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BIOSCIENCE V ad e me c u m Table of contents 8. Insertion of the Central Catheters 9. Transcranial Doppler 2. FAST (Focused Assessment by Sonography in Trauma) 10. Diagnosis and Treatment of Fluid Collections and Other Pathology 3. Chest Trauma 11. Open Applications 4. Abdominal Aortic Aneurysm Screening in the Emergent Setting 12. Laparoscopic Applications 5. Appendicitis 13. Breast Ultrasound 14. Vascular 15. Rectal 6. Pediatric Applications Ultrasound for Surgeons 1. Education Credentialing and Getting Started: With Attention to Physics and Instrumentation V ad eme c um LANDES LANDES BIOSCIENCE V ad e me c u m Ultrasound for Surgeons 7. Surveillance of Deep Vein Thrombosis (DVT) The Vademecum series includes subjects generally not covered in other handbook series, especially many technology-driven topics that reflect the increasing influence of technology in clinical medicine. The name chosen for this comprehensive medical handbook series is Vademecum, a Latin word that roughly means “to carry along”. In the Middle Ages, traveling clerics carried pocket-sized books, excerpts of the carefully transcribed canons, known as Vademecum. In the 19th century a medical publisher in Germany, Samuel Karger, called a series of portable medical books Vademecum. ISBN 1-57059-597-6 All titles available at www.landesbioscience.com 9 781570 595974 Frankel The Landes Bioscience Vademecum books are intended to be used both in the training of physicians and the care of patients, by medical students, medical house staff and practicing physicians. We hope you will find them a valuable resource. Heidi L. Frankel v a d e m e c u m Ultrasound for Surgeons Heidi L. Frankel, M.D., F.A.C.S. Associate Professor of Surgery Section of Trauma and Surgical Critical Care Yale University New Haven, Connecticut, U.S.A. LANDES BIOSCIENCE GEORGETOWN, TEXAS U.S.A. VADEMECUM Ultrasound for Surgeons LANDES BIOSCIENCE Georgetown, Texas U.S.A. Copyright ©2005 Landes Bioscience All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Printed in the U.S.A. Please address all inquiries to the Publisher: Landes Bioscience, 810 S. Church Street, Georgetown, Texas, U.S.A. 78626 Phone: 512/ 863 7762; FAX: 512/ 863 0081 ISBN: 1-57059-597-6 Library of Congress Cataloging-in-Publication Data Frankel, Heidi L. Ultrasound for surgeons / Heidi L. Frankel. p. ; cm. -- (Vademecum) Includes index. ISBN 1-57059-597-6 1. Ultrasonics in surgery. 2. Operative ultrasonography. I. Title. II. Series. [DNLM: 1. Ultrasonography--methods--Handbooks. 2. Surgical Procedures, Operative--methods--Handbooks. WN 208 F828u 2004] RD33.7.F73 2004 617'.07543--dc22 2003025277 While the authors, editors, sponsor and publisher believe that drug selection and dosage and the specifications and usage of equipment and devices, as set forth in this book, are in accord with current recommendations and practice at the time of publication, they make no warranty, expressed or implied, with respect to material described in this book. In view of the ongoing research, equipment development, changes in governmental regulations and the rapid accumulation of information relating to the biomedical sciences, the reader is urged to carefully review and evaluate the information provided herein. Dedication Dedicated to my husband, John, and spouses like him, who allow us to practice our craft. Contents Foreword ......................................................................... 12 Acknowledgements ......................................................... 14 1. Education Credentialing and Getting Started: With Attention to Physics and Instrumentation ............... 1 Vicente H. Gracias, Heidi Frankel and Ronald I. Gross Historical Perspective .................................................................................. 1 Education in Surgeon-Performed Ultrasound: Training/Credentialing and Practice Domains ......................................................................... 1 Credentialing in Ultrasound ....................................................................... 2 A Physics Primer ......................................................................................... 6 Appendix I. CESTE Guidelines Surgeon Eligibility and Verification in Basic Ultrasonography .......................................... 7 Appendix II. Credentialing Requirements for Granting of Privileges to Surgeons to Perform the Focused Abdominal Sonogram in Reply To: Trauma (FAST) ............................................................... 9 General Principles ....................................................................................... 9 Training ...................................................................................................... 9 Maintenance of Qualifications .................................................................. 10 Use in the Emergent Setting 2. FAST (Focused Assessment by Sonography in Trauma) ... 11 Ronald I. Gross History ..................................................................................................... 12 Technique: Performing the FAST Examination ......................................... 14 Advantages and Drawbacks of the FAST Examination .............................. 19 Application: Uses of FAST in the Acute Setting ........................................ 21 Future Applications of Ultrasound in the Acute Setting ............................ 24 Appendix I. Lectures for Postgraduate Course No. 23: Ultrasound for the General Surgeon .................................................................... 26 3. Chest Trauma .................................................................. 30 Frank Davis and M. Gage Ochsner Cardiac Injuries ........................................................................................ 30 Blunt Cardiac Injuries ............................................................................... 34 Traumatic Effusions (Hemothoraces) ........................................................ 