Ultrasonically Guided Incisional Hernia Treatment: A New Technique

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Ultrasound in Medicine and Biology

Purpose: This paper on an MR-compatible phantom for evaluating the propagation of high intensity focused ultrasound through the skull is presented. Material & Methods: The phantom was constructed using the thermoplastic material of ABS. The attenuation of ABS was measured using the transmission-reception method. Knowing the attenuation of human skull, the thickness of the phantom was chosen appropriately so as to achieve the same attenuation effect as in the case of human skull. The phantom was designed using CAD software and then manufactured in a rapid prototyping machine. In order to test the phantom, a spherically focused transducer operating at either 0.5 MHz or 1 MHz was used. Brain tissue was mimicked either using gel phantoms or freshly excised tissue. Results: It was found that the propagation of ultrasound through the skull was much better with the 0.5 MHz transducer. The skull phantom was tested also inside an MRI scanner, and we were able to detect temperature using the MRI technique of FSPGR indicating that with low frequency ultrasound propagation through the skull is possible. Conclusion: The skull phantom is a very successful tool for evaluating the propagation of ultrasound during the presence of skull.

SS 37.05 Ultrasound-Guided Trigger Point Dry Needling: A New Approach for Myofascial Pain Syndrome Management R. V. Bubnov The Center Ultrasound Diagnostics and Interventional Sonography, Clinical Hospital ‘‘Pheophania’’ of State Affairs Department, Kyiv/UA Purpose: We propose a new method of pain therapy based on ultrasonographic identification of myofascial trigger points with ultrasoundguided inactivation. Material & Methods: The study included two groups with myofascial pain at different locations. 133 patients were randomly assigned to either dry needle trigger point therapy under Ultrasound guidance (91 patients) or to dry needle trigger point therapy using clinical (palpatory) established landmarks (42 patients). Ultrasound scanning with a linear transducer 5-12 MHz frequency using sonoelastography was carried out to identify the myofascial trigger point. In the first group after visual identification of trigger point, dry needling using acupuncture needles (28 gage) was inserted to elicit the LTR effect. Visual analogue scale data (0 to 10) were measured before, immediately after and 24 hours after the intervention. Results: The pain relief effect (more than 50% of VAS decrease) was registered in all patients of two groups. Ultrasound guidance significantly increases the pain relief effect, the level of eliciting LTR (local twitch response), and significantly decreases the average number of needled trigger points and average number of treatment sessions. There were registered significant correlations between eliciting LTR during needling and the pain relief effect. Using sonoelastography increases the level of trigger point detection, but in this study it is not statistically significant. Conclusion: Ultrasound-guided trigger points dry needling may be considered as the only effective method for myofascial pain syndrome treatment. SS 37.06 Ultrasound-Guided Pain Control in the Cervical Spine: A Prospective Randomised Clinical Trial A. Loizides,1 S. Peer,1 M. Plaikner,1 J. Obernauer,2 K. Galiano,2 H. Gruber1 1 Department of Radiology, Innsbruck Medical University, Innsbruck/AT, 2Neurosurgery, Innsbruck Medical University, Innsbruck/AT

