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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 11 Female Pelvis Scanning Protocol 249
rior
Anterior
Left Ovary • Longitudinal Images
Sagittal Plane • Anterior Approach
17. LONG AXIS image of the left ovary measuring length (superior to
inferior) and height (anterior to posterior).
Urinary
Superior
bladder
Infe
Follicles
Left
ovary
4.01 cm
1.78 cm
Follicles
Posterior
Labeled: LT OV SAG LONG AXIS
(Courtesy University of Virginia Health Systems Imaging Center.)
NOTE: If this image of the ovary was angled from midline, then the
image is obliqued and must be labeled: LT OV SAG OBL LONG AXIS
18. Same image as number 17 without calipers.
Follicles
Labeled: LT OV SAG LONG AXIS
(Courtesy University of Virginia Health Systems Imaging Center.)
250 PART IV Pelvic Scanning Protocols
Anterior
ft
Left Ovary • Axial Images
Transverse Plane • Anterior Approach
19. Axial image of the LEFT OVARY with width (right to left) mea-
sure ment.
1.85 cm
Right
Follicles
Urinary
bladder
Left
ovary
Follicles
Posterior
Labeled: LT OV TRV
(Courtesy University of Virginia Health Systems Imaging Center.)
NOTE: If this image of the ovary was angled from midline, then the
image is obliqued and must be labeled: LT OV TRV OBL
20. Same image as number 19 without calipers.
Le
Labeled: LT OV TRV
(Courtesy University of Virginia Health Systems Imaging Center.)
CHAPTER 11 Female Pelvis Scanning Protocol 251
Review Questions
Answers on page 630.
1. The linings of the vagina and uterus
a) are separated by the external os of the cervix.
b) excrete glycogen-rich mucous during the secretory phase.
c) are shed during menses.
d) enclose a continuous cavity or channel through which the fetus
passes at birth.
2. The walls of the uterus are composed of
a) the serosa, basal layer, and endometrium.
b) outer adventita, middle thin smooth muscle, and inner mucosal
lining.
c) endometrium, myometrium, and basal layer.
d) endometrium, myometrium, and serosa.
3. What part of the uterus enlarges during the menstrual cycle?
a) Endometrium
b) Basal layer
c) Myometrium
d) Endometrial canal
4. The functional zone
a) occurs during the proliferative phase.
b) is the superficial layer of the endometrium.
c) is the innermost layer of the myometrium.
d) is not influenced by the menstrual cycle.
5. The isthmus is the slightly constricted portion of
a) the uterine body where it meets the uterine cervix.
b) uterine cervix where it meets the vagina.
c) the uterine body that is abnormal if visualized sonographically.
d) a rare duplicate cervix.
6. The normal position of the uterus is described as
a) anteflexed.
b) retroverted.
c) anteverted.
d) retroflexed.
7. When the urinary bladder is displaced posteriorly
a) look for a mass in the space of Retzius.
b) it is considered a normal variant.
c) the uterus is anteflexed.
d) the uterus is retroflexed.
8. The luteal phase correlates with
a) menses.
b) the proliferative phase.
c) follicle maturation.
d) the secretory phase.
252 PART IV Pelvic Scanning Protocols
9. The follicular phase correlates with
a) menses.
b) the proliferative phase.
c) follicle maturation.
d) the secretory phase.
10. When does the endometrium exhibit a multilayered appearance?
a) During menses
b) During the early proliferative phase
c) During the late proliferative phase
d) During the late secretory phase
11. Which muscles are sometimes mistaken for ovaries?
a) Levator ani
b) Piriformis
c) Obturator internus
d) Coccygeus
12. Which muscles form a hammock across the pelvic floor?
a) Levator ani
b) Piriformis
c) Obturator internus
d) Coccygeus
13. Just before the onset of menses, the endometrium measures ____.
a) 1 mm
b) 12 mm
c) 4 mm
d) 8 mm
14. The maximum anteroposterior diameter of the endometrium
during the secretory phase is ____.
