Wednesday, 4 December 2019

How relevant is for the sonologits & pelvic surgeons on anatomy of uterus& ovaries


Anatomy of Ovaries & Pelvic surgery  : what we have to remember ?? Point 1:- Shape & location of ovaries:--Anatomy of Ovaries & Pelvic surgery  :-All pelvic Surgeon should  remember that in most diseases ovaries are usually but nor always  glued to pelvis along with “ureter in the back” which  is a bit puckered too. –We know that the normal ovary is ellipsoid  in shape     and is variable in both location   and orientation  depending upon the age  and parity of the patient as well as the degree of bladder  distention, endometriotic  adhesions , pelvic adhesive diseases, Kochs and previous pelvic  surgeries
 In the nulliparous adult female the ovaries    are situated in the ovarian fossa (no surgery for leaking CL have been done , but may be adherent if she had had App open in school age)  which is adjacent to the lateral pelvic side wall and is bounded by the obliterated umbilical artery    anteriorly.

 Does mean  ovarian  volume changes in different phases of menst cycle??   Ovarian   volume is calculated by measuring  the ovary in  three dimensions  on two orthogonal    planes and    using the formula for the prolate ellipse . Ovarian    size depends  upon age menstrual cycle. In premenopausal women    the mean  ovarian  volume  is 9.8 ml with the highest volumes  found in the preovulatory phase   and th lowest volumes in the luteal phase. Normal ovarian volume decreases after   the age of 30 years. In one  large study   ovarian   volumes decreases  after the age   of 30 years. In one     large  study mean  ovarian volume significantly   decreased  in each decade up to age  60 years  measuring  6.6 ml   in women   under 30 years of age 6.1 ml  in women 30 to 39 years old 4.8 ml at ages 40   to 49 years  2.6 ml   over age   70 years. The authors  found   a statistically   significant   increased   ovarian   size in tall women but no   relationship    to weight  Despite   the small size of the postmenopausal  ovary the majority  are detectable  by TVS.
The   normal   ovary in  women  of reproductive  age has a variable appearance over   the course  of the menstrual   cycle. Developing   and immature follicles   can  be seen   throughout the entire   menstrual cycle   and appear    as anechoic   unilocular sharply   marginated    cysts measuring   from 2 to 9  mm  by days 8 to 12 of the  menstrual cycle one or more  dominant follicles    will grow   to a diameter   of approximately   20 to 25   mm and then rupture   at ovulation   releasing the oocyte Up to 80% of     patients have    a second   non dominant  follicle   that becomes almost as a large as the  dominant  follicle. The preovulatory  dominant   follicles . The preovulatory dominant follicle may have a slightly complex appearance with the oocyte and its supporting structures appearing as a ring like  structure   within the follicle    following   ovulation the corpus   luteum evolves  from the remnant of the mature  follicles       through   a process of cellular hypertrophy   and increased   vascularization of the cyst wall. Therefore    a corpus     luteum  is typically  visible   in the secretory   phase  of the menstrual cycle  and in the   first few weeks  of  early pregnancy .

