Ultrasonography:SurgicalApplications

Grace S. Rozycki, M.D. ACS Surgery 2003. 2003 WebMD Inc. All rights reserved. Posted 06/30/2003

Introduction
Although the scientific principles underlying ultrasonography first began to be elucidated in the 19th century, it was not until the second half of the 20th century that this technology could be effectively applied to medicine. In particular, surgeons in the United States have now embraced ultrasonography as a key diagnostic tool in many areas of clinical practice. Because ultrasonography is noninvasive, portable, rapid, and easily repeatable, it is especially well suited to surgical practice. In addition, computer-enhanced high-resolution imaging and multifrequency specialized transducers have made ultrasonography increasingly user friendly, enhancing its applicability to a variety of surgical settings.

Physics and Instrumentation

Before the application of ultrasound devices to patient evaluation is addressed, it is worthwhile to briefly review certain basic physical principles and terminology associated with ultrasonography (see Table 1, Table 2, and Table 3).[1-5] Nowhere in diagnostic imaging is the understanding of wave physics more important than in ultrasound diagnostic imaging, because ultrasonography is highly operator dependent. To perform an ultrasound examination correctly, a surgeon must be able to interpret echo patterns, determine artifacts, and adjust the machine appropriately so as to obtain the best images. In diagnostic ultrasonography, the transducer or probe interconverts electrical and acoustic energy (see Figure 1).[6] To accomplish this interconversion, the transducer contains the following essential components: 1. An active element. Electrical energy is applied to the piezoelectric crystals within the transducer, and an ultrasound pulse is thereby generated via the piezoelectric effect. The pulse distorts the crystals, and an electrical signal is produced. This signal causes an ultrasound image to form on the screen via the reverse piezoelectric effect. 2. Damping or backing material. An epoxy resin absorbs the vibrations and reduces the number of cycles in a pulse, thereby improving the resolution of the ultrasound image. 3. A matching layer. This substance reduces the reflection that occurs at the transducer-tissue interface. The great difference in density (i.e., the impedance mismatch) between the soft tissue and the transducer results in reflection of the ultrasound waves. The matching material decreases this reflection and facilitates the transit of the ultrasound waves through the body and into the target organ.

Figure 1. Components of ultrasound transducer. Shown are the basic components of an ultrasound transducer. Transducers are classified according to (1) the arrangement of the active elements (array) contained within the transducer and (2) the frequency of the ultrasound wave produced. Transducer arrays contain closely packed piezoelectric elements, each with its own electrical connection to the ultrasound instrument.[7] These elements can be excited individually or in groups to produce the ultrasound beam. There are four main transducer arrays: (1) the rectangular linear array, which yields a rectangular image, (2) the curved array, which yields a trapezoidal image, (3) the phased array, a small transducer in which the sound pulses are generated by activating all of the elements in the array, and (4) the annular array, in which the elements are arranged in a circular fashion. The advantage of transducer arrays is that the ultrasound beam can be electronically steered without any moving mechanical parts (except for the annular array) and focused.[7,8] In the clinical setting, this arrangement allows the operator to adjust the focal zone so that he or she can accurately image a large organ (e.g., the liver) while still being able to obtain fine details of a lesion. The frequency of the transducer is determined by the thickness of the piezoelectric elements within the transducer: the thinner the piezoelectric elements, the higher the frequency.[7,8] Although diagnostic ultrasonography makes use of transducer frequencies ranging from 1 MHz to 20 MHz, the most commonly used frequencies for medical diagnostic imaging are those between 2.5 and 10 MHz (see Table 4). Ultrasound beams of different frequencies have different characteristics: higher frequencies penetrate tissue poorly but yield excellent resolution, whereas lower frequencies penetrate well but at the cost of compromised resolution. Accordingly, transducers are generally chosen on the basis of the depth of the structure to be imaged.[9] For example, a 7.5 MHz transducer is a suitable choice for imaging a superficial organ such as the thyroid, but a 3.5 MHz transducer would be preferable for imaging a deep structure such as the abdominal aorta. Ultrasound machines vary in complexity, but each has the following essential components: 1. A monitor (for displaying the ultrasound image). 2. A keyboard (for labeling the image and making adjustments to produce a quality image). 3. A transducer (for interconverting electrical and acoustic energy).

