Search Results (370)

Pleural adhesions can complicate access in robotic cardiac surgery, risking lung injury or conversion to sternotomy. The sliding test using thoracic ultrasound can predict thoracic adhesions and guide the surgeon during robotic set-up. We evaluated the utility of the sliding test in robotic cardiac surgery. The pleural sliding test was performed in 300 consecutive robotic cardiac surgery patients between August 2022 and September 2025. The test was performed by the surgeon using a linear probe at six intercostal sites after intubation. Intraoperative findings were used to validate the test. Tailored port placement and minithoracotomy strategies were used when adhesions were suspected. The mean age was 60.3 ± 13.7 years and 91 (30.3%) of the patients were female. Adhesions were encountered in 20 (6.7%) patients. Prior cardiothoracic surgery was associated with thoracic adhesions (p < 0.001). The pleural sliding test had a sensitivity of 95.0%, specificity of 97.9%, positive predictive value of 76.0%, negative predictive value of 99.6%. No pulmonary injuries occurred and no conversions to sternotomy were necessary in the cohort. Patients with adhesions had higher 24 h chest tube output (p = 0.006) but had similar mechanical ventilation times and intensive care unit stay durations. Pleural adhesions are not rare in patients undergoing robotic cardiac surgery, and their optimal management enhances the safety and efficiency of robotic cardiac procedures. The pleural sliding test offers high accuracy for preoperative detection, enabling tailored access strategies that enhance safety and maintain benefits of the robotic approach. Full article

Background/Objectives: Intravenous leiomyomatosis (IVL) is a rare, histologically benign proliferation of uterine smooth-muscle cells that extend intravascularly. The clinical significance of IVL lies in the potential for mechanical obstruction of the major veins and heart, as well as possible thromboembolic complications. Methods: A retrospective case series included four patients with confirmed IVL, treated at the Clinic for Gynaecology and Obstetrics “Narodni front” between 1 January 2020 and 31 December 2025. The following were recorded: medical history, imaging diagnostics (ultrasound, MRI), operative findings, histopathology, and follow-up data. The study was approved by the Ethics Committee, and written informed consent for participation in the study was obtained from all the patients. Results: The series included four patients aged 40 to 73 with histologically confirmed IVL who were treated surgically. In one patient, an intraoperative complication occurred in the form of sigmoid colon lesion and consequential resection, requiring surgical reconstruction, while the remaining procedures were completed without major complications. Histopathological findings in all cases indicated benign smooth-muscle differentiation with the presence of intravascular nodules of smooth-muscle cells (IVL). Residual disease and recurrence were documented in one patient. Conclusions: Our cases reflect a diverse spectrum of clinical presentations of IVL indicating the heterogeneity of the disease and the importance of a multimodal, multidisciplinary approach to the optimal management of this rare entity. The absence of further disease progression in our patients following bilateral oophorectomy, i.e., iatrogenic menopause, suggests the possible hormonal dependence of IVL. Full article

Thoracolumbar and lumbar hemilaminectomy in dogs requires effective perioperative analgesia. The erector spinae plane (ESP) and retromammillary (RM) blocks are ultrasound-guided regional anesthesia techniques targeting the dorsal branches of spinal nerves, but comparative clinical data are lacking. This retrospective cohort study compared perioperative analgesic requirements and complication rates between ESP (n = 62) and RM (n = 207) blocks in client-owned dogs undergoing hemilaminectomy. The primary outcome was intraoperative opioid rescue analgesia; secondary outcomes included rescue analgesia using any analgesic agent, perioperative opioid consumption (expressed as morphine equivalents, mg kg⁻¹), pain scores, time to voluntary food intake, and complications. Multivariable logistic regression, with covariates selected using a directed acyclic graph, assessed independent predictors of intraoperative opioid rescue administration. Dogs receiving ESP blocks were more likely to require intraoperative opioid rescue than those receiving RM blocks (59.7% versus 38.7%; adjusted odds ratio (OR) 3.4, 95% confidence interval (CI) 1.7–6.6; p < 0.001). Rescue analgesia using any analgesic agent was also more frequent in the ESP group (64.5% versus 43.0%; p = 0.004). Postoperative pain scores, time to first voluntary food intake, and complications were similar between groups. The RM block was associated with reduced intraoperative rescue analgesia compared to the ESP block, though both techniques provided effective postoperative analgesia within multimodal protocols. Prospective randomized trials are warranted to confirm these findings. Full article