 On  sonographic imaging, the corpus   luteum  typically   has a relatively thick   homogenously echogenic   wall the  inner margin of which may be  slightly irregular with a crenulated appearance . on color   Doppler   the wall of the  corpus  luteum often  demonstrates  a   circumferential ring  of arterial flow with  a low   resistance spectral  Doppler  waveform. Internal echoes are common reflecting   variable amounts  of internal hemorrhage that   occurred at  the time of ovulation and occasionally   a corpus  luteum  may be  filled  with homogenous  low level echoes   mimicking a solid mass. However   there  is usually   evidence of enhanced through transmission because of    the fluid content  and there will be   no central   vascularity . Typically the corpus  lute is under 3.0   cm in maximal dimension   but rarely    it may become  larger. If pregnancy   does not occur   the corpus   luteum gradually involutes and   atrophies to become the corpus    albicans    which is typically      not sonographically identifiable.   Small    echogenic foci measuring 1 to  3 mm  may be noted    in the periphery of otherwise    normal appearing    ovaries  in approximately     half   of women    undergoing TVS   particularly  in the perimenopausal  age  group  . These foci   often demonstrate ring down   artifact and    are a benign   finding likely related   to the presence of  tiny cysts possibly   cholesterol or hemosiderin deposition  and less likely  tiny calcifications. These   tiny echogenic foci may come and go underneath the surface epithelium and         should not   raise  concerns or result in follow up imaging.
In the postmenopausal patient    ovarian size  decreases  correlating  with hormonal  status and length  of time since menopause  Mean  postmenopausal ovarian volumes have been reported    to range from 1.2   to 5.8 n ml with   an ovarian  volume of greater  than 8 ml  considered abnormal in all cases. Some    authors have suggested that a unilateral  ovarian size twice that of the opposite     side   regardless of the size should also be considered abnormal . Even though folliculogenesis   has ceased  the postmenopausal   ovaries are not  as   quiescent as initially  though . Small   simple adnexal cysts       measuring as   large   as 3 cm have  been reported in   up to 15%   of postmenopausal   women most of   these spontaneously   regress on  serial   sonographic examinations. These   simple  cysts seen  early   in menopause most likely represent an occasional    ovulatory  event or   an atretic   follicle. However   any anechoic   cystic lesion in a postmenopausal   ovary should   generally be referred   to as a cyst. In late menopause   although  ovulation  is rare smaller   cysts less than or equal  to 1 cm   have been   reported in up  to 21 % of  women. TVS  will detect these cysts  more readily than TAS   because  of the higher  resolution of the higher  frequency   transvaginal    probe   . These   simple appearing   cysts  measuring    less than  1 cm  in maximal  diameter   do not need further  follow up  and whether  or not they  are described in the final report   can be left     to the discretion of the interpreting  physician.  The   shape   and size of the uterus   vary throughout life affected  mostly by hormonal   status. The  mean   measurement   of the prepubertal    uterus  is 2.8 cm in length  and 0.8 cm  in maximum   anteroposterior  dimension with the cervix     accounting for two thirds of the total length     and contributing    to the pear shaped   appearance  . It is    important to remember    that in the   immediate post delivery   state the neonatal   uterus    can be slightly   larger owing  to the effects  of residual    maternal  hormones,. For the  same reason     the echogenic   endometrium   is well seen   and a small  amount of fluid can be  present  in the endometrial cavity.
 Point2: Are U Surgeon?? Where is the danger?? It is in the post aspect & ovarian fossa!!! The ureter   and internal   iliac artery   form the posteriorly   and the external iliac vein superiorly. Any stitch, clamp or bite can cause inclusion, clamping crushing or even through and through cutting of the ureter. Like Gut this part  also merit too much respect for radiation heat and such thing must be kept in mind  in doubt and after opening the abdomen one feels it is difficult to locate ureter  in the true pelvis then it the safe practice  is to pinch up the P periosteum  at the brim level at the bifurcation site and make a gentle incision by scissors and then by gentle finger dissection the cord like structure (almost like spermatic cord)  can be rolled, If you are a trainee then can pass a  soft rubber catheter beneath the ureter and put a clamp on the rubber catheter but too much dissection from the peritoneum may invite ischemic fistula later, Further at  this  point of brim there is a danger of puncturing Ext iliac van ,Butyl pl don’t be nervous ,Just gentle pressure for 10 minutes will cause stoppage  bleeding, Vascular clips may cause harm. No tie or extra needle pricks in a hurry please. The inferior aspect of the ovary is slightly smaller   than the superior   or tubal aspect  and is bound to the uterine cornu  by the ovarian    ligament which    lies within   the broad  ligament .