4. An image recorder (for producing copies of the ultrasound images). Finally, there are three scanning modes, A, B, and M; these modes evolved over several years.[10] A mode (amplitude modulation), the most basic form of diagnostic ultrasonography, yields a one-dimensional image that displays the amplitude or strength of the wave along the vertical axis and the time along the horizontal axis. Therefore, the greater the signal returning to the transducer, the higher the "spike." B mode (brightness modulation), the mode most commonly used today, relates the brightness of the image to the amplitude of the ultrasound wave. Thus, denser structures appear brighter (i.e., whiter, more echogenic) on the image because they reflect the ultrasound waves better. M mode relates the amplitude of the ultrasound wave to the imaging of moving structures, such as cardiac muscle. Before real-time imaging became available, M-mode scanning formed the basis for echocardiography.[10,11]

Clinical Applications of Ultrasonography in Surgical Practice

As an extension of the physical examination, ultrasonography is a valuable adjunct to surgical practice in the office, the emergency department, the OR, and the SICU. Once surgeons have learned the essential principles of ultrasonography, they can readily build on this experience and extend the use of this technology to various specific aspects of surgery. In what follows, I list and briefly describe several clinical areas in which surgeonperformed ultrasonography has proved to be an effective diagnostic and interventional tool. Breast Ultrasound-directed biopsy of breast lesions is now a common office procedure for general surgeons. The increase in the number of screening mammograms performed since the late 1970s has led to the detection of more nonpalpable breast lesions. The traditional choice for further evaluation of such masses has been open surgical excision, but the yield of malignancies with this approach has been only about 20%.[12-14] Advances in ultrasound technology, including automated biopsy needles, high-resolution transducers,[15] and computer-aided diagnosis programs,[16] have prompted a surge of interest in fine-needle and core biopsy tissue sampling as an alternative to open biopsy. Such procedures are appealing because they are minimally invasive, are about as accurate as open biopsy,[17] and can be performed by the surgeon in the office setting.[18] Essentially, surgeons use ultrasound to evaluate the breast for the presence of a solid or cystic lesion and to identify those characteristics of a lesion that suggest whether it is benign or malignant. Current indications for breast ultrasonography include (1) evaluation of mammographically detected microcalcifications or nonpalpable, new, or growing masses, (2) evaluation of duct size in the presence of nipple discharge, (3) assessment of a dense breast or a vaguely palpable mass, (4) differentiation between a solid palpable mass and a cystic one, and (5) guidance of percutaneous drainage of an abscess.[19-24] Additional uses include postoperative follow-up for hematomas, seromas, and prostheses. Ultrasound-guided interventions now in clinical use include cyst aspiration, biopsy of solid lesions, preoperative needle localization, axillary lymph node fine-needle aspiration (FNA), and peritumoral injection for sentinel lymph node biopsy (see V:3 Lymphatic Mapping and Sentinel Lymph Node Biopsy).[25] Reports suggest that high-resolution ultrasonography can accurately detect intraductal spread of tumors and delineate their multiple foci. Ongoing developments in imaging technology and contrast agents have given perfusion studies an enhanced contrast resolution that increases the sensitivity of ultrasonography for small nodal metastases. Accordingly, the use of breast ultrasonography in the office setting has become considerably more sophisticated and sensitive, allowing more patients to be screened for microdisease.[18] Gastrointestinal Tract Endoscopic and endorectal ultrasonography have added a new dimension to the preoperative assessment and treatment of many GI lesions. Endoscopic ultrasonography (EUS) involves the visualization of the GI tract via a high-frequency (12 to 20 MHz) ultrasound transducer placed through an endoscope. With the transducer near the target organ, images of the gut wall and the surrounding parenchymal organs can be obtained that are detailed enough to define the depth of tumor penetration with precision and to detect the presence of involved lymph nodes as small as 2 mm. When done preoperatively, EUS is 80% to 90% accurate at predicting the stage of the tumor; if an endoscopically directed biopsy attachment is used, the diagnostic potential is even higher.[26]