35 Ultrasound Diagnosis of Pneumothorax ................................................... 37 TEE ......................................................................................................... 39 IVUS Assessment of Traumatic Injury to the Thoracic Aorta .................... 44 4. Abdominal Aortic Aneurysm Screening in the Emergent Setting .................................................. 49 David B. Pilcher Relation of Aneurysm Size to Risk of Rupture .......................................... 49 Ultrasound Equipment ............................................................................. 49 Information by Ultrasound Other Than Aneurysm Presence and Size ....... 52 Performing Aortic Aneurysm Ultrasound .................................................. 52 Comparison to CT Scan and Plain X-Rays ............................................... 52 5. Appendicitis .................................................................... 54 Shyr-Chyr Chen Historical Review ...................................................................................... 54 Graded Compression Technique ............................................................... 55 Modified Compression Method ................................................................ 57 Sonography of Normal Appendix ............................................................. 60 Sonographic Diagnosis of Appendicitis ..................................................... 61 6. Pediatric Applications ..................................................... 68 Oluyinka Olutoye, Richard Bellah and Perry Stafford Acute Appendicitis .................................................................................... 68 Hypertrophic Pyloric Stenosis (HPS) ........................................................ 70 Intussusception ......................................................................................... 72 Intestinal Malrotation ............................................................................... 73 Testicular Torsion ...................................................................................... 73 Trauma ..................................................................................................... 76 Use in the ICU 7. Surveillance of Deep Vein Thrombosis (DVT) ................ 78 Rajan Gupta and Jeffrey Carpenter History and Indications ............................................................................ 78 Technique and Pitfalls ............................................................................... 80 8. Insertion of Central Catheters......................................... 84 Tarek Razek and Michael Russell Background .............................................................................................. 84 The Problem ............................................................................................. 84 Guided Techniques ................................................................................... 85 Potential Disadvantages to the Routine Use of Ultrasound Guidance ........ 87 Clinical Efficacy of Ultrasound Guided Central Venous Cannulation ....... 87 9. Transcranial Doppler ...................................................... 91 George Counelis and Grant Sinson Technique ................................................................................................. 91 Clinical Usage ........................................................................................... 92 Cerebrovascular Disease ............................................................................ 94 Aneurysmal Subarachnoid Hemorrhage .................................................... 96 Occlusive Disease ...................................................................................... 97 Arteriovenous Malformations ................................................................... 98 Traumatic Brain Injury ............................................................................. 98 Intracranial Pressure and Brain Death ....................................................... 99 10. Diagnosis and Treatment of Fluid Collections and Other Pathology ..................................................... 102 Mark McKenney and Morad Hameed Technical Considerations ........................................................................ 102 Specific Applications—Indications, Methods, and Limitations ............... 104 Placement of Suprapubic Catheters ......................................................... 109 Use in the Operation Room 11. Open Applications ........................................................ 111 Paul V. Gallagher, David Wherry and Richard Charnley General Indications for Intraoperative Ultrasound .................................. 111 Ultrasound Equipment for IOUS and LUS ............................................ 112 The Scope of Operative Ultrasound ........................................................ 113 Intraoperative Ultrasound of the Liver .................................................... 114 Intraoperative Ultrasound of the Pancreas ............................................... 122 IOUS and LUS during Cholecystectomy ................................................ 125 Other Indications of Intraoperative Ultrasound ...................................... 125 12. Laparoscopic Applications ............................................ 128 Raj R. Gandhi Indications for Use of LUS ..................................................................... 128 Instruments ............................................................................................ 128 Techniques .............................................................................................. 130 LUS: Specific Techniques and Applications ............................................. 130 Use in the Office / Preoperative Setting 13. Breast Ultrasound ......................................................... 