Over the past 40 years, thoracic ultrasound (TUS) has relied predominantly on the analysis of artefacts generated by the marked acoustic impedance mismatch between the chest wall and pulmonary air. However, ambiguous terminology has often conflated distinct physical phenomena, compromising their diagnostic utility. This review explores the physical basis underlying the genesis of vertical artefacts (B-lines), starting from the theory of ultrasound propagation in aerated parenchyma. The first comprehensive description of vertical artefacts in pulmonary pathology, termed “radiating streaks”, dates back to 1986. Furthermore, a strict distinction is emphasised between pure, rapidly decaying reverberation phenomena (comet-tail) and resonance phenomena (ring-down or B-lines). By analysing different scenarios, we demonstrate that semantic confusion, combined with an alphabetical nomenclature, has led to an overestimation of the diagnostic potential of TUS artefacts. Although B-lines represent physical artefacts rather than direct anatomical images, they retain valuable clinical utility. For instance, they serve as a rapid screening and diagnostic triage tool in emergency settings, raising the suspicion of underlying pulmonary pathologies (e.g., acute pulmonary oedema, pulmonary fibrosis, or ARDS). “B-lines” on TUS are the manifestation of acoustic phenomena (artefacts) that are also present in the residual cavity of patients who have undergone pneumonectomy, as well as in the abdominal region. These artefacts depend primarily on the soft tissue/air–fluid interface—as demonstrated by the absence of vertical artefacts during intraoperative ultrasound—and not on any actual interstitial anatomical alteration. By analysing different scenarios, this review criticises the overestimation of the diagnostic potential of TUS artefacts. We must move beyond the semi-quantitative counting of these artefacts in favour of an integrated interpretation that acknowledges the physical limitations of the method, thereby avoiding the transformation of a simple TUS software error into a specific pathological measurement. Full article

Background/Objectives: Parkinson’s disease (PD) is a prevalent neurodegenerative disorder, and its comorbid peripheral neuropathy (PN) severely worsens patient prognosis. The diagnostic gold standard, nerve electrophysiological examination, has critical limitations, including invasiveness. This study aimed to explore the diagnostic value of high-frequency ultrasound combined with shear wave elastography (SWE) for PD-associated PN. Methods: Intra- and inter-observer reproducibility of ultrasound parameters (cross-sectional area [CSA], shear wave velocity [SWV]) of the median and common peroneal nerves was validated in 30 PD patients. A case–control study was conducted in 40 PD patients (stratified into PD-alone and PD-PN groups via the electrophysiological gold standard) and 40 healthy controls. Correlation analysis, logistic regression, and receiver operating characteristic (ROC) curve analysis were performed to assess diagnostic efficacy. Results: All measured parameters showed good reproducibility (intraclass correlation coefficient [ICC] > 0.855). Median nerve longitudinal SWV and common peroneal nerve SWV increased sequentially across the control, PD-alone, and PD-PN groups (after age adjustment using analysis of covariance (ANCOVA), p < 0.001), and showed weak-to-moderate statistically significant correlations with median nerve motor conduction latencies after Bonferroni correction for multiple comparisons. Age and common peroneal nerve SWV were identified as independent risk factors for PD-PN, while median nerve longitudinal SWV showed a positive but non-significant association in the multivariable model. A combined model incorporating age, median nerve longitudinal SWV, and common peroneal nerve SWV achieved an area under the ROC curve (AUC) of 0.938 (sensitivity 93.75%, specificity 91.67%; bootstrap-corrected AUC = 0.906). Conclusions: SWE-derived SWV has favorable diagnostic value for PD-associated PN with good reproducibility. The combination of age and multi-nerve SWV further improves diagnostic efficiency, providing a reliable non-invasive imaging biomarker for early PD-PN diagnosis. However, given the observational design and significant age imbalance between groups, residual confounding cannot be fully excluded, and prospective studies with age-matched cohorts are needed for definitive confirmation. Full article