Indications for EUS include (1) preoperative staging of GI malignancies, (2) preoperative localization of pancreatic endocrine tumors, particularly insulinomas, (3) evaluation of submucosal lesions of the GI tract, and (4) guidance of imaging during interventional procedures (e.g., tissue sampling and drainage of a pancreatic pseudocyst).[27-30] Currently, EUS is being used in conjunction with FNA biopsy to evaluate submucosal lesions of the GI tract as well as lesions of the pancreas. This combination is especially useful for pancreatic lesions: EUSguided FNA accurately detects neoplastic pancreatic cysts and therefore may be helpful in determining whether medical or surgical treatment is indicated.[31,32] Endorectal ultrasonography is used in the evaluation of patients with benign and malignant rectal conditions.[33-41] It is commonly performed with an axial 7.0 or 10.0 MHz rotating transducer that produces a 360 horizontal cross-sectional view of the rectal wall. This special transducer is 24 cm long and is covered with a water-filled latex balloon. After the transducer is advanced above the rectal lesion, the balloon that surrounds the transducer is filled with degassed water to create an acoustic window for ultrasound imaging. The transducer is gradually withdrawn while the examiner views the layers of the rectal wall (see Figure 2) by means of real-time imaging. [42,43] These layers are important landmarks in ultrasonographic staging, just as they are in postoperative pathologic staging. For example, if the middle white line (i.e., the submucosa) is intact, a benign lesion may be removed via a submucosal resection. A classification of preoperative tumor staging called uTNM has been proposed that is analogous to the TNM classification for tumor staging.[44] This classification is based on ultrasonographic determination of the infiltrative tumor depth (the prefix u stands for ultrasonography).

Figure 2. Five-layer model of rectal wall anatomy. Depicted is the five-layer model of rectal wall anatomy as delineated by endorectal ultrasonography.[110] The sensitivity of ultrasonography in determining the depth of tumor invasion is about 85% to 90%; however, it can sometimes overestimate the extent of invasion in the presence of tissue inflammation and edema.[35] Further research is needed to assess the accuracy of ultrasonography in detecting recurrent cancer after surgery.[45] Errors in staging are likely to occur with tumors that invade the lamina muscularis mucosae or are associated with inflammation of the lamina propria mucosae.[46] In addition, lesions characterized by ultramicroscopic invasion of the submucosa may be misstaged because the technology currently available cannot provide the fine resolution necessary to assess such invasion.[35,47] Flexible 360 rotating transducers are now available for the evaluation of rectal lesions. Investigators from Madigan Army Medical Center found that whereas rigid endoscopic transducers were slightly more sensitive than flexible transducers in detecting lesions, the flexible devices were highly accurate (77%) in staging rectal cancers; learning curves were comparable for the two types of transducers.[48] Endoanal ultrasonography is an important part of the evaluation of anal incontinence because it is capable of detecting defects in the internal and external sphincters.[49-53] It is done in much the same way as endorectal ultrasonography, except that the 10 MHz transducer is covered with a sonolucent hard plastic cone instead of a water-filled balloon. Although endoanal ultrasonography does not measure sphincter function, ultrasounddetected sphincter disruption correlates well with pressure measurements[54,55] and operative findings.[53,56]

Additional indications for endoanal ultrasonography include evaluation of patients with an exophytic distal rectal tumor (e.g., a villous adenoma) and assessment of patients who have a perianal abscess, fistula in ano, a presacral cyst, or a rectal ulcer. Acute Conditions Traumatic. The FAST (Focused Assessment for the Sonographic examination of the Trauma patient) is a rapid diagnostic test developed for the evaluation of patients with potential truncal injuries. Historically, its development is rooted in several fundamental studies that demonstrated the high sensitivity of ultrasonography in detecting small degrees of ascites,[57] splenic injury,[58] and hemoperitoneum in the hepatorenal space and the pelvis.[59] The FAST determines the presence or absence of blood in the pericardial sac and three dependent abdominal regions, including Morison's pouch, the splenorenal recess, and the pelvis. Ultrasonography may also be used in traumatic settings to detect hemothorax, sternal fracture, and pneumothorax.[60-62] Nontraumatic. In the acute nontraumatic setting, surgeons are currently using ultrasonography for the following purposes:

1. Assessment for multiple loculations and drainage of a soft tissue abscess.[63,64]

2. Early diagnosis of wound dehiscence through visualization of the fascial defect (see Figure 3).

3. Detection of a foreign body in soft tissue.[65-67] 4. Evaluation of a patient with abdominal pain (e.g., from gallstones).[63,64,68,69] 5. Confirmation of the reduction of an incarcerated hernia through identification of the fascial defect and
observation of the reduction occurring with real-time imaging (see Figure 4).[70] 6. Identification of an abdominal aortic aneurysm in a patient who presents with back pain and hypotension. Intramural calcification and intraluminal thrombus are common findings (see Figure 5). If the aortic aneurysm ruptures into the peritoneal cavity, the FAST can detect the presence of hemoperitoneum.

