinum toxin injections, and 1 repeated closed reduction and nerve transfer. 1 patient was lost to follow -up. The age at the time of closed shoulder reduction was significantly lower in the 7 children who did not require subsequent open reduction. •Early closed reduction of shoulder dislocation in patients with birth brachial plexus injuries improves PER, HHC, and alpha angle.•Early detection and closed treatment can prevent subsequent open reduction in 27% of children.•The authors recommend ultrasound screening of all children with BBPI and loss of PER.Figure 23-2All patients were immobilized for 4–6 weeks with the arm in 30° abduction and maximum external rotation with intraoperative ultrasound confirmation of shoulder reduction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Preoperative Ultrasound Prediction of Essential Landmarks for Successful Fetoscopic Laser Treatment of Twin-Twin Transfusion Syndrome

Introduction: The insertion site of the fetoscope for laser occlusion (FLOC) treatment of twin-twin transfusion syndrome (TTTS) determines the likelihood of treatment success. We assessed a standardized preoperative ultrasound approach for its ability to identify critical landmarks for successful FLOC. Methods: Three surgeons independently performed preoperative ultrasound and deduced the likely orientation of the intertwin membrane (ITM) and vascular equator (VE) based on the sites of the cord insertion, the lie of the donor, and the size discordance between twins. At FLOC, these landmarks were visually verified and compared to preoperative assessments. Results: Fifty consecutive FLOC surgeries had 127 preoperative assessments. Basic ITM and VE orientation were accurately predicted in 115 (90.6%), 109 (85.8%), and 105 (82.7%) assessments. Predictions were anatomically correct in 96 (75.6%), 70 (55.1%), and 58 (45.7%) assessments with no differences in accuracy between operators of different training level. The ITM/VE relationship was most poorly predicted in stage-3 TTTS (χ², p = 0.016). Conclusion: In TTTS, preoperative ultrasound identification of placental cord insertion sites, lie of the donor twin, and size discordance enables preoperative prediction of key landmarks for successful FLOC.

P089: The effect of patient positioning on ultrasound landmarking for cricothyrotomy

Introduction: The cricothyroid membrane is used as a landmark for emergent surgical airway access. Ultrasound identification of the cricothyroid membrane is more accurate than landmarking by palpation. The objective of this study was to determine whether head of bed elevation affects the position of the cricothyroid membrane as identified by ultrasound. Methods: This was a prospective, observational study on a convenience sample of adult patients presenting to the emergency department. Participants underwent ultrasound scans by trained physicians at 0, 30 and 90 degrees head of bed elevation to identify the cricothyroid membrane. The cricothyroid membrane position identified at 0 degrees was used as a reference, and the change in position of the external landmark of the cricothyroid membrane with the patient at 30 and 90 degrees was measured. Additionally, the patients gender, age, body mass index (BMI) and Mallampati score were recorded for comparison. Linear mixed effects models with 95% confidence intervals were used to determine the effect of head of bed elevation, age, BMI and Mallampati score on the differences between measured distances. Results: One hundred and two patients were enrolled in the study. The average change in position from reference was statistically significant for both 30 degrees [2.72±0.77mm (p&lt;0.01)] and 90 degrees [4.23±0.77mm (p&lt;0.01)] head of bed elevation. The adjusted linear mixed effects model showed age greater than 70, BMI over 30 and higher Mallampati score were associated with greater change in distance between cricothyroid membrane landmarks. Conclusion: There was a statistically significant difference in the position of the cricothyroid membrane comparing 0 degrees to 30 and 90 degrees head of bed elevation. However, the relatively small differences suggest that this finding is not clinically relevant. Further study is required to evaluate if these differences impact the actual successful performance of cricothyrotomy.

3:09 PM Abstract No. 293 Guidance on ultrasound: the efficacy of a short, reproducible, interactive course aimed at improving core ultrasound procedural competencies in fourth year medical students

