Intraoperative ultrasonography in surgery for liver tumors

Intraoperative ultrasonography was used in 37 patients during surgery for suspected liver tumors. The size, number, and site of the lesions were determined together with the relationship of the tumor to the intrahepatic vessel, as well as possible small daughter lesions within the liver. Final diagnosis in these patients was hepatocellular carcinoma in 19 cases, metastases from colorectal cancers in 15 cases, and benign lesions in three cases. Previously undetected small tumors were revealed in one patient with sigmoid cancer and in five patients with liver cell carcinoma who had cirrhosis. Vascular tumoral infiltrations were easily displayed and the surgical approach modified accordingly: a more extended resection was performed in two cases of huge central hepatic metastases. Intraoperative ultrasonography revealed seven cases of small (2 to 3 cm) hepatocellular carcinomas in cirrhotic livers that were not visible or palpable, thus allowing a subsegmentary resection. Finally, in three cases of atypical tumors, an intraoperative echo-guided biopsy specimen was required to establish the benign nature of lesions and resection was avoided. Intraoperative ultrasonography facilitates the diagnosis of small liver tumors and can also aid the surgeon in his choice of technique, especially in cases of cirrhosis of the liver. A resection can be avoided altogether when multiple lesions are involved, or echo-guided subsegmentary resections can be performed in cirrhotic livers when a less extended resection is required. This technique makes it possible to establish the relationship between the tumor and intrahepatic vessels, thus preventing vascular injury and making radical hepatic resection safer.     

Intraoperative ultrasonography in AVM surgery

Intraoperative ultrasonography was used for the surgical resection of arteriovenous malformations in three cases. In the first case, intraoperative ultrasonography clearly demonstrated residual micro-AVM, which had seemed to be resected completely during surgery. In the second case, diminished flow of the draining vein by clipping of the feeding artery was demonstrated by ultrasonography. In the third case, intraoperative ultrasonography revealed stasis of the flow in the varix by clipping of the feeding artery. Intraoperative ultrasonography is easy to use and less expensive compared with intraoperative digital subtraction angiography or MRI and it is also effective for identifying AVMs as well as the flow patterns of the feeding arteries or draining veins. Intraoperative ultrasonography is a useful device for AVM surgery.     

术中超声用于机器人辅助肝切除术

机器人辅助肝切除术(RALR)克服了传统腹腔镜肝切除术(LLR)的瓶颈,使之具备完成更大型、更复杂手术的能力。术中超声(IOUS)用于RALR扩展了RALR适应证,提高了肿瘤完整切除率及手术安全性。本文结合笔者经验对IOUS辅助RALR的应用体会进行综述。     

术中超声在肝脏肿瘤手术中的应用价值

目的 探讨术中超声在肝脏肿瘤手术中的应用价值.方法 对45例肝脏肿瘤患者行术中超声检查(Logiq 500型超声仪,5～7.5 MHz线阵式术中专用探头),并与术前超声(PHILIPSHDI 5000型超声仪,3.5～5 MHz凸阵式探头)和增强CT检查对比分析,比较三者在病灶检出率方面的差异.结果 术中超声对直径≥1 cm病灶的检出率为100%,高于术前超声(89.80%)和CT(97.96%)的检出率,但差异无统计学意义(术前超声xc2=3.372,P>0.05,CT Fisher确切概率为P=1.00);术中超声对直径<1 cm病灶的检出率为90.70%,明显高于术前超声的检出率(62.79%)和CT检出率(74.42%)(术前超声x2=9.382,CT x2=3.957,均P<0.05);术中超声对病灶的总体检出率为95.65%,明显高于术前超声的检出率(77.17%)和CT检出率(86.96%)(术前超声x2=13.378,CT x2=4.381,均P<0.05),所有新发现的病灶都在术中超声的引导下行手术切除或无水乙醇瘤内注射.结论 与术前影像学检查相比,术中超声可以提高隐匿部位和微小病灶的检出率,有助于指导外科操作和手术治疗.     

Intraoperative ultrasonography in open and laparoscopic abdominal surgery: an overview

This article reviews the current state of intraoperative ultrasonography in open surgery (IOUS) and laparoscopic surgery (LUS). The review is based on extensive study of data published (Pubmed search) and on 25 years of personal experience with intraoperative ultrasonography. The main application areas of IOUS and LUS and its use during liver, biliary tract, and pancreatic surgery are discussed. The benefits and limitations as well as future expectations with regard to the existing and emerging applications also are discussed. New developments in ultrasound technology and the increasing experience of surgeons in ultrasonography secure the future for IOUS and LUS.     