Background and Objective: The ultrasound sliding sign dynamically assesses pouch of Douglas (POD) obliteration in suspected endometriosis. Transvaginal (TVS) and transrectal (TRS) ultrasound are used in patients with and without a self-reported history of vaginal intercourse, respectively, and thus in clinically distinct populations. We evaluated sliding sign performance for predicting surgically confirmed complete POD obliteration in patients with ovarian endometriomas and described findings in route-defined TVS and TRS groups. Materials and Methods: This retrospective cohort study enrolled 318 patients with surgically and pathologically confirmed ovarian endometriomas; intraoperative POD status was evaluable in 309. Patients with and without a self-reported history of vaginal intercourse underwent TVS (n = 247) and TRS (n = 71), respectively. A negative sliding sign (absent movement between the uterus and rectum) was the positive index test result for complete POD obliteration. The unadjusted full-cohort diagnostic accuracy analysis was the primary analysis. Because no parous patient underwent TRS (a lack of overlap in examination-route assignment among parous patients), exploratory adjusted analyses were restricted to nulliparous patients, using overlap weighting (principal adjusted analysis) and 1:1 propensity score matching (sensitivity analysis). Results: In the primary unadjusted analysis of the full cohort (n = 309), the negative sliding sign showed limited to moderate discriminative ability (sensitivity 0.71, 95% CI 0.63–0.78; specificity 0.60, 95% CI 0.52–0.67; PLR 1.78, 95% CI 1.44–2.20; NLR 0.48, 95% CI 0.36–0.64) and was associated with complete POD obliteration (p < 0.001). The between-route sensitivity difference was inconclusive (0.19, 95% CI −0.01 to 0.38). In the exploratory overlap-weighted analysis of nulliparous patients (n = 217), the association remained significant (weighted OR = 2.80, 95% CI 1.17–6.69; p = 0.021), without significant sliding sign-by-route interaction (p = 0.302); findings were consistent in the matching sensitivity analysis (66 pairs). Conclusions: The sliding sign was associated with surgically confirmed complete POD obliteration in patients with ovarian endometriomas, but evidence that this association differed between route-defined groups was inconclusive. Route-specific findings are exploratory because the examination route was determined by sexual history rather than randomization. Whether TRS offers performance comparable to TVS remains undetermined, because the two techniques were not evaluated in the same population and TRS feasibility was not formally assessed. Full article

Endourological stone surgery frequently relies on intraoperative X-ray fluoroscopy for guidewire and access sheath placement, retrograde pyelography, stent positioning, and percutaneous renal access. Although radiation exposure from an uncomplicated procedure is usually limited, recurrent imaging and interventions contribute to cumulative patient exposure, and repeated procedures result in occupational exposure among operating-room personnel. This narrative review examines fluoroscopic workflows in ureteroscopy, retrograde intrarenal surgery, percutaneous nephrolithotomy, and endoscopic combined intrarenal surgery, with particular emphasis on dose metrics, determinants of exposure, and practical optimization. Readily implementable measures consistent with the as-low-as-reasonably-achievable (ALARA) principle include low-dose and pulsed fluoroscopy, reduced pulse rates, collimation, last-image hold, optimized C-arm geometry, protective equipment, dosimetry, feedback, and team training. Evidence also supports fluoroscopy-free or fluoroscopy-minimized ureteroscopy and retrograde intrarenal surgery in selected patients, as well as ultrasound-guided percutaneous nephrolithotomy, including hybrid ultrasound-fluoroscopy workflows. Endoscopically assisted puncture, three-dimensional reconstruction, image fusion, navigation, augmented reality, and computer vision span different stages of clinical maturity; AI-assisted dose optimization remains experimental and lacks endourology-specific clinical validation. Standardized multidimensional reporting of patient and staff dosimetry, evidence-based technology classification, and procedure- and complexity-specific benchmarks are needed. Prospective multicenter studies should evaluate integrated image-guided workflows using clinically relevant outcomes, including radiation dose, stone-free outcomes, complications, operative time, usability, and cost. Full article