Residents in many specialties perform ultrasound-guided procedures regularly; however, few medical school curricula offer formal education on the topic. The purpose of this study is to evaluate the efficacy of a reproducible, two-day, interactive course aimed at improving core ultrasound procedural competencies in fourth year medical students. All medical students enrolled in a fourth year radiology elective from 2015 to 2017 at an academic medical center attended a two-day interactive ultrasound course led by interventional radiology (IR) faculty. Students completed an anonymous web-based survey before and after the session. Survey topics included knowledge of ultrasound anatomy, transducer selection, procedure identification, and procedural safety (including needle tip versus shaft recognition). Average scores were calculated for each pretest and posttest category and paired sample t-tests were used to evaluate the improvement in each category, with a significance value of 0.01 after Bonferroni correction. 138 students completed the course and both the pre- and postintervention tests. Paired t-test data showed significant improvement in scores on questions regarding ultrasound anatomy (mean scores: +18%, 95% CI: ± 5%, p < 0.001), transducer selection (+33%, ± 6%, p<0.001), procedure identification (+23%, ± 5%, p < 0.001), and questions regarding confirmatory safety measures, e.g., needle tip versus shaft recognition (+34%, ± 5%, p < 0.001). Ultrasound-guided procedures, including paracenteses, thoracenteses, and central line placements, are performed by residents in a variety of specialties, despite the lack of formal education in medical school curricula. Medical students demonstrated significant improvement in key ultrasound procedural competencies following a short, reproducible, interactive course led by IR faculty. Implementation of a similar hands-on session in other curricula may improve procedural competency of future residents and, ultimately, patient safety.

The utility of magnetic resonance imaging in the diagnosis and management of pediatric benign ovarian lesions

BackgroundThe utility of magnetic resonance imaging (MRI) in the diagnosis and management of pediatric ovarian lesions has not been well defined. MethodsA retrospective review of all girls who underwent MRI evaluation of ovarian masses during the period 2009–2015 was performed. The accuracy of MRI was evaluated by comparing results with surgical findings, pathology reports, and subsequent imaging. The influence of the MRI on the treatment plan was specifically explored. ResultsEighteen girls, 12–17years of age, underwent 27 MRIs, subsequent to ultrasound identification of ovarian lesions. Of 9 neoplastic lesions diagnosed on MRI, 8 (89%) were confirmed by surgical and pathological findings. Of 18 functional lesions, 17 (94.4%) were confirmed pathologically or by resolution on subsequent imaging. Twenty MRI exams (74%) directly influenced the treatment plan, by leading to appropriate operative intervention in 9 and appropriate observation in 11. The extent of ovarian resection was guided by MRI findings in 8 of 9 (89%) neoplastic lesions. For characterizing lesions as neoplastic, the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of MRI were 89%, 94%, 94%, 89%, and 93% respectively. ConclusionsMRI can differentiate functional from neoplastic pediatric ovarian masses, and guide ovarian resection in appropriate cases. Level of studyII

The Use of Ultrasonography to Identify the Intersection of the Dorsomedial Cutaneous Nerve of the Hallux and the Extensor Hallucis Longus Tendon: A Cadaveric Study

Terminal branches of the superficial fibular nerve are at risk of iatrogenic damage during foot surgery, including hallux valgus rigidus correction, bunionectomy, cheilectomy, and extensor hallucis longus tendon transfer. One terminal branch, the dorsomedial cutaneous nerve of the hallux, is particularly at risk of injury at its intersection with the extensor hallucis longus tendon. Iatrogenic injuries of the dorsomedial cutaneous nerve of the hallux can result in sensory loss, neuroma formation, and/or debilitating causalgia. Therefore, preoperative identification of the nerve is of great clinical importance. The present study used ultrasonography to identify the intersection between the dorsomedial cutaneous nerve of the hallux and the extensor hallucis longus tendon in cadavers. On ultrasound identification of the intersection, dissection was performed to assess the accuracy of the ultrasound screening. The method successfully pinpointed the nerve in 21 of 28 feet (75%). The sensitivity, positive likelihood ratio, and positive and negative predictive values of ultrasound identification of the junction of the dorsomedial cutaneous nerve and the extensor hallucis longus tendon were 75%, 75%, 100%, and 0%, respectively. We have described an ultrasound protocol that allows for the preoperative identification of the dorsomedial cutaneous nerve of the hallux as it crosses the extensor hallucis longus tendon. The technique could potentially be used to prevent the debilitating iatrogenic injuries known to occur in association with many common foot surgeries.

The ultrasound identification of fetal gender at the gestational age of 11-12 weeks.