Intraoperative cholangiography using a balloon catheter in liver surgery

To prevent intraoperative injury of the bile ducts, we designed a balloon catheter and used it in the intraoperative cholangiography of 36 patients undergoing hepatectomy for primary carcinoma of the liver at the Second Department of Surgery of Osaka City University Hospital during the past 4 years. After cholecystectomy, the balloon catheter was inserted through the cystic duct up to the common bile duct, and cholangiography was performed before and after liver resection. This method makes intrahepatic bile ducts easier to visualize. In 14 of the 53 patients in whom cholangiography using a balloon catheter or conventional catheter was done, the abnormal branching of the intrahepatic bile ducts was found before resection, and the liver was resected without injuring the ducts. In 2 of the 36 patients in whom cholangiography with a balloon catheter was performed, leakage of the contrast medium from the resected liver surface was visible, and this part of the liver was sutured. With this new method, postoperative complications caused by bile leakage decreased. No side effects developed after the balloon catheter was used. We have used basically the same technique in other kinds of hepatobiliary disease.

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Resumen Con el objeto de prevenir la lesión intraoperatoria de los canales biliares hemos diseñado un catéter de balón, el cual ha sido utilizado en la colangiografía intraoperatoria de 36 pacientes sometidos a hepatectomía por carcinoma primario del hígado en el 2° Departamento de Cirugía del Hospital Universitario de la ciudad de Osaka en los últimos 4 años. Al término de la colecistectomá, el catéter de balón fue insertado a través del canal ctico hasta llegar al colédoco, y la colangiografía fue realizada antes y después de la resección hepática. El método hace posible la fácil visualización de los canales biliares. En 14 de 53 pacientes en que se realizó colangiografía mediante el balón de catéter o un catéter convencional, se pudo demostrar una ramificatión anormal de los canales intrahepáticos antes de la resección, y la resección hepática pudo ser realizada sin lesionar los canales. En 2 de 36 pacientes en que se hizo colangiografía con el catéter de balón, se visualizó escape del medio de contraste a partir de la superficie de la resección hepática, lo cual hizo posible el suturar esta región del hígado. Gracias a este método novedoso se logró disminuír el número de complicaciones postoperatorias causadas por el escape de bilis. No se observaron efectos indeseables colaterales con el uso del catéter de balón. Hemos utilizado básicamente la misma técnica en el manejo de otros tipos de enfermedad hepato-biliar.

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Résumé Afin de prévenir le traumatisme des canaux biliaires, les auteurs ont mis au point un cathéter gonflable qu'ils ont utilisé au cours des cholangiographies peropératoires chez 36 patients opérés par hépatectomie pour un carcinome primitif du foie. Les interventions ont été pratiqués dans le 2ème Département de Chirurgie du Centre Hospitalier de Osaka durant les 4 dernières années. Après cholecystectomie, le cathéter gonflable est inséré a travers le canal cystique jusqu'à la voie biliaire commune. Une cholangiographie est réalisée avant et après la résection hépatique. Cette méthode permet une visualisation plus aisée des canaux intrahépatique. Chez 14 patients parmi les 53 dont la cholangiographie a été réalisée en utilisant le cathéter gonflable ou un cathéter conventionnel, il a été possible de visualiser les embranchements anormaux des canaux biliaires intrahépatiques avant la résection, permettant de résequer le foie sans endommager ceux-ci. Chez 2 patients parmi les 36 dont la cholangiographie a été pratiquée avec le cathéter gonflable, une fuite du produit de contraste provenant de la surface résequée a été visualisée, permettant la suture de cette partie du foie. Avec cette nouvelle méthode, les complications postopératoires provoquées par les fuites biliares ont diminué. Aucun effet secondaire n'a été observé après l'utilisation du cathéter. Les auteurs ont utilisé, à la base, la même technique dans d'autre types de pathologies hépatobiliaires.

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Presented at the Société Internationale de Chirurgie in Paris, September 1985.     