a) 14 to 16 mm
b) 15 to 28 mm
c) 4 mm
d) 8 mm
15. It is normal to visualize a small amount of free fluid in the
_____________.
a) vesicouterine pouch
b) anterior cul-de-sac
c) posterior cul-de-sac
d) lateral pelvic recesses
16. The pouch of Douglas is also known as the _____________.
a) vesicouterine pouch
b) anterior cul-de-sac
c) posterior cul-de-sac
d) lateral pelvic recesses
17. The rectouterine pouch is also known as the _____________.
a) vesicouterine pouch
b) anterior cul-de-sac
c) posterior cul-de-sac
d) lateral pelvic recesses
18. Label the following:
19. Label the following:
CHAPTER 11 Female Pelvis Scanning Protocol 253
20. Label the following:
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CHAPTER 12
Transvaginal Scanning Protocol
for the Female Pelvis
Betty Bates Tempkin
NOTE: In most institutions it is standard practice to begin a sonographic
evaluation of the female pelvis with a transabdominal study. If the transabdominal study provides the diagnosis, then the transvaginal scan is
not necessary.
Objectives
At the end of this chapter, you will be able to:
• Describe the transducer options for transvaginal scanning.
• List the scanning planes and image orientations for transvaginal
scanning.
• List the suggested patient position (and options) for transvaginal
scanning.
• Describe the patient prep for transvaginal scanning.
• Name the survey steps and how to evaluate the entire length,
width, and depth of the female pelvis and its structures.
• Explain the order and exact locations to take representative
images of the female pelvis and its structures.
• Answer the review questions at the end of the chapter.
Overview
Transvaginal sonography is an ultrasound performed inside the vaginal cavity with an endocavital transducer or probe. Most experts feel
that transvaginal sonography is a limited and incomplete evaluation
of the female pelvis because of its narrow field of view (compared
to transabdominal scanning, which has a much wider field of view).
Therefore, “trans” or “endo” vaginal sonography is typically used in
conjunction with transabdominal sonography when pelvic contents
require further evaluation. Resolution of pelvic structures is better with
transvaginal imaging than transabdominal imaging because there is
less attenuating tissue between the transvaginal transducer and pelvic
structures. This provides better anatomic detail than transabdominal
sonography because the transvaginal transducer can be placed closer
to areas of interest. Ideally, transabdominal sonography may
255
256 PART IV Pelvic Scanning Protocols
show the size and location of a pelvic mass, which can then
be better characterized with transvaginal sonography.
Preparation
Patient Prep
• Verbal or written consent is required from the patient. Explain the
details of the examination; inform the patient that the examination is virtually painless, that the inserted transducer feels like a
tampon, and the examination is necessary for the interpreting
physician to make an accurate diagnosis.
• The examination should be chaperoned by a female health care
professional. The initials of the witness should be included as part
of the film labeling.
• Empty urinary bladder.
• The patient, sonographer, or physician may insert the transducer.
Patient Position
• Transducer design determines patient position, so ideally having a
gynecological examining table and the ability to put the patient in
lithotomy position is optimal.
• The patient can be positioned at the end of the examining table or
stretcher with the hips elevated by a pillow or foam cushion.
Transducer
• 5.0 MHz or higher.
• Apply gel to the end of the transducer and then cover it with a
condom or disposable sheath. Make sure there are no air bubbles
at the tip. Apply additional gel to the outside of the condom or
sheath before insertion. If infertility is a consideration, water or
nonspermicidal gel may be used.
• Following the examination, the condom or sheath covering the trans-
vaginal probe should be disposed. The probe should be soaked in an
antimicrobial solution. Follow the manufacturer’s instructions and
infectious disease control recommendations for solution type and
soak time. If the sheath or condom was torn during the procedure, the
probe’s fluid channels must be flushed with the antimicrobial solution.