Introduction:The early prenatal identification of fetal gender is of great importance. Accurate prenatal identification is currently only possible through invasive procedures. The present study was conducted to determine the accuracy and sensitivity of ultrasound fetal gender identification.Materials and Methods:The present cross-sectional study was conducted on 150 women in their 11th and 12th weeks of pregnancy in Hamadan in 2014. Ultrasound imaging performed in the 11th and 12th weeks of pregnancy for fetal gender identification identified the fetus either as a girl, a boy, or as a “gender not assigned.” Frequency, sensitivity, specificity, positive and negative predictive values, and accuracy of the gender identification was assessed using SPSS version 20. The significant level was 0.05 in all analyses.Results:Of the total of 150 women, the gender was identified as female in 32 (21.3%), as male in 65 (43.3%), and not assigned in 53 (35.3%); overall, gender identification was made in 64.6% of the cases. A total of 57 male fetuses were correctly identified as boys, and 8 female fetuses were wrongly identified as boys. As for the female fetuses, 31 were correctly identified as girls, and 1 was wrongly identified as a boy. The positive predictive value for the ultrasound imaging gender identification was 87.6% for the male fetuses and 96.8% for the female fetuses.Conclusion:The present study had a much higher gender identification accuracy compared to other studies. The final success of fetal gender identification was about 91% in the 11th and 12th weeks of pregnancy.

Validation of tracheal intubation of wire-reinforced endotracheal tube with ultrasonography

Objective. The use of ultrasonography (US) is a new method for verifying the location of the endotracheal tube.Design. Our study was designed as a paired-data and investigator-blind clinical study for evaluating the effectiveness of US for verification of wire-reinforced endotra-cheal tube (WR-ETT) placement compared with capnography.Setting.&nbsp;This study was conducted on 56 patients scheduled for elective surgery un-der general anesthesia.Patients.&nbsp;Fifty patients completed the study as 6 were excluded for various reasons. Intervention. Two different investigators performed the ultrasonography and intu-bation independently from one another. While investigator 1 attempted to verify the location of the WR-ETT with a portable ul-trasonography with sagittal trans-tracheal view, investigator 2 intubated the patient and verified the location of the ETT using capnography.Measurements. Time for verifying the loca-tion of the ETT using both US and capnog-raphy was recorded.Main Results.&nbsp;When the ultrasonography method was compared with capnography for verification of the WR-ETT placement, the results showed 95.75% sensitivity and 100% specificity. The average verification times for endotracheal intubation were 12.78 ± 7.46 s. and 24.44 ± 1.45 s. with US and capnography, respectively (p=0.003). Conclusion. Our results suggest that ultra-sound identification of a WR-ETT within the trachea is a rapid and accurate method for confirmation of tracheal placement. Larger studies are needed before wide-spread use of this technique.

Ultrasound Identification of Diaphragm by Novices Using ABCDE Technique.

In this study, we examined the consistency, rapidity, and reproducibility of the ABCDE technique for diaphragm identification. Operators using this method place the probe at the Anterior axillary line, watch for Breathing (lung sliding), and then move the probe Caudally to identify the Diaphragm for Examination. A convenience sample of 100 patients was recruited from the preadmission clinic. Two novice operators each scanned the diaphragm using a linear ultrasound transducer in B-mode. Both operators completed the examination on all participants using the ABCDE technique, their times were averaged, and clinical success was defined as identification of the diaphragm in less than 2 minutes. An average of 33.7 seconds was taken to scan and identify the right hemidiaphragm (RD) (median, 25 seconds; 95% confidence interval, 28.8-38.5 seconds) with a 98% clinical success ratio, and an average of 46.9 seconds was taken to identify the left hemidiaphragm (LD) (median, 39.5 seconds; 95% confidence interval, 40.2-53.6 seconds) with a 97% clinical success ratio. In patients with a body mass index (BMI) of less than 30 kg/m, a 100% success ratio was seen when scanning the RD and 97% when scanning the LD. For those with a BMI of 30 kg/m or greater, a 94% success rate was seen when scanning the RD and 97% when scanning the LD. No clinically significant differences were found between the times required for scanning either side of the diaphragm, regardless of the BMI. The ABCDE technique demonstrates a fast, reliable, and simple method in which ultrasound can be used to visualize the diaphragm.