Figure 3. Ultrasound of midline abdominal wound dehiscence. Ultrasound image shows midline abdominal wound dehiscence. Transducer orientation is sagittal with respect to long axis of wound. Interruption in horizontal white line (arrows) represents separation of fascia.

Figure 4. Sagittal ultrasound showing ventral hernia. Sagittal ultrasound image shows ventral hernia with fascial defect (arrow).

Figure 5. Transverse ultrasound showing abdominal aortic aneurysm. Transverse ultrasound image shows abdominal aortic aneurysm with intraluminal thrombus. Laparoscopy and Intraoperative Use

Examination with intraoperative or laparoscopic ultrasonography is an integral part of many hepatic, biliary, and pancreatic surgical procedures. With this tool, surgeons can detect previously undiagnosed lesions or bile duct stones,[71] avoid unnecessary dissection of vessels or ducts, clarify tumor margins, and perform biopsy and cryoablation procedures.[72] Compared with preoperative imaging modalities, intraoperative ultrasonography is much more sensitive in detecting malignant or benign lesions.[73] The precision with which intraoperative ultrasonography can delineate small lesions (5 mm) and define their relationship to other structures facilitates resection, reduces operative time, and frequently alters the surgeon's operative strategy.[73-76] Intraoperative ultrasonography makes use of both contact scanning and so-called standoff scanning for imaging. [77] In contact scanning, the transducer is directly applied to the organ so that the deepest part of the organ is accurately depicted. This technique is most often used for imaging large organs (e.g., the liver). In standoff scanning, the transducer is placed about 1 to 2 cm away from the structure in a pool of sterile saline solution that permits the transmission of ultrasound waves. This technique is often used to image blood vessels, bile ducts, or the spinal cord; it allows good visualization of the structure without compression by the transducer. The size, shape, and type of ultrasound transducer used for intraoperative scanning depend on the anatomic structure to be examined. For example, a pencillike 7.5 MHz transducer is used for scanning the common bile duct, whereas a side-viewing T-shaped 5 MHz transducer is preferable for imaging a cirrhotic liver. Intraoperative ultrasound examinations are conducted systematically to ensure that no subtle pathology is missed and that the examination is reproducible. For example, the liver is imaged sequentially according to a system based on Couinaud's anatomic segments (see V:31 Hepatic Resection).[78] Similar principles apply to laparoscopic ultrasonography, except that the transducers are made to adapt to the laparoscopic equipment.[79,80] Indications for this modality include detection of common bile duct stones, staging of pancreatic cancer to prevent unnecessary celiotomy, and resection or cryoablation of hepatic metastases.[80] Vascular System Color flow duplex imaging and endoluminal ultrasonography have significantly expanded the diagnostic and therapeutic aspects of vascular imaging. Vascular diagnostic imaging is commonly used for diagnosing arterial disease or deep vein thrombosis (DVT); however, it is also helpful for diagnosing other disorders, such as Raynaud disease and thoracic outlet syndrome. In the office setting, surgeons use ultrasonography to screen for abdominal aortic aneurysm or to follow patients with a diagnosed aneurysm, because it is capable of detecting change in aortic diameter as small as a few millimeters.[81] In patients who have undergone repair of an abdominal aortic aneurysm, color flow duplex imaging is highly specific for the diagnosis of anastomotic false aneurysms. In one study, this modality was compared with B-mode ultrasonography, CT, digital subtraction arteriography, and magnetic resonance imaging and emerged as the diagnostic test of choice when the accuracy, cost, safety, and availability of each method were assessed.[82] Color flow duplex scanning is also used to examine the patency and size of the portal vein and the hepatic artery in patients who have undergone liver transplantation, to assess the resectability of pancreatic tumors, to diagnose superior mesenteric artery occlusion, and to diagnose a pseudoaneurysm or an arteriovenous fistula after percutaneous arterial catheterization.[83,84] In the acute setting, several investigators have found color flow duplex imaging to be a reliable, time-saving, noninvasive alternative to arteriography for the detection of arterial injury.[85-89] Duplex imaging of the lower extremity is used to assess the patency of the deep venous system and is capable of detecting DVT reliably.[90] The addition of color flow imaging facilitates the examination by making the artery and its associated vein easier to identify. By performing serial duplex venous ultrasound imaging to detect DVT, one group of investigators was able to identify a subgroup of injured patients who were at highest risk for pulmonary embolism; they suggested that these patients be given DVT prophylaxis and undergo close surveillance with duplex imaging.[90] Intraoperative duplex imaging can be used to detect technical errors in vascular anastomoses as well as abnormalities in flow.[91] Arteriography assesses the patency of an anastomosis and measures distal arterial runoff, but it is invasive. Intraoperative duplex imaging, on the other hand, permits rapid visualization of the anatomic and hemodynamic aspects of a vascular reconstruction, and it is noninvasive, easily repeatable, and less time-consuming than arteriography. Surgical Intensive Care Unit