Image Orientation
• Standard transvaginal scanning utilizes sagittal and coronal planes
from an inferior approach. Transvaginal image orientations from an
inferior approach are described in Figures 12-1 and 12-2. Manipulation of the transducer causes variation from these standard interpretations (Figure 12-3). As a result, image orientation for transvaginal
sonography can vary among institutions, authors, and textbooks.
CHAPTER 12 Transvaginal Scanning Protocol for the Female Pelvis 257
SAGITTAL PLANE/TRANSVAGINAL (TV)
C
• Proper image orientation is challenging in transvaginal scanning
due to the narrow field of view, the inferior scanning approach, and
normal positional variations of the reproductive organs. Therefore,
it is important to determine proper positioning of the probe prior
to insertion at the beginning of the examination. Proper positioning of the probe in the sagittal plane is confirmed when touching
the edge of the probe, which is directed toward the ceiling, creates visible motion at the left of the image. From this position, the
probe can be rotated 90 degrees counterclockwise in order to scan
in the coronal plane.
INFERIOR SOUND WAVE APPROACH
Uterine
myometrium
Uterine
endometrium
Sound beam
Anterior
Superior
Posterior
A
IMAGE DISPLAY MONITOR
Inferior
(approach)
Near field
(inferior)
Anterior
Far field
(superior)
Uterine
myometrium
Inferior
Collapsed urinary
bladder
Transducer in
vaginal canal
Rectum
Bowel
Uterine
endometrium
Posterior
TV SAGITTAL IMAGE ORIENTATION
Superior
Posterior
ROTATE
IMAGE
Anterior
B
Anterior
Inferior
Inferior
Posterior
Superior
Superior
Bowel
D
Figure 12-1 Transvaginal (TV) sagittal plane orientation.* A, Illustrates the TV transducer position and sagittal plane field of
view. B, Depicts the rotation of the image as seen on the display monitor. C, Illustrates a longitudinal section of the uterus in a TV
sagittal plane. The apex of the image on the display monitor corresponds to the anatomy closest to the face of the transducer. In
TV sonography, the near field and left side of the sagittal plane image generally correspond to the inferoposterior region of the true
pelvis. The far field and right side of the sagittal plane image generally correspond to the anterosuperior region of the true pelvis.
D, Longitudinal section of the uterus taken in a TV sagittal scanning plane. Note how the section of uterus fills the screen, limiting
the overall view of the pelvis but providing increased anatomic detail of the uterus. (*Denotes corresponding locations in A and C.)
258 PART IV Pelvic Scanning Protocols
CORONAL PLANE/TRANSVAGINAL (TV)
TV CORONAL IMAGE ORIENTATION
INFERIOR SOUND WAVE APPROACH
Superior
Right
Uterus
Acoustic
beam
Left
A
IMAGE DISPLAY MONITOR
Inferior
Near field
Right
Far field
(superior)
(inferior)
Uterine
myometrium
Bladder
Transducer in
vaginal canal
Inferior
Rectum
Bowel
Uterine
endometrium
Left
Superior
Right
B
ROTATE
IMAGE
Left
Inferior
C
Superior
D
Figure 12-2 Transvaginal (TV) coronal plane orientation.* A, Illustrates the TV transducer position and coronal plane field
of view. When the bladder is empty, the fundus of the typical anteverted (anteflexed) uterus tilts forward toward the anterior
abdominal wall. Therefore, in TV imaging the uterus is seen in short axis from a coronal plane. B, Depicts the rotation of the image
as seen on the display monitor. C, Illustrates an axial or short-axis section of the uterus in a TV coronal plane. The apex of the
image on the display monitor corresponds to the anatomy closest to the face of the transducer. In TV sonography, the near field
and left side of the coronal plane image generally correspond to the inferolateral region of the true pelvis. The far field and right
side of the coronal plane image generally correspond to the superolateral region of the true pelvis. D, Axial or short-axis section
of the fundus of the uterus taken in a TV coronal scanning plane. Note how the section of uterus fills the screen, limiting the overall
view of the pelvis but providing increased anatomic detail of the uterus. (*Denotes corresponding locations in A, B, and C.)