There  is another mountain with sleeping volcano  where too  you can’t force /  temp  an experienced Eagle to fly over that mountain!!!!!  Where we face danger ?? The lateral surface of the ovary . This is  in contact with the parietal    peritoneum  lining  the ovarian fossa    and most of the medial surface is covered  by the fallopian tube  . Th anterior border of the ovary   is attached to the mesovarium  through  which  the vascular   channels and nerves  pass into the ovarian   hilum. To remember ovarian vessels are the direct lateral branch of abd aorta –a high pressure vessels. If a stitch slips then the haematoma will trace quite high up .this also applies to pampiniform plexus of veins ,The resultant haematoma(if the Asstt releases the clamp too early before surgeon pushes the knot too firmly then such venous big size haematoma can occur, Then too   one should call for  Urosurgeonas , keep on pressing the haeamtoma by hot mops(disposable desirable) till Urosurgeonas arrives at theatre,. May have a requisition of 2 units of blood Tr/PCV), If U are competent enough the after release of pressure U  can try to locate the ureter at brim and the again pass a  rubber Catheter all around the freed ureter ask the second asst to keep a gentle  pull on it(ureter)  and then one can pass N0 1 Chr catgut en masse excluding the ureter with confidence (the life line-water line).. Usually two stitches are required. Such an incidence also happens if A forces used for clamping the I P ligament is as old as mine and gets slipped of its own before surgeon puts the knot firmly. IN TLH this doesn’t happen except when electric line is off and standbys line takes some time. . That is why some beginners do clap at mesoaslpinx and remove the uterus ,Late the only ovary is removed . But be it LH or open TAH double ligation of I P ligament safe. In CS cases pl do make a habit of palpating the ureters so in times of need  U can trace the ureter from brim to ureteric tunnel thought such wide dissection(  making the ureters naked) are not recommended in good surgical practice .
Point 4 : Uterus & sonologist :--From  birth  until 4 years of  age   the    uterus decreases  in size. At  approximately  8 years of age     the uterus   starts to grow preferentially in the fundus. The uterus   continues to grow   for several    years   after menarche   until it reaches  the mean dimensions of a reproduction age uterus which are approximately 7 cm long and 4 cm wide. Parity increases    the size  of the uterus    with a multiparous   uterus  measuring   approximately   8.5 cm by 5.5 cm .
Following   menopause   the uterus   decreases in size. The   decrease in size   is related to the number  of years  since   menopause  although the    reduction in size is believed  to be most  repaid durng   the first decade   following   menopause . The   length  of the normal   post menopausal  uterus    has been reported   to range  from 3.5  to 6.5   cm and the   antero posterior dimension form 1.2   to 1.8 cm.

The urinary  bladder     distal  ureters  and urethra & USG
 The  appearance of the urinary  bladder depends  on the degree of distension. The distended bladder will be round  on a superior  transverse   imaging plane. More  inferiorly the pelvic   musculature     and bones   cause   the bladder to be square  in the   transverse  plane. The bladder   wall is homogenously echogenic and should be uniform in  thickness measuring   less than  3 mm when well  distended. The ureteric   and urethral orifices  are visualized at the base and neck   of the bladder   respectively    . IN the upper pelvis the ureter  lies   anterior to the  internal  iliac artery   and posterior  to the ovary   More  inferiorly the ureter  courses anteromedially   to lie within  the inferomedial portion   of the broad   ligament   where it is in close  proximity   to the uterine     artery. The ureter  then  runs  anteriorly situated in front  of the lateral fornices of  the vaginal   about 2 cm    lateral to  the   supravaginal  cervix  and then passes medially  to enter the  trigone of the bladder  anterior to the vagina   . The relationship of the ureter to the  ovary   cervix   uterine artery   and vagina  is of clinical importance   because   pelvic   disease may obstruct   the ureter resulting   in secondary hydronephrosis  The distal portion of the  ureter just   proximal  to the ureteral  orifice is  often well seen on TAS   through the distended bladder . the distal   ureter   and ureterovesical   junction  can also   be well seen   on TVS  if the  bladder  is partially   distended. Hence  TVS  is an excellent means of searching for UVJ  stones  especially  in the pregnant patient  . The presence of  a ureteral jet in the bladder  on color Doppler  is a normal finding  on both TAS  and TVS and indicates  that the ureter is at least partially  patent.
TVS  enables better  visualization of the trigoone  one and posterior  wall of the urinary bladder  as well as the urethra in comparison to TAS. To   visualize the urethra the probe   is placed at the introitus or just partially inserted into the vagina  and directed upward     .surrounding the inner echogenic layer of the mucosa there is  a thin layer of smooth  muscle and then  an outer sheath of striated muscle. The   longitudinally oriented  smooth  muscle   is thicker anteriorly in the  middle  third of the urethra. The para urethral gland  of skene  lie  posterior to the urethra near the UVJ  and empty through the periurethral duct near   the external urethral orifice. Urethral diverticula  are distened  and   obstructed   urethral mucous glands  and are found posterior   and lateral  to th urethra  anywhere along  its length. They may be a source   of pelvic    pain and recurrent urinary   tract infection   and  can be     easily documented on TVS. They may be   round or horseshoe shaped   partially  encircling   the  urethra although   these  diverticula are  usually    anechoic  internal echoes  may be  observed either   diffuse  or layering This non   specific    finding may be   secondary   to infection   or debris from stasis  or  chronic  inflammation. Echogenic shadowing   calculi may also be observed  in urethral   Diverticula  as stasis predisposes to calculus  formation as well as  infection

