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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5774_Библиотеки_им_академика_М_И_Перельмана.pdf
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7 Interventional Ultrasound inObstetrics andGynecology
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a
b
c
Fig. 7.13 Sonohysterography of multiple endometrial polyps combined with incomplete uterus septum. (a) The patient is 27years old,
who was diagnosed with primary infertility. The manifestation of ultrasound shows two separate uterine cavities, with thickened and inhomogeneous endometrium. (b) The transverse view of the uterus shows two
uterine cavities. (c) After injection of contrast agent, the right uterine
cavity is observed to be separated by 1.0cm, and left uterine cavity
separated by 1.1cm. Several slightly hyperechoic masses are found on
each wall in each uterine cavity. The shape is smooth, the boundary is
clear, the maximum diameter of the mass is 1.5cm
Fig. 7.14 Sonohysterography of submucosal uterine myoma (I).
(a) The patient is 60 years old. Sonogram shows the slightly
hypoechoic occupation in the uterine cavity, with unclear boundary.
(b) After the injec tion of contrast agents, the hypoechoic mass in the
size of 2.2 cm × 1.7 cm × 1.5 cm is attached to the posterior wall of the
uterine cavity. And the width of attachment surface is 1.5 cm
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Fig. 7.15 Sonohysterography of submucosal uterine myoma (II). (a)
The patient is 45years old and has a history of menorrhagia with blood
clots. Sonogram shows the slightly hypoechoic mass in the uterine cavity with the diameter of about 3cm. (b) After the injection of contrast
a
c
agents, the hypoechoic mass in the size of 2.7cm×2.5cm×1.7cm is
attached to the anterior wall of the uterine cavity, with inner
attenuation
b
Fig. 7.16 Sonohysterography of intramural uterine myoma extruding
to the cavity. (a) The patient is 34 years old, and the sonogram shows
the occupation in the uterine cavity. (b) After injection of the contrast
agent, the hypoechoic mass in the uterine cavity is attached to the right
anterior wall, near the fundus; (c). About two-third of the mass is protruding into the uterine cavity, and one-third is located in the muscle
wall
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7 Interventional Ultrasound inObstetrics andGynecology
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– Obstructed fallopian tube: When injecting the con-
trast agent, the resistance is large, and the reux
will happen when the injection stops. The fallopian tube is absent or partially displayed. There is
no strong echo around the ovary and no microbubble echoes in the pelvic cavity (Fig.7.28)
– The fallopian tube is partially obstructed: There is
resistance when injecting contrast agents and a
small amount of reux. The fallopian tube is
locally slender or nodular, and runs in the tortuous
and angled way. There is half a circle of strong
echo around the ovaries and a small amount of
microbubble in the rectouterine pouch and intestinal space (Fig. 7.29).
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Fig. 7.17 Endometrial atrophy. Sonohysterography shows the thin
endometrium, only 1mm in thickness
• patency assessment of the fallopian tube (negative
contrast agent),
– The fallopian tube is unobstructed: After injection,
the contrast agent quickly ows out from the bilateral fallopian tubes, and the ultrasonography
shows a hyperechoic band around adnexa. Liquid
display in the rectouterine pouch and there is no
resistance during injection (Fig.7.30).
– Obstructed fallopian tube: After injection of con-
trast medium, the contrast medium forms a vortex at the corner of the uterus, and no contrast
medium passes through the fallopian tube. There
is no band-like hyperechoic ow seen in the
adnexa area, and no obvious liquid dark area in
the rectouterine pouch. The resistance is high,
and the patient feels abdominal pain or bloating.
In hydrosalpinx cases, the injected contrast agent
ows in the dilated fallopian tube (Fig.7.31).
– The fallopian tube is partially obstructed: After
the contrast medium is injected, the contrast
medium slowly passes through the fallopian
tube, and there is no obvious banding hyperechoic ow around the adnexa, and a little liquid in the rectouterine pouch. When injecting,
resistance can be felt.
IV. Intraoperative monitoring during intrauterine surgery.
With the extensive development of uterine cavity sur-
gery, complications have also increased. Application of
ultrasonography as intraoperative monitoring can help to
ensure the safety of surgery and reduce the occurrence of
complications. In the past three years, 676 cases of various difcult transvaginal operations have been con-
Fig. 7.18 Sonohysterography of endometrial hyperplasia (I). (a) The
patient is 40years old, and occupation lesion is suspected in the uterine
cavity. (b) After injecting the contrast agent, sonogram shows the endo-
metrium is uneven, and the posterior wall is locally thickened by
1.0cm, with a range of 1.9 cm×1.6 cm, which is homogeneous and
clearly demarcated from the myometrium
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a
b
c
Fig. 7.19 Sonohysterography of endometrial hyperplasia (II). (a) The
patient is 36years old and has a history of menorrhagia for 6months.