Choledochal cyst, polysplenia and situs ambiguous: A rare and new association

Abstract Introduction Situs ambiguous (SA) is a rare clinical entity that includes a spectrum of abnormalities in which organs and vessels are opposed to their normal arrangement. SA is frequently associated with other malformations such as splenic alterations, biliary atresia and vascular abnormalities. We report two cases of patients with SA, polysplenia and choledochal cyst. This association has never been described to date. Case reports Two patients, both males, came to our attention at the ages of 7 and 8 months after ultrasound identification of choledochal cysts. One patient, who had a prenatal suspicion of situs ambiguous and dextrocardia, presented with failure to thrive and increased hepatic enzymes. The other patient was asymptomatic, but prenatal evaluation showed gastric malposition. Post-natal laboratory tests were normal. Preoperative radiological diagnostic work-up showed polysplenia, intestinal anomaly of rotation and fixation, pre-duodenal portal vein in one baby. Both patients underwent surgical correction by cyst excision and Roux-en-Y hepaticojejunostomy. Follow-up (3 months and 3.5 years respectively) was uneventful. Biochemical hepatic parameters normalized soon after surgery. Discussion Situs anomalies in children are often associated with other malformations. The most common are splenic and cardiac defects but intestinal malformations and hepatico-biliary abnormalities have been reported too. Above all, the BASM (biliary atresia splenic malformation) syndrome has been extensively examined, obtaining important information on the etiology of the cystic form of biliary atresia. Conclusions A careful evaluation of patients with situs ambiguous is important to exclude associated anomalies and to plan the most appropriate surgical approach. The association with choledochal cyst should be taken into account.

Determining the amount of training needed for competency of anesthesia trainees in ultrasonographic identification of the cricothyroid membrane

BackgroundAirway guidelines recommend the use of ultrasound to localize the cricothyroid membrane prior to airway manipulation in difficult airways. In this study, we aimed to determine the amount of training anesthesia trainees would need to achieve competence in bedside ultrasound to identify the cricothyroid membrane.MethodsThis is a prospective non-randomized cohort study in the Department of Anesthesia at Mount Sinai Hospital (Toronto, Ontario, Canada). Following institutional ethics approval, six anesthesia trainees consisting of four residents and two fellows underwent a 2-h training session on neck ultrasound to identify neck landmarks and the cricothyroid membrane. The trainees had no previous airway ultrasound experience. One-two weeks later, each trainee performed consecutive neck ultrasound scans on 20 healthy volunteers to identify the cricothyroid membrane. Cumulative sum (CUSUM) learning curves were constructed for each trainee. Primary outcome was the number of ultrasound examinations required to achieve competence, defined as 90% success rate in a series of 20 ultrasound scans. Secondary outcomes were the overall success rate, the time (sec.) required to perform the task, and 3-month skills assessment.ResultsCUSUM analysis showed four trainees achieved competence with a mean [range] success rate of 94.0% [90–100%] and a median [range] number of attempts of 14 [9–18]. Two trainees did not achieve competence, but obtained a success rate of 75.0 and 80.0% each. Overall (number of attempts) success rate was 88.3% (106/120) with a mean (SD) time of 36.9 (9.0) sec. Three months after training, ultrasound of five consecutive neck scans showed a mean success rate of 86.7% (26/30) and mean (SD) time of 47.7 (16.0) sec.ConclusionsAfter a short 2-h training session, most anesthesia trainees (n = 4/6) achieved competence in ultrasound-identification of the cricothyroid membrane with less than 20 scans in a mean time less than 60 s., and that they remain reasonably competent 3 months later. The learning curve for ultrasound identification of the cricothyroid membrane seems to be short even without prior airway ultrasound experience.

Multiplex PCR approach to simultaneously identify several mutations in fine needle cytology thyroid samples.

The most frequent initial manifestation of thyroid cancer is the appearance of a nodule. More than 20% of the general population has a palpable thyroid nodule and the percentage rises to 70% based on ultrasound identification. In 95% of cases the nodule is simply a hyperplastic or benign lesion. The most reliable diagnostic test for thyroid nodules is fine needle aspiration (FNA), but cytological discrimination between malignant and benign follicular neoplasms remains difficult. Cytological analysis is now, almost routinely, being combined with molecular genetics to enable the pathologist to make a more objective diagnosis. In this study, we performed the molecular analysis using a new simplified procedure that involves a panel of BRAF, RAS, RET and RET/PTC gene mutations in easily obtainable FNA samples, in the attempt to improve the efficacy of the FNA diagnosis of thyroid nodules and thus patient management. In this new procedure, PCR and sequencing analysis are used to detect point mutations, and, in parallel, RT-PCR is used to detect the chimeric RET/PTC1 and RET/PTC3 transcripts in RNA extracted from FNA.

Large renal calculus and ipsilateral flank (incisional) hernia: Perhaps another indication for Mini PCNL?