Emergency laparotomy is frequently performed in dogs with cardiovascular compromise, making perioperative anesthesia and nociceptive management particularly challenging. Although ultrasound-guided regional anesthesia techniques have demonstrated opioid-sparing effects during elective procedures, evidence supporting their use in emergency surgery remains limited. Medical records of 61 client-owned dogs were reviewed, and 41 met the inclusion criteria. Dogs were retrospectively allocated to one of four groups according to the analgesic technique received: thoracic paravertebral (TPV, n = 12), erector spinae plane (ESP, n = 11), quadratus lumborum (QL, n = 7), or no regional anesthesia (comparison group, n = 11). All regional blocks were performed using ropivacaine. Total intraoperative fentanyl consumption differed significantly among groups (p < 0.0001), with all regional anesthesia groups requiring less fentanyl than dogs managed without a regional block. Block execution time also differed significantly, with the ESP block requiring the shortest execution time. No significant differences were observed in block-related complications. Intraoperative hypotension did not differ significantly among the regional anesthesia groups; however, significant differences were observed between the control group and both the TPV and ESP groups. Ultrasound-guided TPV, ESP, and QL blocks were associated with lower intraoperative rescue fentanyl requirements than systemic analgesia alone, while block-related technical complications were uncommon. These techniques may represent useful components of multimodal anesthesia for selected dogs undergoing emergency laparotomy, providing opioid-sparing effects without increasing the incidence of intraoperative hypotension compared with systemic opioid analgesia alone. Full article

Background: Centrally located breast tumors (CLBTs) present unique challenges in surgical management, requiring a delicate balance between oncological outcomes and cosmetic preservation. Oncoplastic techniques have emerged as a promising solution, allowing larger excisions while maintaining cosmetic appearance and function. This study aims to evaluate the surgical management of CLBT using oncoplastic breast surgery (OBS) treated at a single surgeon center in India. Methods: Among 138 patients with CLBT who underwent OBS, diagnosis and staging adhered to NCCN guidelines, with treatment decisions made via a multidisciplinary tumor board and patient counseling. Intraoperative ultrasound, specimen mammography, and frozen-section evaluation guided resection margins and axillary staging. Results: The median patient age was 52.7 years. Seventy-three percent of patients had unifocal disease, with 67% presenting at the cT2–cT3 stage, and 50% being clinically node-positive. Level 1 OBS was used in 21.73% of cases, Level 2 in 42.75%, and Level 3 in 35%, with 28% qualifying as extreme oncoplasty. Post-surgical complications were observed in 13% cases. Cosmetic outcomes were good to excellent in 94% of cases. At a median follow-up of 57 months, overall survival (OS) was 91.93%, and disease-free survival (DFS) was 88.17%. The BREAST-Q PROM response rate was 94%, with high satisfaction across all domains. Conclusions: This study highlights the safety and efficacy of OBS in CLBT. Key factors such as multidisciplinary management, meticulous surgical planning, and rigorous intraoperative rad-path assessment contributed to its success. These findings highlight the potential of OBS to optimize outcomes and enhance quality of life, even in difficult cases and resource-limited settings. Full article

The conventional workup for suspected early-stage lung cancer requires multiple visits, anesthetics, and procedures. Single anesthetic event lung cancer surgery integrates shape-sensing robotic bronchoscopy, cone-beam CT, rapid on-site cytologic evaluation (ROSE), endobronchial ultrasound staging, lesion localization, and minimally invasive resection into one operative encounter. In this narrative review, we describe the technical components of this pathway, summarize the supporting literature, and offer expert, institution-based troubleshooting guidance for common intraoperative dilemmas. Reported diagnostic yields for shape-sensing robotic bronchoscopy range from 80 to 96%, with approximately 90% concordance between ROSE and final pathology. Published single-institution series report reductions in time from detection to resection of 15–51 days, cost savings of approximately $3000–$10,000, and perioperative outcomes (length of stay 1.8–3.6 days; complication rates comparable to traditional pathways) similar to staged care. The supporting evidence is retrospective and derived from small, single-institution, high-volume referral cohorts; no prospective comparative trials or long-term survival data yet exist. Single anesthetic event lung cancer surgery is therefore best regarded as an emerging, resource-intensive care pathway for carefully selected patients at experienced centers rather than an established standard of care, pending prospective, multicenter validation. Full article