Volume 37, Number 8S, 2011 Purpose: Pararadicular and facet-joint injections are widely used for alleviation of cervical pain. Injections are preferentially performed with fluoroscopy or with CT guidance. Ultrasound guidance has the potential advantages of real-time monitoring, broad availability and lack of radiation. Material & Methods: 44 adult patients with chronic low back pain were consecutively enrolled and randomly assigned to an ultrasound (n 5 21) or a CT group (n 5 23). Accuracy of ultrasound interventions was controlled with CT. Time savings, radiation doses and pain relief were evaluated for both groups. Results: All (US and CT) combined pararadicular and facet-joint injections were performed correctly. CT control showed correct placement of injection in all 21 patients in the ultrasound group. The mean duration of the procedure was 4.6 (1.3-8.4) minutes in the ultrasound group and 10.4 (5.3-15.5) minutes in the CT group. Mean radiation dose was 22.7 (16-40) mGy*cm for CT-control, and 144.8 (56-312) mGy*cm for CT interventions. Both groups showed a comparable overall benefit from pararadicular and facet-joint injections. Conclusion: The US-guided approach to the pararadicular compartment and the facet-joints in the cervical spine is technically feasible with high accuracy. A comparable pain reduction is achieved when compared to CT-guided injections, but without exposing the patient to ionizing radiation. SS 37.07 Ultrasound-Guided Versus Computed Tomography-Controlled Pararadicular Injections in the Lumbar Spine: A Prospective Randomised Clinical Trial A. Loizides,1 S. Peer,1 M. Plaikner,1 J. Obernauer,2 K. Galiano,2 H. Gruber1 1 Department of Radiology, Innsbruck Medical University, Innsbruck/AT, 2Neurosurgery, Innsbruck Medical University, Innsbruck/AT Purpose: Pararadicular injections are widely used for alleviation of back pain. Injections are preferentially performed with fluoroscopy or CT guidance. Ultrasound guidance has the potential advantages of real-time monitoring, broad availability and lack of radiation. This study was performed to evaluate the feasibility of ultrasound-guided pararadicular injections. Material & Methods: 32 adult patients with chronic low back pain were consecutively enrolled and randomly assigned to an ultrasound or a CT- group. Exclusion criteria were BMI .35 and postsurgical state. Accuracy of ultrasound interventions was controlled with CT. Time savings, radiation doses and pain relief were evaluated for both groups. Results: In all 18 patients of the ultrasound group the intertransverse ligament (the lead-structure for ultrasound guidance) was clearly visible and the pararadicular injection was technically feasible. CT control showed correct placement of injection in all 18 patients. The mean duration of the procedure was 4,82 minutes in the ultrasound group and 6,9 minutes in the CT group. Mean radiation dose was 26,73 mGy*cm for CT-control, and 63,57 mGy*cm for CT interventions. Both groups showed a similar benefit regarding pain relief. Conclusion: These initial results, which will be evaluated in a larger study, show that the ultrasound approach to the pararadicular compartment in the lumbar spine is technically feasible in a majority of patients and results in a significant reduction of procedure duration and radiation dose when compared with CT controlled injections. SS 37.08 Ultrasonically Guided Incisional Hernia Treatment: A New Technique D. G. Piccolboni,1 A. Settembre,2 L. Miranda3 1 General Surgery, Monaldi Hospital, Naples/IT, 2Monaldi Hospital, Naples/IT, 3Monaldi Hospital, Naples/IT

Abstracts Purpose: Pre-operative imaging studies are useful in planning the most effective abdominal wall incision when dealing with ventral hernias. The optimal location for incision can be estimated through thin sliced CT or high resolution ultrasound: the latter allows a fast and sharp evaluation of the site of the hernia, the size of the fascial leak and the content of the hernia sac. When a "swiss cheese’’ hernia is detected, with multiple small fascial defects inhabited by pre-peritoneal tissue, ultrasonic study can, in our opinion, change surgical approach. Material & Methods: 20 patients have been selected according to the following criteria: ventral hernia with no more than three fascial defects, not exceeding 2.5 cm width; good aspect of the surrounding fascial layer. The procedure can be performed under general or local anesthesia, depending on the number and size of fascial defects, and compliance of the patient. Results: No major post-operative complications were recorded and the outcome was positive with no relapsing hernias. Patients were discharged after 1-3 days. Conclusion: Instead of positioning a wide and probably unnecessary large mesh, small incisions can be done as pointed out by ultrasound and, after dissecting the fascial defect, polipropilene plugs can be inserted in the pre-peritoneal space, in as many defects as required, and fixed to the fascial layer by means of non absorbable sutures.

