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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 12 Transvaginal Scanning Protocol for the Female Pelvis 259
IMAGE DISPLAY MONITOR
Anterior
Superior
Anterior
Superior
Inferior
Posterior
Posterior
Near field
(anterior)
Inferior
Far field
(posterior)
Figure 12-3 Transvaginal imaging: anteroinferior approach. Most TV imaging is performed from the standard inferior
approach as explained in Figures 12-1 and 12-2. Alternatively, manipulation of the TV transducer causes variation from the
standard TV orientation. For example, these illustrations show that when the transducer is lifted anteriorly, toward the pubic
symphysis, the sound beam is directed more posteriorly making the near and far fields of the TV sagittal plane image correspond
to anterior and posterior regions of the pelvis instead of inferior and superior regions (from an inferior approach). The left and
right sides of the image now correspond more closely to the superior and inferior regions of the pelvis instead of anterior and
posterior (from an inferior approach). Utilizing a posterior TV approach also causes significant variation in image orientation.
Consequently, image orientation for TV sonography can vary among institutions, authors, and ultrasound texts.
Transvaginal Female Pelvis Survey
NOTE: Because of the limited field of view, the uterus and adnexa are
scanned in sections by slightly angling the inserted transducer in different directions.
NOTE: During the transvaginal evaluation, adnexal structures can be
brought into view by using one hand to compress the lower abdominal
wall while the other hand operates the transducer.
Uterus and Adnexa • Longitudinal Survey
Sagittal Plane • Inferior Approach
1. Begin scanning by slowly lowering the handle toward the floor to
view a longitudinal section of the fundus of the uterus. Now move
the transducer a little to the right, then to the left to evaluate its
lateral margins. Note and evaluate the centrally located endometrial canal. If the bladder contains any urine, it will be seen anteriorly (on the left side of the imaging screen).
2. Withdraw the transducer slightly, and slowly lift the handle toward
the ceiling to view the body and cervix of the uterus and the post erior cul-de-sac. Now move the transducer a little to the right,
260 PART IV Pelvic Scanning Protocols
then to the left to evaluate the lateral margins. Note and evaluate
the centrally located endometrial and endocervical canals.
3. After evaluating the uterus, continue the longitudinal survey to the
adnexal regions. Very carefully reinsert the partially withdrawn
transducer. Keep the transducer straight at the midline and lower
the handle to relocate the uterine fundus and then the pelvic cavity region superior to the uterus. Now slowly move the transducer
handle toward the patient’s left thigh in order to scan through the
right adnexa. Return to midline; slowly move the transducer handle
toward the patient’s right thigh to scan through the left adnexa.
NOTE: For a retroverted uterus, the uterine fundus is visualized by lifting the transducer handle towards the ceiling. It may also be helpful to
rotate the probe 180 degrees and invert image orientation.
4. Repeat these lateral sweeps through the adnexal regions at the
levels of the uterine body and cervix.
Uterus and Adnexa • Axial Survey
Coronal Plane • Inferior Approach
1. Following the longitudinal survey from the sagittal plane, rotate
the transducer 90 degrees counterclockwise into the coronal plane.
2. Begin scanning by slowly lowering the handle of the inserted transducer toward the floor to evaluate the uterine fundus.
3. Withdraw the transducer slightly and slowly lift the transducer
handle toward the ceiling to scan through the uterine body, cervix,
and posterior cul-de-sac.
4. After evaluating the uterus, continue the axial survey through the
adnexa. Moving the transducer handle toward the floor, relocate
the uterine fundus. Now slowly move the transducer handle toward
the patient’s left thigh to visualize the right adnexa, and very slowly
move the transducer handle toward the ceiling in order to sweep
through the area.
5. Return the transducer to the midline, then slowly move the handle
toward the patient’s right thigh to visualize the left adnexa. By
very slowly moving the transducer handle up and down, sweep
through the area.
Right Ovary • Axial Survey
Coronal Plane • Inferior Approach
1. The ovaries are most easily evaluated by beginning in the coronal scanning plane. From initial insertion of the transducer in the
sagittal plane, the transducer handle should be rotated 90 degrees
counterclockwise into the coronal plane.
2. Begin scanning by putting the transducer in a right oblique position. This is done by slowly moving the transducer handle toward
CHAPTER 12 Transvaginal Scanning Protocol for the Female Pelvis 261
the patient’s left thigh, which angles the beam toward the right
adnexa. Find the ovary by slightly moving the transducer handle
up and down. Identify the adjacent iliac vessels.
RT
LT
3. When the ovary is located, very slightly move the transducer handle
as far up and down as necessary to scan through the ovarian margins.