Intraoperative ultrasonography through a burr-hole

Summary Intraoperative ultrasound diagnosis through a burr-hole was performed in 22 cases using a 5 MHz electronic sector-scanning transducer. The pathology along with the landmarks, such as ventricles and the interhemispheric fissure, were visualized. In two cases, a second burr-hole was placed nearby, and aspiration of the fluid was accomplished under real-time ultrasonic monitoring using the first hole as an acoustic window. Our results suggest a possibility of ultrasound-guided stereotactic surgery of the brain through twin burr-holes.     

Intraoperative angiography during aneurysm surgery: a prospective evaluation of efficacy

OBJECT: Indications for intraoperative angiography during aneurysm surgery remain unclear. To define its use, the authors report the results of a prospective study in which this modality was used in all patients undergoing surgery for intracranial aneurysms. METHODS: Intraoperative angiography was performed prospectively in the surgical treatment of 517 consecutive aneurysms regardless of the lesion's location, size, or complexity. In 64 (12.4%) of 517 aneurysms intraoperative angiography findings prompted a change in surgical treatment. Residual aneurysm (47%) was the most frequent finding leading to clip revision. In 44% of cases, intraoperative angiography revealed vessel compromise. Surgery for aneurysms of the proximal internal carotid artery (ICA) was the most frequently altered, with lesions located at the superior hypophyseal artery (SHA) and clinoidal region having the highest revision rates, eight (40%) of 20 and eight (44%) of 18, respectively. Aneurysm size predicted the need for revision; giant aneurysms (> 24 mm) underwent revision in nine (29%) of 31 cases, whereas large aneurysms (15-24 mm) were revised in 12 (22%) of 54 cases. In a multivariate logistic regression model, factors related to increased revision rates included the SHA and clinoidal locations, as well as giant and large size. Ninety-five patients underwent both intraoperative and postoperative angiography. Five discrepancies were noted (95% accuracy); four were flow-related and one involved a previously unrecognized residual aneurysm. Complications attributable to intraoperative angiography occurred in 0.4% of cases. CONCLUSIONS: Proximal ICA location and large aneurysm size significantly predicted revision of surgery following intraoperative angiography. Unexpected findings, even in less complex locations, are frequently identified on intraoperative angiography. Low complication rates, high accuracy, and the unexpected need for clip readjustments favor a more widespread use of intraoperative angiography.     

Intraoperative ultrasonography imaging in spinal surgery (technique and indications).

Intraoperative ultrasonography was conducted in 20 patients; the technique of intraoperative ultrasonography for use in spinal surgery is described. The authors emphasize that this non-invasive method obtains real time images of considerable diagnostic importance, allowing for a significantly minor use of image intensifier, with a consequent reduction in doses for both the patient and the staff.     

Intraoperative ultrasonography in detecting and assessment of colorectal liver metastases.

OBJECTIVE: to assess the clinical value of intraoperative ultrasonography (IOUS) in detecting and assessment of liver metastatic tumours in colorectal cancer patients. METHODS: a study is a retrospective analysis of 388 patients operated on for colorectal carcinoma between 1997 and 2004. In all the patients intraoperative ultrasound was performed. The authors analyzed of sensitivity, specificity, PPV, NPV and accuracy of pre- and intraoperative ultrasonography in detecting and staging of colorectal metastatic lesions. RESULTS: Intraoperative ultrasonography showed the highest sensitivity, specificity and accuracy in both, tumor detection (99.1, 98.5 and 98.9%, respectively) and assessment (95.4, 99.5 and 99.1%, respectively). Overall sensitivity of IOUS was significantly better in detection and staging compared with preoperative ultrasonography 91.1 and 72.2%, respectively). CONCLUSIONS: IOUS should be used as routine diagnostic modality in colorectal cancer patients with hepatic metastases or suspected metastases. Transabdominal ultrasonography cannot be used as the only diagnostic tool in the evaluation of liver lesions, but may be helpful in preoperative screening.     

Intraoperative use of real time ultrasonography applied to aneurysm surgery

The intraoperative application of real time ultrasonography during 13 neurosurgical operations for intracranial aneurysms is reported. In 2 cases, the aneurysms themselves could be detected clearly by real time ultrasonic imaging. In the case of a large aneurysm, information about the nature of the aneurysmal wall was obtained. Other lesions coexisting with the aneurysm (namely, intracerebral hematoma, massive subarachnoid hemorrhage, and hydrocephalus) could be recognized clearly. Real time intraoperative ultrasonography is considered to be useful in aneurysm surgery.