Indications for surgeon-performed ultrasonography in the SICU include localization of a central vein or an artery for hemodynamic monitoring[92] and detection of a pleural effusion (see Figure 6). Not only are fewer lateral decubitus x-rays ordered when ultrasonography is done in the SICU, but the safety of thoracentesis is also enhanced when it is performed under ultrasound guidance.[93,94]

Figure 6. Sagittal ultrasound: pleural effusion. Sagittal ultrasound image demonstrates pleural effusion.

General Considerations for Diagnostic Ultrasound Examinations

Instrumentation Before an ultrasound examination is performed, the following three steps should be observed: 1. The correct ultrasound machine and transducer should be chosen for the specific type of examination to be done. For example, if a vascular study is to be performed, the machine should have Doppler capability and, ideally, color flow capability as well. 2. The transducer should be chosen according to the structure or organ to be imaged. It must provide both sufficient depth of penetration to image the entire organ and sufficient resolution to allow the examiner to distinguish the details of lesions. 3. Although many machines have preset controls for power and gain, a standard image should be obtained to confirm that the settings are correct for the specific examination being done. For example, the FAST begins with an image of the heart so that blood can be identified and the gain controls adjusted (if necessary) to permit accurate detection of hemoperitoneum. Patient Positioning The patient should be positioned so that all of the images required for a particular examination can be readily obtained. The surgeon should take time to review the scanning planes (see Figure 7) and understand the orientation of the patient on the monitor screen in relation to the transducer. It is also important to follow conventional scanning protocols so that when the images are reviewed, a lesion can be accurately located and the scan can be reproduced even by another ultrasonographer. An example of such a protocol is the radial-

scanning technique recommended for examination of the breast (see Technique for Selected Surgical Applications of Ultrasonography, Breast Examination).

Figure 7. Scanning planes. Depicted are scanning planes used in ultrasonography. Documentation The machine's annotation keys are used to record the patient's name and identification number, the area of interest, and the scanning plane. Most machines have function keys that automate the recording of these data. Furthermore, the internal clock automatically labels each image with the date and time (accurate to 0.01 second). Any hard copies of the ultrasound images that may be required should be printed, saved, and reviewed. Ideally, the ultrasound images should be videotaped, because the dynamic real-time image provides more information than still images, thereby increasing the confidence level associated with each observation. Continuous Performance Improvement As part of the performance improvement process, ultrasound images should be routinely reviewed, with special attention paid to false positive or false negative examinations. The goal of this process is to help identify any correctable factors associated with such examinations and thereby minimize or prevent their recurrence. Some studies have noted the presence of a pronounced learning curve, as a result of which the sensitivity and specificity initially achieved by new surgeon-ultrasonographers have been relatively low[68,95-97]; however, there is