In North    America   approximately 8% to 15% of couples   is which the female   partner is 15 to 45  years of age   experience  some form of infertility  that is they  have  not conceived  after 12 months of unprotected sexual    intercourse . normal    fertility is   considered to be   between  20%  to 22%    per cycle    and approximately  50%  after   three    cycles. Therefore   in a normal  population   approximately  60%   of women   will become     pregnancy within 6 months   80%   within 12  months   and 90%  within 18  months . In  a fertility focused  intercourse   study pregnancy   was achieved  in 76%   90%  and 98%  of cases by the first    third and  sixth cycles   respectively the   age of the female  partner is of paramount  importance  in  making decisions  about when to begin investigations . In couples in which  the woman   is younger than   35 years of age  986. It is  generally accepted that infertility investigations be initiated after 12 to 18 months of unprotected   intercourse   . however   if the female partner is older than 35 years of  age has menstrual abnormalities a history   of pelvic  disease or surgery  earlier initiation of  the  infertility  work up may be   considered It is  important to   remember that   infertility is a couple’s   issue and each couple  will present     with a different     level of  desire  to pursue   infertility investigation and  therapy . Evaluation   and management   of infertility diagnosis and    therapy   will typically    involve   several members   of a multi disciplinary   team. Consensus   documents outlining  the optimal   work up of couples  who present with  infertility   and  optimal     evaluation of  the infertile   female are   available from   the Canadian Fertility    and Andrology  society   and the American   Society  for Reproductive  Medicine. These guide lines should be consulted     for best   practices  in determining  the sequence   of diagnostic investigation and therapeutic intervention.       
Ultrasonography  is an integral and essential part of  both the diagnostic and therapeutic  steps   in  ameliorating infertility  . Although  the causes  of infertility  may have  only female   factors only male factors   a combination of issues  from each partner  or are  idiopathic in nature  the steps taken  toward resolution of the couple’s   inability  to conceive   are shared  Each   step  in the diagnostic   or therapeutic process  should entail  clear communication    and   involve   education  and   counseling   so that the couple   understands   the  reasons   for   each test is involved  in each  decision  at each   stage of   therapy  and has realistic expectations of the therapeutic   interventions. An  ultrasound   examination during   the initial   infertility    consultation in clinics where   ultrasonography   is an   integral part of   clinical   practice. There is a tremendous      amount of  information  to be gained using ultrasonography   early in infertility investigations. We believe  that imaging  has become the de facto standard for obtaining   information   once thought    to be the purview   of more conventional   tests  and should now  be considered  as a   standard in infertility  studies. Uterine  and ovarian   abnormalities    such as cysts  tumors fibroids   endometriomas hydrosalpinx  and congenital abnormalities may be  instantly visualized  and appropriate  action taken. In addition  a conceptus may be visualized  very  early   in gestation.                                                                                            


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