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280 M. M. Malek and M. D. Jarboe
Fig. 24.6 Intraoperative renal ultrasound showing
Wilms’ tumor for margin planning
In bilateral Wilms, partial nephrectomy is the
treatment option [15, 16]. Sparing some of each
kidney often allows retention of adequate renal
function to avoid dialysis. Obtaining appropriate
margins is important and these margins are not
always obvious from visual inspection. Intraoperative ultrasound can guide resection margins
for the partial nephrectomy and is becoming the
standard of care today (Fig. 24.6).
Foreign Body
Fluoroscopy has proven to be an invaluable adjunct in the localization of radiopaque foreign
bodies and is utilized extremely often for this
purpose. In the case of foreign bodies that cannot be seen on X-ray, surgeons are often forced
to rely on palpation to locate the object. The lack
of imaging guidance can make these cases extremely challenging and certainly decrease the
success rate of foreign body removal. Ultrasound
is an excellent tool in this situation, as the foreign
body will typically have a different echogenicity
than the soft-tissue and will therefore be easily
visible on ultrasound (Fig. 24.7a and b). If planning to use ultrasound intraoperatively to locate
a foreign body, it is best to have a preoperative
ultrasound to confirm that the foreign body can
be visualized. Once that is confirmed, the ultrasound will be very valuable in the operating
room. Wooden splinters are notoriously difficult to find, and cannot be identified with fluoroscopy. Ultrasound is typically able to identify
wooden splinters and has been used to aid in their
removal [17–19].
Supprelin implants are subdermal implants
utilized for long-term delivery of the gonadotropin-releasing hormone analog histrelin in patients with central precocious puberty. These implants allow hormone delivery without the need
for frequent intramuscular injections and are the
preferred method for patients and families. The
implants need to be removed and replaced at
regular intervals. Removal can be challenging as
the implants are soft and colorless, and implant
Fig. 24.7 Foreign body in soft tissue. a Foreign body seen in intraoperative ultrasound. b Ultrasound guidance of
instrument (hemostat) to foreign body
28124 An Introduction to Intraoperative Ultrasound
Fig. 24.8 Ultrasound-guided placement of percutaneous
ECMO cannulas. a Placement of an veno-venous Avalon
cannula with tip in the inferior vena cava ( IVC). The prox-
fracture is not an uncommon event. Ultrasound
can be used in this situation to find the fractured
implant and assist in its removal [20].
Extracorporeal Membrane Oxygenation (ECMO) Cannula Placement
Percutaneous placement of ECMO cannulas has
become more common, in part due to the excellent visualization afforded by echocardiogram.
Proper positioning of the cannula is critical to
maintain good flows on the ECMO circuit. Cardiac ultrasound is used to identify the position of
the cannula and guide its placement. Ultrasound
guidance can be used for placement of a single
double-lumen cannula for veno-venous ECMO
such as the Avalon cannula (Fig. 24.8a) as well
as for placement of a single lumen venous cannula that will be used for either veno-venous or
arterio-venous ECMO (Fig. 24.8b). These are
typically placed in the internal jugular vein. Correct positioning can be a challenge, as the cannulas are large and often will have a hard time
traversing through the right atrium and into the
IVC, which often reaches the heart at an angle.
A guidewire is essential, and can be seen on ultrasound (Fig 24.8c) and confirmed with fluoroscopy. Once the guidewire has passed down the
IVC, you can thread the cannula over the wire
and watch the tip of the cannula pass down the
IVC as well. In the case of the Avalon cannula, it
is critical that the catheter is placed in the proper
position as the more proximal hole will need to
imal hole is lined up with the tricuspid valve. b Placement
of a single lumen venous cannula with the tip in the right
atrium ( RA). c Wire in retrohepatic IVC
be oriented to face toward the tricuspid valve.
Incorrect placement can lead to cardiac perforation. Catheter tip position can be determined with
cardiac ultrasound or transabdominal ultrasound.