evidence that surgeons' performance may be improved with the help of an ultrasound training course that focuses on those pitfalls of imaging that were found to be problems in the clinical setting. For example, in one study, surgeons learned both to perform examinations correctly and to interpret positive results accurately in patients with minimal as well as pronounced ascites; as a result, they were better able to distinguish relatively subtle differences within the spectrum of positive FAST results.[97] Other suggestions for improving performance are (1) to perform the ultrasound examination initially on normal tissue (as in evaluation of a breast mass) and (2) to perform the examinations on patients with known disease (e.g., a palpable breast mass, ascites, gallstones, or benign pericardial effusion). The rationale for the latter suggestion is that it should help the surgeon learn more rapidly how to recognize lesions with varying degrees of pathology. Technical Tips The following general technical tips should prove useful in a wide range of ultrasonographic applications: 1. The ultrasound machine should be inspected according to the guidelines of the institution's department of biomedical engineering to ensure that it is functioning properly. 2. The patient's orientation on the monitor or screen relative to the position of the transducer should be checked by applying gel to the transducer's footprint (i.e., the part of the transducer that is in contact with the patient's skin) and then rubbing the footprint with a finger near the indicator line of the transducer. Motion on the left side of the screen indicates that the transducer is properly oriented. 3. Liberal amounts of gel should be applied to the area being examined. The gel acts as an acoustic coupler, helping to transmit the ultrasound waves and reduce their reflection. If not enough gel has been applied, the waves will not be transmitted properly, and a dark area will appear on the ultrasound image. 4. The transducer should be manipulated with small movements (not wide sweeps), and gentle pressure should be applied initially. This second point is especially important in imaging the breast or the thyroid: the tissues are superficial, and too much pressure can easily compress them and distort the ultrasound image. 5. The gain and time-gain compensation settings should be rechecked for each new examination. For example, after completing a breast examination, the sonographer should not begin an examination of the carotid vessels without confirming that these settings are correct. 6. Normal tissue should be examined ultrasonographically before the sonographer turns to the area of interest. For example, if the goal is to assess an abscess or DVT in one extremity, the first step should be to inspect the other extremity to see what the corresponding normal tissue looks like. This helps to sensitize the examiner to subtle pathologic changes in the abnormal tissue. 7. The patient should be asked to take a deep breath so that the motion of the diaphragm and the organs can be observed. If the motion of these structures is impaired, inflammation or an abscess may be present. 8. If the left upper quadrant is difficult to examine (as is sometimes the case in the FAST), a nasogastric tube should be inserted to decompress the stomach and minimize the presence of air so that it does not interfere with the transmission of the ultrasound waves. 9. Although B-mode ultrasound is usually sufficient to identify blood vessels, it sometimes is unable to distinguish the artery from the vein because of pulsations transmitted from the artery. In such cases, use of the Doppler mode, compression of the vessel (veins compress very easily), or having the patient perform the Valsalva maneuver can help differentiate arterial from venous anatomy. In addition, the vena cava is more readily identified as the patient completes inspiration. 10. A full bladder is needed for pelvic ultrasound examinations: it acts as an acoustic window, facilitating visualization of the pelvic structures. It should not, however, be so full that it is overdistended. If the bladder is not full enough, the urinary catheter can be clamped to allow it to fill; if it is too full, the catheter can be unclamped to allow it to drain. In this way, hematomas in the pelvis can be more easily detected.

Technique for Selected Surgical Applications of Ultrasonography

Focused Assessment for the Sonographic Examination of the Trauma Patient The FAST is performed during the Advanced Trauma Life Support secondary survey while the patient is in the supine position (see I:2 Trauma Resuscitation). With the thoracoabdominal area exposed, warmed hypoallergenic, water-soluble ultrasound transmission gel is applied to the abdomen in four specific areas. A focused, limited examination for the detection of blood in these four regions is conducted in sequence as follows: (1) the pericardial area, (2) the right upper abdominal quadrant, (3) the left upper abdominal quadrant, and (4) the pouch of Douglas (see Figure 8).

Figure 8. Transducer positions used in FAST. FAST. Shown are four transducer positions used in FAST: (1) pericardial area, (2) right upper quadrant, (3) left upper quadrant, and (4) pelvis.[95] The transducer is oriented for sagittal sections and placed in the subxiphoid region. The heart is then identified, with the density of blood used as a standard. The subxiphoid approach through the longitudinal axis is taken to enable the examiner to identify the heart and to look for blood in the pericardial region (see Figures 9a and 9b).

Figure 9a. FAST of normal heart. FAST. Sagittal ultrasound image of heart shows pericardium as single echogenic (white) line; normal findings.

Figure 9b. FAST: Blood in pericardium. Sagittal ultrasound image of heart shows separation of pericardial layers by blood. The transducer is then placed in the right midaxillary line region between the 11th and 12th ribs to enable the examiner to identify the liver, the kidney, and the diaphragm and to look for blood in Morison's pouch (see Figures 10a and 10b).