IntroductionThe use of the Mini PCNL has been gaining momentum since its first description in 2001. The range of indications for this particular procedure may also be expanding. We describe a case of a large renal calculus in a renal collecting system, found in a patient who underwent an Anatrophic Nephro-Lithotomy [ANL] procedure a few years back. He subsequently developed a flank (incisional) hernia after the ANL. Some, twenty years later he presented with another large (22mm) stone in the same system. ObservationAttempt at stone clearance was performed using the Mini PCNL. To avoid iatrogenic injury to the surrounding bowel loops in the hernia sac, a combined ultrasound and fluoroscopic technique was performed, with limited respiration and suspended abdominal fat at the time of renal access. The dilation was performed to accommodate the Mini PCNL sheath, thus minimizing the possibility of iatrogenic bowel injury. A serial balloon dilator was not used, in the presence of such severe fibrosis from the previous open surgery (ANL). ConclusionThe presence of a hernial sac within the ipsilateral flank may be amenable to Mini PCNL, provided the basic principles of puncture are maintained. This includes the use of adequate positioning, limited respiration and the use of ultra-sound identification of the bowel loops during access puncture and tract dilatation. A new indication for the use of Mini PCNL is thus reported.

Cadaver study of anatomic landmark identification for placing ankle arthroscopy portals

BackgroundArthroscopy-assisted surgery is now widely used at the ankle for osteochondral lesions of the talus, anterior and posterior impingement syndromes, talocrural or subtalar fusion, foreign body removal, and ankle instability. Injuries to the vessels and nerves may occur during these procedures. ObjectiveTo determine whether ultrasound topographic identification of vulnerable structures decreased the risk of iatrogenic injuries to vessels, nerves, and tendons and influenced the distance separating vulnerable structures from the arthroscope introduced through four different portals. HypothesisUltrasonography to identify vulnerable structures before or during arthroscopic surgery on the ankle may be useful. Material and methodTwenty fresh cadaver ankles from body donations to the anatomy institute in Strasbourg, France, were divided into two equal groups. Preoperative ultrasonography to mark the trajectories of vessels, nerves, and tendons was performed in one group but not in the other. The portals were created using a 4-mm trocar. Each portal was then dissected. The primary evaluation criterion was the presence or absence of injuries to vessels, nerves, and tendons. The secondary evaluation criterion was the distance between these structures and the arthroscope. ResultsNo tendon injuries occurred with ultrasonography. Without ultrasonography, there were two full-thickness tendon lesions, one to the extensor hallucis longus and the other to the Achilles tendon. Furthermore, with the anterolateral, anteromedial, and posteromedial portals, the distance separating the vessels and nerves from the arthroscope was greater with than without ultrasonography (P=0.041, P=0.005, and P=0.002), respectively; no significant difference was found with the anterior portal. DiscussionPreoperative ultrasound topographic identification decreases the risk of iatrogenic injury to the vessels, nerves, and tendons during ankle arthroscopy and places these structures at a safer distance from the arthroscope. Our hypothesis was confirmed. Level of evidenceIV, cadaver study.

Point-of-care ultrasound identification of pneumatosis intestinalis in pediatric abdominal pain: a case report

We describe a case report of an infant with intussusception who presented to a pediatric emergency department with diarrhea and increased irritability. Pneumatosis intestinalis (intra-mural air) detected on point-of-care ultrasonography (but not apparent on plain abdominal radiographs) alerted the emergency physicians towards the severity of disease process.

Reliability of Ultrasound in the Identification and Measurement of Blood Supply to the Anterior Part of the Mandible

ABSTRACTObjectiveThe aim of this study is to identifyin vivothe main blood supply to the bony chin and to determine the efficacy of ultrasound Doppler in determining this aspect and then compare it with radiograph.Materials and methodsThe study was carried on 50 subjects divided into two equal groups. In the first group, the lingual foramen was identitifed on intraoral periapical (IOPA) radiograph of the mandibular incisor region. Ultrasound Doppler identification of blood supply to the anterior part of the mandible was carried out. In the second group of 25 subjects, the procedure was reversed. This was done to avoid procedural bias.DiscussionIn our patients, the midline artery entering the lingual foramen was seen by ultrasound and radiograph. Their average diameters and velocities were measured. It was identified in 46 cases by the ultrasound Doppler examination. The IOPA radiographic examination was successful in identifying the foramen in 30 cases. The average diameter of the midline artery entering the lingual foramen was found to be 0.14 cm. The average velocity of blood flow in this artery was found to be 25.5 cm/second.ConclusionThe ultrasound Doppler is a reliable tool to visualize and measure the blood supply to the anterior part of the mandible.How to cite this articleKiran MS, Manjunath M, Shukla AK, Vidya S. Reliability of Ultrasound in the Identification and Measurement of Blood Supply to the Anterior Part of the Mandible. J Med Sci 2017;3(1):20-24.