Vascular Access
Intraoperative ultrasound is invaluable for vascular access. Ultrasound provides consistency and
safety in vascular access and allows very good
assessment of key anatomy while gaining access
(Fig. 24.9). Needle guidance in to vascular structures is discussed extensively in other chapters.
Fig. 24.9 View of great vessels with ultrasound place-
ment just above the clavicles and the probe aimed in the
caudal direction
282 M. M. Malek and M. D. Jarboe
Fig. 24.10 a Laparoscopic view of spleen with cyst and ultrasound probe. b Ultrasound image very near to the margin
of the cyst from laparoscopic probe
Splenic Cysts
Partial splenectomy for cysts can be challenging
when attempting to determine the margin for resection. Laparoscopic partial splenectomy is well
described and the minimally invasive approach
can result in favorable postoperative coarse in
comparison to open resection. That challenge
only increases in the case of laparoscopic partial
splenectomy [21]. Intraoperative ultrasound can
provide excellent guidance when determining the
resection margin (Fig. 24.10).
Perirectal Fistula and Abscesses
Crohnʼs disease is a common and challenging
disease process seen in the pediatric population.
Perirectal Crohnʼs is especially difficult to treat
with the recurrent fistulas and abscesses. Given
the inflammatory nature of the disease process,
seton drainage of the fistulas and abscesses is
often preferred over straight forward incision
and drainage. Endorectal ultrasound is a very
useful tool in both evaluating the perirectal area
for seton placement and abscess drainage [22].
Endosonography can be used to locate fistulas
and abscesses in the rectal canal and ultrasound
can even be used to guide precise seton placement through fistulas that wax and wane in their
patency (Fig. 24.11).
Fetal Interventions
In twin-twin transfusion syndrome (TTTS), fetoscopic laser ablation of communicating vessels
is standard therapy [23]. In twins with monochorionic/diamniotic pregnancy, one twin shunts
blood to the other through communicating vessels. With a standard posterior placenta this procedure is relatively straightforward and is per-
formed through the motherʼs anterior abdominal
wall with standard ultrasound. With an anterior
placenta this maneuver is much more complex.
Uterine entry must be posterior enough to avoid
the placenta and enable visualization of the communicating vessels on the placenta surface. Several methods are described but using maternal
laparoscopy with laparoscopic ultrasound probe
enables laparoscopic manipulation of the uterus
and also visualization of the fetus while entering
with a needle (CO2 inflation of abdomen precludes useful transabdominal ultrasound) [24].
The needle in the uterus allows wire passage
and ultimately trocar placement over the wire
(Fig. 24.12).
Summary
Intraoperative ultrasound is a powerful tool that
has a wide spectrum of utility. This chapter reviews a few common uses and shows that the
ultrasound can be very helpful and has a signifi-
28324 An Introduction to Intraoperative Ultrasound
Fig. 24.11 a Endorectal ultrasound demonstrating intersphincteric abscess and a fistula. b Endorectal ultrasound dem-
onstrating a Crohn’s supralevator abscess. c Ultrasound-guided needle placement through fistula and abscess
Fig. 24.12 Laparoscopic ultrasound assisted access of the uterus in twin-twin transfusion syndrome laser ablation with
anterior placenta
cant impact on an operation. In certain cases, it
enables the surgeon to perform an operation in a
more effective or efficient manner. In other cases,
the ability of ultrasound to clarify anatomy and
relationships may change the operative plan in
real time. We are likely underutilizing intraoperative ultrasound at this point; its use will surely
increase as surgeons become more adept with the
technology and identify additional situations in
which it can provide valuable information.