Figure 10a. FAST: Normal liver, kidney, and diaphragm. FAST. Sagittal ultrasound image of liver, kidney, and diaphragm yields normal findings.

Figure 10b. FAST: Blood in right upper quadrant. Sagittal ultrasound image of right upper quadrant shows blood between liver and kidney and between liver and diaphragm. Next, the transducer is positioned on the left posterior axillary line between the 10th and 11th ribs to enable the examiner to visualize the spleen and the kidney and to look for blood in the space between these organs and posterior to the spleen (see Figures 11a and 11b).

Figure 11a. FAST: Normal spleen and kidney. FAST. Sagittal ultrasound image of spleen and kidney yields normal findings.

Figure 11b. FAST: Blood in upper left quadrant. Sagittal ultrasound image of left upper quadrant shows blood between spleen and kidney. The transducer is then oriented for transverse sections and placed in the midline approximately 4 cm superior to the symphysis pubis to determine whether there is blood around the full bladder (see Figures 12a and 12b).

Figure 12a. FAST of normal pelvis. FAST. Coronal ultrasound image of pelvis shows full bladder; normal findings.

Figure 12b. FAST: Bladder surrounded by blood. Coronal ultrasound image of pelvis shows full bladder surrounded by blood. An analysis of 1,540 injured patients undergoing FAST examinations performed by surgeon-ultrasonographers reached the following conclusions[97]:

1. Ultrasonography should be the initial diagnostic adjunct for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate and augments the surgeon's diagnostic capabilities. 2. Surgeon-performed FAST is most accurate when used for the evaluation of patients with precordial or transthoracic wounds and a possible hemopericardium and for the evaluation of hypotensive patients with blunt torso trauma. 3. Because of the high sensitivity and specificity of ultrasonography when it is used for the evaluation of patients with precordial or transthoracic wounds and hypotensive patients with blunt torso trauma, immediate operative intervention is justified in these patients when the ultrasound examination is positive (see Figures 13 and 14).

Figure 13. Evaluation of patients with penetrating precordial wounds. FAST. Shown is an algorithm for use of ultrasonography in evaluation of patients with penetrating precordial wounds.[111]

Figure 14. Evalutaion of patients with blunt abdominal trauma. FAST. Shown is an algorithm for use of ultrasonography in evaluation of patients with blunt abdominal trauma.[110]

Although the FAST accurately detects the presence or absence of hemoperitoneum in patients with blunt trauma, it does not readily identify intraparenchymal or retroperitoneal injuries. Therefore, a computed tomographic scan of the abdomen may be needed to complement the FAST and reduce the incidence of missed injuries.[95,97-100] There is some evidence that false negative results are more common in patients with pelvic ring fractures, which suggests that CT of the abdomen is routinely indicated in such patients.[101] The increase in surgeon-performed ultrasound examinations has led to decreased performance of diagnostic peritoneal lavage and CT scanning in the trauma setting. It has become apparent that the FAST can replace central venous pressure monitoring in the diagnosis of hemopericardium and can replace diagnostic peritoneal lavage in the detection of hemoperitoneum in many injured patients. Although CT scanning remains a valuable diagnostic test, the indications for its use in the evaluation of injured patients are now narrower than they once were. Breast Examination The surgeon must be thoroughly familiar with the ultrasonographic anatomy of normal breast tissue to be able to recognize a mass, discern its ultrasonographic characteristics, and determine whether it is likely to be benign (see Figure 15) or malignant (see Figure 16).[102,103] Analytic criteria for the interpretation of focal lesions detected on breast ultrasound examinations have been well described and depicted elsewhere (see Figure 17).[102]

Figure 15. Breast examination: simple cyst. Breast examination. Ultrasound image shows simple cyst (arrow) of breast characterized by sharp, smooth margins and homogeneous, anechoic interior.

Figure 16. Breast examination: malignancy. Breast examination. Ultrasound image shows malignant breast lesion (arrow) with indistinct, jagged margins, few internal echoes, and slight posterior shadowing.