The endometrium is thickened and inhomogeneous. (b) After injection
ducted by the monitor of ultrasonography, in our hospital
with a success rate of 97.7%, no serious complications
occurred. Ultrasonography has been used as a routine
monitoring technique in intrauterine surgery.
• Indications
– Difcult uterine cavity surgery, such as abnormal
uterine position, uterine malformation, abnormal
pregnancy, and various kinds of uterine cavity surgery that need to be performed again after failure.
– Hysteroscopy surgery.
• Operation process
The transabdominal approach is often chosen as
ultrasound monitoring for intrauterine surgery.
– Require the patient to properly ll the bladder
before surgery. The patient took the bladder
lithotomy position, routinely get disinfected and
draped.
of contrast agents, the thickness of the posterior endometrium is 1.1cm.
(c) Sonogram shows the irregular surface of the endometrium after
injection of contrast agent
– Ultrasound monitoring is processed in the longitu-
dinal section. Before surgery, observe the position
of the uterus, intrauterine gestational sac, villi
attachment, and the relationship between occupation disease, uterine cavity, and muscle wall.
– During the operation, the probe moving up and
down, guiding the surgical equipment, and ensures
the operation of equipment is within the track.
– Observe whether there is an abnormal situation in
the pelvis cavity after the operation.
• Notes
– Pay attention to prevent the occurrence of uterine
injury and perforation, track the position of the
device, and constantly inform the surgeon of the
direction and location of the device.
– Intraoperative ultrasound images show that the
operating instruments are strongly echoed with
7 Interventional Ultrasound inObstetrics andGynecology
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a
b
c
Fig. 7.20 Sonohysterography of endometrial hyperplasia (III). (a) The
patient is 29years old, and occupational disease is suspected in the uterine cavity. (b) After injection of contrast agent, the thickness of the
endometrium is uneven. The endometrial thickness of the anterior wall
metallic shadows and pay attention to identify artifacts (Fig.7.32).
V. Contrast-enhanced ultrasonography
Contrast-enhanced ultrasonography (CEUS) is noninvasive functional imaging of blood perfusion. Ultrasound
contrast microbubbles enter the blood circulation after
injected into the peripheral vein, and the microbubbles
form nonlinear signals in the sound eld under the action
of ultrasound. Due to the weak signals of the surrounding
tissues and blood, and the signal to noise is improved by
ultrasound contrast imaging technology, the visualization
of blood perfusion in microcirculation has been greatly
improved. Contrast microbubbles can ow and distribute
along with the blood system throughout the body. It is an
excellent blood imaging agent. CEUS is now used in
many clinical disciplines.
is 0.3cm, whereas that of the posterior uterine wall is 0.8cm. (c) After
the injection of the contrast agent, sonogram shows the focal thickened
endometrium
• Indications
– Gynecological diseases such as ovarian tumors,
uterine myoma, adenomyosis, endometrial cancer,
and residual in the uterine cavity.
– It can be used to understand the blood supply of
lesions.
• Preoperative preparation
– Transvaginal probe with the frequency of
5~7.5MHz or transabdominal with the frequency
of 3.5MHz.
– Contrast agent: SonoVue contrast agent produced
by Italian Bracco company, each contrast agent
contains hexauoride Sulfur (SF6) gas encapsulating 59 mg of phospholipid. Before usage, mix
with 5 ml of normal saline and shake to extract
4.8ml of white milky microbubble suspension.
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Fig. 7.21 Sonohysterography of the incomplete uterus septum. (a)
The patient is 30years old, and uterus septum is suspected by ultrasound examination; (b) After injection of contrast agent, the left uterine
a
c
cavity is separated by 0.7cm, and the right uterine cavity is divided by
0.8cm. No specic occupation is found in the uterine cavity on both
sides. The width of the septum is about 1.0cm
b
Fig. 7.22 Sonohysterography of complete uterus septum. (a) The
patient is 26years old, and uterus septum is suspected. (b) After injection of contrast agent, two uterine cavities separate from the cervix to
the fundus of the uterus. (c) After injection of contrast agent, the septum
is approximately 0.6cm in width and about 3.2cm long
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7 Interventional Ultrasound inObstetrics andGynecology
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Fig. 7.23 Sonohysterography of intrauterine residues (I). (a) The
patient is 26 years old and had a miscarriage 2 months ago.