284 M. M. Malek and M. D. Jarboe
http://www.cancer.gov/types/kidney/hp/wilms-treat
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Erratum to: Fine Needle
Aspiration (FNA) of the
Thyroid Gland
Ranjith Vellody
Erratum to: S� Scholz, M� D� Jarboe (eds�), Diagnostic and Interventional Ultrasound in Pediatrics
and Pediatric Surgery, DOI 10�1007/978-3-319-21699-7_20
The Publisher regret that in chapter 20 only one author was listed as chapter and corresponding author
i�e� Ranjith Vellody� However, there are additional two co-authors contributed in this chapter� The
details of those two authors are as follows:
Matthew Hermann, MD
Department of Radiology
University of Michigan
Ann Arbor, MI, USA
Joseph J. Gemmete
Department of Radiology,
University of Michigan,
Ann Arbor, MI, USA
The correct order of the authors for chapter opening page will be:
Matthew Hermann, Joseph J. Gemmete and Ranjith Vellody
The online version of the original chapter can be found under
http://dx�doi�org/10�1007/978-3-319-21699-7_20
R� Vellody ()
Department of Radiology , University of Michigan,
1500 E� Medical Center Drive, Room UH B1-0502,
Ann Arbor , MI 48109 , USA
e-mail : ranjithv@med�umich�edu
© Springer International Publishing Switzerland 2016
S� Scholz, M� D� Jarboe (eds�), Diagnostic and Interventional Ultrasound in Pediatrics
and Pediatric Surgery, DOI 10�1007/978-3-319-21699-7_25
E1
Index
A
Abdominal Doppler
Abdominal mass 58, 66, 86, 121, 122, 126, 127, 159
diagnosis of
Abdominal Trauma 77, 79, 133
children with 202
tion of
evalua
evaluate blunt 201
Abscess 24, 35, 42, 87, 104, 145, 162
abdomen 241
abdominals 115
breast 243
liver 242
pelvic 238, 241
Adnexal torsion 171
Adrenal gland 91, 126
cystic lesions 161
fetal development of
non-neoplastic changes 161, 162
solid tumor of 156, 159
Adrenal hemorrhage 157, 161
neonatal 159
traumatic 160
Appendicitis 112, 128
diagnosis of 103, 112
Arterial line 211
Arterial venous malformations (AVM)
clinical presentation of
diagnostic imaging of 257, 258
natural history of 257
treatment of 258
Arteriovenous malformation (AVM) 256
Ascites 103, 109, 110, 148, 170, 175, 223, 236
with idiopathic 242
Atresia
59
biliary
instestinal 108
86
146
133
155
257
Biliary tree
Biopsy
core 25
tissue 65, 114, 115
C
Cancer
adult gastric 277, 278
breast 198
fatal
thyroid 23, 24, 229
Capillary malformation (CM) 253
clinical presentation of 256
diagnostic imaging of 256
natural history of 256
treatment of 257
Caudal regression syndrome 13
Chest 27, 239
posterior
Chest wall 35, 36, 217
Children 97, 177, 229
Cholangitis 66, 70, 122
Cholecystitis 63, 69, 241
Choledochal cyst 64, 65, 66
Choledocholithiasis 64, 70, 74
Cholelithiasis 68, 76
Coaxial needle 211, 224
Compression syndromes 94
Congenital adrenal hyperplasia 161
Contrast-enhanced ultrasound (CEUS)
strengths of 198
Core needle 148, 222, 223
Cutting needle 223, 224
Cyst 14, 21, 46
filar 9
Cystic tumor 25, 78
70
128, 148, 221, 223
173
f
risk o
137
28
197, 198, 199, 202
B
Biliary atresia 65, 85
common bile duct (CBD) 65
common hepatic duct 65
extrahepatic bile ducts 65
types of 65
© Springer International Publishing Switzerland 2016
S. Scholz, M. D. Jarboe (eds.), Diagnostic and Interventional Ultrasound in Pediatrics
and Pediatric Surgery,
DOI 10.1007/978-3-319-21699-7
D