Figure 17. Criteria for interpretation of breast sonograms. Breast examination. Shown is a schematic representation of analytic criteria for the interpretation of breast sonograms.[102] As noted, breast examination should be done according to a specific scanning protocol. The recommended approach is the radial-scanning technique reported by Teboul.[104] A 7.5 MHz linear-array transducer is used, and the patient is placed in the supine position with the ipsilateral arm behind the head. The transducer is placed at the 6 o'clock position; the breast tissue is scanned, and the transducer is then advanced toward the periphery beyond the breast tissue. Next, the 5 o'clock region is evaluated in the same manner. Each sector (or "hour") of the breast is then scanned in a sequential counterclockwise fashion until the process is completed. Some experts recommend that the nipple be used as a visual pivot point during scanning, remaining in the upper left corner of the monitor throughout the ultrasound examination.[105] To image the nipple-areola complex, the transducer is placed next to the nipple and angled toward the retroareolar area. Several transverse scans are performed to assess the uniformity of the ligamentous structures and to detect any small tumor that may be present between these structures. Finally, the axilla is scanned with transverse and longitudinal sweeps of the transducer to inspect for lymph nodes.[105]

An important principle in the performance of breast ultrasonography is that the examination must be performed in a consistent and methodical manner so that findings can be accurately described and reproduced. If this principle is followed, a trained examiner can probably identify 80% to 90% of mammographically detected nonpalpable breast masses.[106] One important drawback to remember, however, is that ultrasonography generally will not reveal lesions less than 5 mm in diameter or lesions with an isoechoic appearance.[107] For more information, visit . to ACS Surgery: Principles and Practice.

Tables Table 1. Ultrasound Physics Terminology Relevant to Ultrasonographic Imaging[4-6]

Term Ultrasound Frequency

Definition High-frequency (> 20 KHz) mechanical radiant energy transmitted through a medium Number of cycles/sec (106 cycles/sec = 1 MHz) Diagnostic ultrasound: 1-20 MHz

Significance

Increasing frequency improves resolution

Wavelength

Distance traveled by wave per cycle: as frequency becomes higher, wavelength becomes smaller Strength or height of wave Decrease in amplitude and intensity of wave as it travels through a medium; attenuation is affected by absorption, scattering, and reflection Conversion of sound energy into heat Redirection of wave as it strikes a rough or small boundary Return of wave toward transducer Speed with which wave travels through soft tissue (1,540 m/sec)

Wavelength is related to spatial resolution of object: shorter wavelengths yield better resolution but poorer penetration Amplitude and intensity are reduced (attenuated) as waves travel through tissue; time-gain compensation circuit compensates for this attenuation

Amplitude Attenuation

Absorption Scattering Reflection Propagation speed

Propagation speed (determined by density and stiffness of medium) is greater in solids than in liquids and greater in liquids than in gases

Table 2. Essential Principles of Ultrasound

Principle Piezoelectric effect Pulse-echo principle Acoustic

Explanation Piezoelectric crystals expand and contract to interconvert electrical and mechanical energy When ultrasound wave contacts tissue, some of signal is reflected while some is transmitted into tissue; these waves are then reflected to crystals within transducer, generating electrical impulse comparable to strength of returning wave Acoustic impedance = density of tissue x speed of sound in tissue

impedance

Strength of returning echo depends on difference in density between two structures imaged: structures of different acoustic impedance (e.g., bile and gallstone) are relatively easy to distinguish from one another, whereas those of similar acoustic impedance (e.g., spleen and kidney) are more difficult to distinguish

Table 3. Terminology Used in Assessment of Ultrasonograms[3,108]

Term

Definition

Echogenicity Degree to which tissue echoes ultrasonic waves (generally reflected in ultrasound image as degree of brightness) Anechoic Isoechoic Hypoechoic Showing no internal echoes, appearing dark or black Having appearance similar to that of surrounding tissue Less echoic or darker than surrounding tissue

Hyperechoic More echoic or whiter than surrounding tissue Resolution Lateral Axial Ability to distinguish between two different structures; spatial resolution improves as frequency increases Resolution transverse to ultrasound wave; relates to width of structure Resolution parallel to ultrasound wave; relates to depth of structure

Table 4. Clinical Applications of Selected Transducer Frequencies

Frequency 2.5-3.5 MHz Renal Aortic

Applications

General abdominal 5.0 MHz Transvaginal Pediatric abdominal Testicular 7.5 MHz Vascular Foreign body in soft tissue Thyroid

References
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Grace S. Rozycki, M.D., Associate Professor, Department of Surgery, Emory University School of Medicine, and Director of Trauma/Surgical Critical Care, Grady Memorial Hospital