Mon, Aug 29, 2011 Hall D SS 38 16:00-17:30 Obstetrics SS 38.02 Fetal Weight and Maternal Ethnicity: Our Experience in a Region with a High Immigration Rate L. Driul,1 A. Fruscalzo,2 A. P. Londero,3 G. Tonizzo,1 A. Biasioli,1 S. Bertozzi,4 D. Marchesoni1 1 Clinic of Obstetrics and Gynecology, University of Udine, Udine/IT, 2 Gynecology and Obstetrics, Mathias-Spital, Rheine/DE, 3Gynecology and Obstetrics, University of Udine, Udine/IT, 4Department of Surgery, University of Udine, Udine/IT Purpose: Our region experienced a high immigration in the last decade. The aim of this study is to evaluate the accuracy of fetal weight estimation in women of different ethnicity. Material & Methods: We retrospectively analyzed clinical and obstetric data collected during 2008 in a tertiary center for feto-maternal medicine in the North-East Italy. We included in the study the first 611 deliveries, excluding twin pregnancies and those with incomplete files. 70% of the patients came from Italy, 15% from East-Europe, 10% from Sub-Saharan Africa, and 5% from Northern Countries and America. Results: The ultrasonographically estimated MoM of neonatal weight based on the Hadlock formula results significantly lower in the Italian population and significantly higher in the Sub-Saharan one, whereas it results accurate in the group of women who came from Northern Countries and East-Europe. Conclusion: Even if without any clinical significant difference among actual and estimated fetal weight in our sample, the Hadlock formula seems to overestimate the weight of the Sub-Saharan African fetuses and to underestimate the Italian ones. This may consequently lead to an under-monitoring of small sub-Saharan fetuses, even considering

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that the Sub-Saharan African population in our setting results to have the highest incidence of intrauterine fetal deaths.

SS 38.03 Obstetric Management and Perinatal Outcome in Pregnancies with AFI Less Than 10 and Intact Fetal Membranes K. Blanas,1 M. Theodora,1 N. Papantoniou,1 M. Syndos,1 E. Domali,1 G. Daskalakis,1 S. Mesogitis,1 P. S. Zoumpoulis,2 A. Antsaklis1 1 1st of Obsetrics & Gynecology, University of Athens, Alexandra Hospital, Athens/GR, 2Ultrasound, Diagnostic Echotomography SA, Kifissia/GR Purpose: To examine the attitude of the obstetricians and the perinatal outcome of pregnancies complicated by the finding of borderline oligohydramnios in the third trimester. Borderline oligohydramnios was defined as an AFI between 5 and 10. Material & Methods: 24 singleton pregnancies with borderline oligohydramnios and without history of ruptured amniotic membranes or congenital fetal malformations were included. The patients were Hospitalized for various reasons in the antenatal ward. Initial ultrasound assessment of the pregnancy happened shortly after admission. The fetal-placental circulation as assessed with umbilical artery Doppler was normal. No patients had invasive karyotype testing. The patients were divided in two groups depending on whether the borderline oligohydramnios was isolated (37,5%) or associated with other pregnancy complications or risk factors (62,5%). Results: Increased obstetric interventions (caesarean section) occurred in our study. Particularly in the cases of borderline oligohydramnios associated with other complications or risk factors, the rate of caesarean section approached 87%. 44% was the caesarean section rate in the cases of isolated borderline oligohydramnios. The perinatal outcome was good especially after 34 weeks. There were no perinatal deaths or major perinatal morbidity. Two neonates born before the 34th week of gestation were admitted to neonatal intensive care unit. Conclusion: Meticulous surveillance of the pregnancy and increased intervention follows the finding of borderline oligohydramnios. The perinatal outcomes appear satisfactory. Are such perinatal outcomes feasible without a cascade of obstetric intervention?

SS 38.04 Premature Rupture of the Amniotic Membranes. Obstetric Management and Perinatal Outcome in Borderline Oligohydramnios M. Theodora,1 N. Papantoniou,1 K. Blanas,1 I. Arabatzis,1 M. Syndos,1 G. Daskalakis,1 S. Mesogitis,1 P. S. Zoumpoulis,2 A. Antsaklis1 1 1st of Obsetrics & Gynecology, University of Athens, Alexandra Hospital, Athens/GR, 2Ultrasound, Diagnostic Echotomography SA, Kifissia/GR Purpose: To examine the attitude of the obstetricians and the perinatal outcome of pregnancies complicated by premature rupture of the amniotic membranes (PROM) with associated borderline oligohydramnios. Borderline oligohydramnios was defined as an AFI between 5 and 10. Material & Methods: Over six months we reviewed all singleton pregnancies who were admitted because of PROM in the antenatal ward. Initial assessment of the pregnancy with ultrasound happened shortly after admission. Cases with borderline oligohydramnios were included in the study. The fetal-placental circulation as assessed with umbilical