133 Sheryl Gabram and Nicos Labropoulos Biopsy Types ........................................................................................... 133 Training and Credentialing ..................................................................... 135 Equipment and Technique ...................................................................... 136 Ultrasound Classification of Lesions ....................................................... 138 Ultrasound Biopsy Technique ................................................................. 140 14. Vascular ......................................................................... 142 David Neschis and Jeffrey Carpenter General Concepts Used in Evaluating the Vasculature with Doppler Ultrasound ................................................................ 145 Effects of Stenoses ................................................................................... 147 Specific Indications for Use of Duplex Ultrasound in the Office Setting ........................................................................ 148 15. Rectal ............................................................................ 155 John Winston and Lee E. Smith Indications .............................................................................................. 155 Preparation and Technique ..................................................................... 156 Anatomy ................................................................................................. 157 Staging of Carcinomas ............................................................................ 161 Sphincter Injuries .................................................................................... 161 Abscesses and Fistulas ............................................................................. 163 Follow-Up of Tumors .............................................................................. 164 Retrorectal Tumors and Biopsies ............................................................. 165 Biopsies .................................................................................................. 165 Results, Accuracy, Sensitivity and Specificity ........................................... 165 Index ............................................................................. 169 Editor Heidi L. Frankel Associate Professor of Surgery Section of Trauma and Surgical Critical Care Yale University New Haven, Connecticut, U.S.A. Chapter 1 Contributors Richard Bellah Surgical Resident Children's Hospital of Philadelphia Philadelphia, Pennsylvania, U.S.A. Chapter 6 Jeffrey Carpenter Associate Professor of Surgery University of Pennsylvania School of Medicine Director, Vascular Laboratory Hospital of the University of Pennsylvania Philadelphia, Pennsylvania, U.S.A. Chapters 7, 14 Richard Charnley Consultant Hepatobiliary and Pancreatic Surgeon Hepato-Pancreato-Biliary Surgery Unit Freeman Hospital Newcastle upon Tyne, U.K. Chapter 11 Shyr-Chyr Chen Vice-Chairman and Associate Professor Department of Emergency Medicine National Taiwan University College of Medicine Taipai, Taiwan Chapter 5 George Counelis Attending Neurosurgeon Diablo Neurosurgical Medical Group, Inc. Walnut Creek, California, U.S.A. Chapter 9 Frank Davis Assistant Chief Trauma, Surgical Critical Care Memorial Health University Medical Center Associate Professor of Surgery Mercer School of Medicine Savannah, Georgia, U.S.A. Chapter 3 Sheryl Gabram Director, Breast Care Center Cardinal Bernardin Cancer Center Vice Chairman of Education and Program Director Associate Professor of Surgery Loyola University Medical Center Maywood, Illinois, U.S.A. Chapter 13 Paul V. Gallagher Consultant Surgeon Northumbria Health Care NHS Trust North Shields, Tyne and Wear, U.K. Chapter 11 Raj R. Gandhi Medical Director for Trauma Services Hillcrest Baptist Medical Center Waco, Texas, U.S.A. Chapter 12 Vicente H. Gracias Assistant Professor of Surgery University of Pennsylvania Medical Center Philadelphia, Pennsylvania, U.S.A. Chapter 1 Ronald I. Gross Assistant Professor of Traumatology and Emergency Medicine University of Connecticut School of Medicine Associate Director of Trauma Hartford Hospital Hartford, Connecticut, U.S.A. Chapters 1, 2 Rajan Gupta Assistant Professor of Surgery Division of Traumatology and Surgical Critical Care University of Pennsylvania School of Medicine Philadelphia, Pennsylvania, U.S.A. Chapter 7 Morad Hameed Assistant Professor of Surgery University of British Columbia Trauma Services, Vancouver General Hospital Vancouver, British Columbia, Canada Chapter 10 Nicos Labropoulos Assistant Professor of Surgery Director, Vascular Laboratory Department of Surgery Loyola University Medical Center Maywood, Illinois, U.S.A. Chapter 13 Mark McKenney Professor of Surgery Department of Surgery University of Miami Miami, Florida, U.S.A. Chapter 10 David Neschis Assistant Professor of Surgery Division of Vascular Surgery University of Maryland Medical Center Baltimore, Maryland, U.S.A. Chapter 14 M. Gage Ochsner Professor of Surgery Mercer University School of Medicine Savannah, Georgia, U.S.A. Chapter 3 Oluyinka Olutoye Surgical Resident Children's Hospital of Philadelphia Philadelphia, Pennsylvania, U.S.A. Chapter 6 David B. Pilcher Professor of Surgery Division of Vascular Surgery University of Vermont College of Medicine Burlington, Vermont, U.S.A. Chapter 4 Tarek Razek Assistant Professor of Surgery McGill University Health Center Montreal General Hospital Montreal, Quebec, Canada Chapter 8 Grace S. Rozycki Department of Surgery Emory University School of Medicine Atlanta, Georgia, U.S.A. Foreword Michael Russell Assistant Professor Anesthesia and Surgical Critical Care University of Pennsylvania Director, Anesthesia and Cardiopulmonary Services The Outer Banks Hospital Nags Head, North Carolina, U.S.A. Chapter 8 Lee E. Smith Professor of Surgery Georgetown University Director, Section of Colon and Rectal Surgery Washington Hospital Center Washington, D.C., U.S.A. Chapter 15