Intraoperative Ultrasound

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History

We developed this technique to be used on any abdominal organ but is especially effective in case of infiltrative, focal and multifocal GI lesions. The problem is that the surgeon cannot often see what the clinical sonographer is observing from a transabdominal sonographic perspective. If the organ serosa is not visibly affected, the surgeon will simply perform a “shopping spree” of intestinal biopsies as opposed to a precise sampling procedure of the most representative lesion that we observe sonographically. Hence we may identify and resect the most representative mural lesions with this method.

Procedure

Acoustic gel is placed into a double surgical glove to keep the outside exposed glove sterile. Cold sterilize the ultrasound probe with alcohol before putting it in the glove. Pull the glove tight on top the probe to ensure adequate probe/gel/glove coupling occurs to avoid any air entrapment. Have the surgeon exteriorize the bowel or expose the target organ to be sampled. A technician pours saline on the bowel (or other organ) as a coupling agent. Scan the organ to define the most representative region of the mural pathology that was observed transabdominally. Then define the best healthy tissue where the infiltrative pattern or pathology subsides and resect the lesion at this identified point of healthy tissue proximal and distal to the affected region. This procedure should take the sonographer 10 minutes or so and the surgeon may do the rest.

Comments

This procedure ensures as complete a resection of unhealthy bowel as possible and also ensures that healthy bowel is utilized for the anastamosis. Postoperative dehiscence may be avoided by this intraoperative intervention. More on this technique may be seen in our abstract from ECVIM 2009 (Intraoperative Ultrasound for Precise Biopsy and Resection of Transabdominally Detected Intestinal Lesions in 3 cats. Lindquist, Casey, Frank)

Free fluid is noted in the abdominal cavity with a dilated portion of small intestine with lack of mural detail. A significant amount of hyperechoic reactive omentum is adhered to the pathological portion of intestine (Far field left portion of image). This is a bowel torsion with peritonitis.

Since the surgeon and sonographer do not know the underlying pathology occurring in this patient at the time of surgery (neoplasia, inflammatory bowel, bowel infarction, mural sepsis…) and wish to resect UNhealthy bowel and anastamose healthy bowel, the clinical sonographer images the bowel directly with the probe covered with a sterile sleeve until the best representation of healthy bowel with clean curvilinear contour and mural detail is found. This healthy bowel from a sonographic perspective (more precise than the serosal surgical perspective) is located proximal to and distal from the affected pathological bowel. The surgeon may attach a suture to the indicated healthy region as a marker for resection and anastamosis.