Right Ovary • Longitudinal Survey
Sagittal Plane • Inferior Approach
1. Still viewing the ovary in the coronal plane, slowly rotate the transducer 90 degrees clockwise to visualize the ovary in the sagittal plane.
2. Begin scanning by very slightly moving the transducer handle to
the right and then to the left to scan through the lateral and medial
margins of the ovary. Identify the adjacent iliac vessels.
Left Ovary • Axial Survey
Coronal Plane • Inferior Approach
1. Return to the coronal scanning plane by rotating the transducer 90
degrees counterclockwise.
2. Begin scanning by putting the transducer in a left oblique position. This is done by slowly moving the transducer handle toward
the patient’s right thigh, which angles the beam toward the left
adnexa. Find the ovary by slightly moving the transducer handle
up and down. Identify the adjacent iliac vessels.
RT
LT
262 PART IV Pelvic Scanning Protocols
3. When the ovary is located, very slightly move the transducer handle as far up and down as necessary to scan through the ovarian
margins.
Left Ovary • Longitudinal Survey
Sagittal Plane • Inferior Approach
1. Still viewing the ovary in the coronal plane, slowly rotate the
transducer 90 degrees clockwise to visualize the ovary in the sagittal plane.
2. Begin scanning by very slightly moving the transducer handle to
the right and then to the left to scan through the lateral and medial
margins of the ovary. Identify the adjacent iliac vessels.
Transvaginal Scanning Protocol for the Female Pelvis Required Images
Uterus and Adnexa • Transvaginal Longitudinal Images
Sagittal Plane • Inferior Approach
1. LONGITUDINAL MIDLINE IMAGE. If the long axis of the
uterus is visualized, then include length and height measurements.
Myometrium
Endometrium
Endometrial
canal (“stripe”)
Labeled: TV SAG ML or TV SAG ML UT LONG AXIS (“TV” = transvaginal)
CHAPTER 12 Transvaginal Scanning Protocol for the Female Pelvis 263
Myometrium
canal
2. Same image as number 1 without calipers.
Labeled: TV SAG ML or TV SAG ML UT LONG AXIS
NOTE: If the long axis was not visualized at the midline, it should be
taken here and labeled: TV SAG UT LONG AXIS
3. LONGITUDINAL MIDLINE IMAGE with anteroposterior measurement of the endometrium.
Endometrium
Labeled: TV SAG ML ENDOM
NOTE: The measurement of the endometrium should include anterior
and posterior portions of the basal endometrium, the thickest echogenic
area, from one interface across the endometrial canal to the other interface. The adjacent hypoechoic myometrium and any endometrial fluid
should not be part of the measurement.
Uterus
Endometrial
264 PART IV Pelvic Scanning Protocols
Endometrium
Myometrium
4. Same image as number 3 without calipers.
Labeled: TV SAG ML ENDOM
5. Longitudinal image of the UTERUS FUNDUS to include the endometrial cavity.
Labeled: TV SAG FUNDUS
Uterine fundus
CHAPTER 12 Transvaginal Scanning Protocol for the Female Pelvis 265
Endocervical
Sidewall
6. Longitudinal image of the UTERUS BODY and CERVIX to
include the endometrial cavity.
Endometrium
Myometrium
Uterine
body
Labeled: TV SAG BODY CERX
Uterus and Adnexa • Transvaginal Axial Images
Coronal Plane • Inferior Approach
7. Axial image of the uterine fundus measuring uterine width.
Myometrium
canal
Uterine
cervix
Endometrium
Labeled: TV COR FUNDUS
Uterine
fundus
shadow
266 PART IV Pelvic Scanning Protocols
8. Same image as number 7 without calipers.
Labeled: TV COR FUNDUS
9. Axial image of the UTERINE BODY.
Myometrium
Labeled: TV COR BODY
Endometrium
Uterine
body
CHAPTER 12 Transvaginal Scanning Protocol for the Female Pelvis 267
Endocervical
Sidewall shadow
Follicle
10. Axial image of the CERVIX.
canal
Uterine cervix
Labeled: TV COR CERX
Right Ovary • Transvaginal Axial Images
Coronal Plane • Inferior Approach
For the sake of instruction, this assumes that the ovary long axis is
visualized in a sagittal plane.
11. Axial image of the right ovary measuring ovarian width.
Follicles
Right ovary
Labeled: TV COR RT OV
268 PART IV Pelvic Scanning Protocols
Follicles
12. Same image as number 11 without calipers.
Right Ovary • Transvaginal Longitudinal Images
Sagittal Plane • Inferior Approach
For the sake of instruction, this assumes that the ovary long axis is
visualized in a sagittal plane.
13. LONG AXIS image of the right ovary measuring ovarian length
and height.
Labeled: TV COR RT OV
Right ovary
Follicles
Labeled: TV SAG RT OV LONG AXIS
Follicles