Dilatation
Doppler 5, 95, 97, 145, 149, 213
55, 64, 145
color 22, 50, 53, 93
power 51, 53
spectral 51
285
286 Index
E
Effusion
36, 41
Emergency Ultrasound
Empyema
Enterocolitis
Extracorporeal membrane oxygenation (ECMO)
F
Fine needle aspiration (FNA)
Focused Assessment with Sonography in
G
Groin
H
Hepatobiliary
Hydrocele 184, 187, 190, 191
Hydronephrosis 121, 139, 140, 143, 144, 177, 179, 243
I
Idiopathic scrotal edema
In-line technique 216
Internal jugular access 212, 216, 218
Intestine 39, 92, 105, 114, 116, 123
Intra-abdominal injuries (IAI) 133, 136
Intussusception 103, 107, 109, 123
L
Laparoscopy
Liver 21, 39, 43, 49, 50, 63, 75, 126
Local anesthetic 232, 233, 265, 266, 267, 268, 274
Lung 27, 28, 36, 39, 41, 42
Lymphatic malformation 21, 22, 23, 32, 36, 156, 161
Lymphatic malformation (LM)
M
Malrotation 85, 93, 107, 142
Myelomeningocele 10, 11
N
Neck ultrasound 17
37, 240
111, 115, 241
281
thyroid
233
Trauma(FAST) 78, 87, 133, 134, 136, 137, 198
185, 194
49, 60, 63, 66, 70
170, 186, 194, 277, 282
biopsy 222, 225
imaging 202
lesions 198, 203, 204
of healthy 84
clinical features of 253
diagnostic imaging of 254
natural history 253, 254
treatment of 254
intestinal 93
for head 18, 23
for neck 18, 23
137
218,
20, 25, 77, 222, 231
191
247
Necrotizing enterocolitis
Neonatal
Neonatal Spinal Ultrasound
Neuroblastoma
Nodule
O
Oncology
Ovaries
P
Pancreas
Pediatric 3, 17, 18, 26, 83, 89, 103
Pediatric Blunt Abdominal Trauma 133
Pelvis 111, 121, 124, 142, 145, 165
Percutaneous biopsy 32
Peripheral
Peripheral nerve blocks (PNBs) 265, 274
Piezoelectric effect 3
Pleural effusion 27, 36, 37, 42
Pseudocyst 75, 77, 80, 124
Pyloric stenosis 103
R
Regional anesthesia
Renal biopsy
Renal transplant 140
Renal ultrasound 139, 145
Retroperitoneal mass 121
S
Sclerosant drugs
Solid organ
Solid tumor 127, 156, 204
Spinal dysraphism 10, 11, 15
Spleen 29, 39, 83, 84, 85, 140, 202
Suction needle 223
T
Technique
Tethered cord 9, 12
Thoracoscopy 266
Thorax 27, 28
108, 124, 126, 142, 155, 160, 218
diagnosis of
thyroid
tumors of
evaluation of 109
masses 222
pelvis 165
reason of 23
ultrasound 17, 137
type of 223
demyelination of 162
risk of 99
children with 133
imaging of 137
157
14, 25, 126, 156, 157, 204
173, 191, 193, 203
229, 231
147, 199, 204, 278
124, 165, 169
49, 73, 75
78, 204
27, 156, 191, 211, 219, 266
148, 223
4, 87, 202
9, 25, 50, 134, 144
111, 115, 241
15
265
251, 252
287Index
Thyroid
19, 21, 23, 229, 231, 232, 239
86, 107, 128, 170, 173, 189
Torsion
Transplant
Transverse technique
Trauma
Tumor
U
Ultrasound basics
Ultrasound elastography
Ultrasound-guided arterial access
Ultrasound-guided peripheral venous access
Ultrasound-guided vascular access
Ultrasound probes
Ultrasound techniques 75
Urinary bladder 158, 165, 174, 176
Urolithiasis 149
Uterus 124
148, 198, 204
50
14, 87
14, 22, 24, 32, 39, 42, 55, 56, 58, 87, 122, 125,
129, 146, 147, 233, 242
6
76, 79
209, 210
209
237
216
V
Vascular anomalies 247
Vascular malformation
Vascular malformations
etiology of
sclerotherapy of
treatment of
Venous malformations
clinical features of 247
diagnostic imaging of
natural history of
treatment of
Voiding urosonography
Volvulus
W
Whirlpool sign;
Wilms tumor 147, 157, 279
Wilms’ tumor 125
247
93, 94, 107
23, 33
259
247
252
249
248
249, 250
199, 200
93, 94, 124, 190