Ultrasonography shows a slightly hyperechoic mass with a diameter of
about 2.0 cm, located in the right uterine corner; (b) After injection of
contrast agent, a slightly hyperechoic mass of 2.1 cm × 0.9 cm × 1.8 cm
is visible at the right corner of the uterine cavity, with irregular shape
and oating in the contrast agent
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Fig. 7.24 Sonohysterography of intrauterine residues (II). (a) The
patient is 26years old and developed amenorrhea after a miscarriage
2months ago. The ultrasonography shows the posterior uterus, and the
hypoechoic mass in the uterine cavity; (b) After injection of contrast
agent, sono gram shows a slightly hypoechoic mass of 2.1 cm × 1.8 cm
× 2.2 cm on the left side of the uterine cavity. The mass is irregular and
inhomoge neous, with surrounding irregular echoless area (contrast
agent)
a b
Fig. 7.25 Sonohysterography of incarcerated IUD. (a) The patient is 46years old and failed to take the IUD out of the uterine cavity for 2 months.
(b) Sonohysterography shows part of the IUD is embedded into the myometrium
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Fig. 7.26 Sonohysterography of intrauterine adhesions. (a) The
patient is 28years old and has amenorrhea for three months after the
abortion. Before the sonohysterography, ultrasound examination shows
that a dark area of 2.1cm×2.5cm×1.4cm in the uterine cavity; (b)
Fig. 7.27 Salpingography of the patent fallopian tube (positive contrast agent). (a) The contrast agent is around the ovary in the pelvis; (b) Three-
dimensional ultrasound shows that the fallopian tubes are unobstructed
After dilating the cervical ostium, about 3ml of old hemorrhage ows
out. After injection of the contrast agent, the uterine cavity is separated
by 1.5cm, and the hyperechoic adhesion of about 1cm is found in the
uterus
Fig. 7.28 Salpingography of the obstructed fallopian tube (positive contrast agent). (a) There is almost no diffusion of contrast agent in the pelvic
cavity; (b) 3-D ultrasound shows the obstructed proximal end of the fallopian tube
7 Interventional Ultrasound inObstetrics andGynecology
Fig. 7.29 Salpingography of the partially obstructed fallopian tube
(positive contrast agent). 3-D ultrasonography shows the partially
obstructed right fallopian tube, and the left fallopian tube hydrops
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• Operative process (taking ovarian tumor as an
example)
CEUS can be taken in two ways: transabdominal
and transvaginal.
– Routine ultrasound examination
Transabdominal and transvaginal ultrasonography is applied to observe uterus, adnexa, and pelvic cavity in multiple views to detect the lesion, as
well as observe the location, shape, size, nature,
boundary, and the internal echo. Color Doppler is
used to observing the blood ow condition. Do not
forget to store the images.
– CEUS examination
2.4ml of Sonovue microbubble suspension was
injected into the left elbow vein within 3s, and
then a bolus of normal saline was injected. The
a
b
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c
Fig. 7.30 Patency of fallopian tube (negative contrast agent). (a) After
the injection of the contrast agent, the hyperechoic owing column of
water is visible around the adnexa, indicating that the patient’s fallopian
tube is unobstructed. (b) After the salpingography, there is a free
anechoic area in the rectouterine pouch, indirectly indicating that the
patient’s fallopian tube is unobstructed. (c) Hysterosalpingography
shows that the patient’s bilateral fallopian tubes are unobstructed
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a b
Fig. 7.31 Hysterosalpingography of hydrosalpinx. (a) When the contrast medium is injected, there are moving dot echoes in the dilated fallopian
tube; (b) Hysterosalpingography shows hydrosalpinx
Fig. 7.32 Sonogram of ultrasound monitoring during intrauterine surgery. (a) Before the surgery, the sagittal view of the uterus. (b) Before
the surgery, the transverse section of the uterus. (c) During the surgery,
in the sagittal view of the uterus, there are hyperechoic bands, followed
by “comet tail sign” in the uterine cavity. (d) During the surgery, in the
transverse section, there is a strong spotty echo in the uterine cavity,
followed by “comet tail sign”