Background/Objectives: Myxofibrosarcoma (MFS) shows infiltrative fascial extensions that complicate margin achievement and drive local recurrence. We evaluated whether intraoperative ultrasound guidance improves negative margin achievement and oncological outcomes compared with conventional excision. Methods: In this retrospective cohort study at a single tertiary referral center, patients with MFS underwent conventional excision (2008–2013; n = 15) or ultrasound-guided excision (2014–2024; n = 50; primary comparative analysis n = 47 after excluding three patients). The primary outcome was negative margin achievement; secondary outcomes were overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS). Exploratory matching-adjusted indirect comparisons (MAICs) were performed against seven published international MFS cohorts. Results: Overall R0 (negative) margin rates did not differ between cohorts (97.9% vs. 93.3%; p = 0.428). Among R0 margins, however, a wide clearance (R0-wide, ≥1 mm) was more frequent in the US-guided cohort, whereas R0-close (<1 mm) margins predominated after conventional excision (R0-wide 83.0% vs. 46.7%; odds ratio 5.38, 95% CI 1.30–23.73; p = 0.014). Median follow-up was 49 months; five-year OS, LRFS, and DMFS were 97.5%, 94.3%, and 83.7%. In the internal historical comparison, LRFS was directionally higher with ultrasound guidance (94.3% vs. 68.2%; HR 0.26; p = 0.059). In MAICs, LRFS favored the US-guided cohort in all five comparisons and OS in two of four. Conclusions: Intraoperative ultrasound guidance was associated with a higher rate of wide (R0-wide, ≥1 mm) negative margins and favorable local disease control in MFS; whether wider microscopic clearance itself improves local control requires prospective multicenter evaluation. Full article

Introduction: Common bile duct (CBD) exploration is indicated in symptomatic patients with choledocholithiasis when endoscopic retrograde cholangiopancreatography (ERCP) is not feasible or has failed. In selected complex cases, robotic surgery may offer technical advantages over conventional laparoscopy. Material and Methods: A 51-year-old woman presented with biliary colic and ultrasound evidence of choledocholithiasis. Past medical history included congenital pyloric stenosis treated with open gastrojejunostomy at the age of 3 days, precluding ERCP. Magnetic resonance cholangiopancreatography (MRCP) and percutaneous transhepatic cholangiography (PTC) demonstrated multiple large distal CBD stones. Interventional radiology attempts failed to achieve complete clearance, and a percutaneous biliary drain was placed. The patient underwent robotic-assisted cholecystectomy and CBD exploration. Results: Following extensive adhesiolysis, robotic cholecystectomy was completed. A longitudinal choledochotomy enabled extraction of multiple stones using the chopstick technique, a Fogarty catheter, and choledochoscopic basket retrieval. After unsuccessful conventional retrieval attempts, an impacted stone was removed using a choledochoscopy-guided robotic intraductal grasping maneuver, with an 8-mm wristed forceps introduced through the choledochotomy and used exclusively for mechanical grasping. The choledochotomy was closed with continuous suturing, and intraoperative cholangiography confirmed unobstructed biliary flow without residual stones. The postoperative course was uneventful, and the patient was discharged on postoperative day seven. At two-month follow-up, cholangiography through the transcystic catheter confirmed persistent ductal clearance, allowing for catheter removal. Conclusions: This case demonstrates the feasibility of robotic CBD exploration in a selected patient with complex choledocholithiasis and altered anatomy when conventional treatment options were not feasible or unsuccessful. Full article

Background/Objectives: Perirolandic brain metastases are challenging to resect because small deviations from the surgical corridor may cause sensorimotor deficits. This study evaluated the stage-specific value and limitations of general-purpose, non-navigated B-mode intraoperative ultrasonography (iUS) with MRI-based frameless neuronavigation in a consecutive surgical cohort of perirolandic metastases. Methods: In this single-center, single-surgeon retrospective case series, 15 consecutive adults underwent microsurgical resection of perirolandic brain metastases using MRI-based frameless neuronavigation and a general-purpose B-mode ultrasound system, without functional mapping or neurophysiological monitoring. Extent of resection was assessed on contrast-enhanced MRI obtained 24 to 36 h after surgery, and post-resection cavity iUS findings were compared descriptively with early postoperative MRI. Results: Gross-total resection was achieved in 13 patients (86.7%). iUS modified intraoperative targeting in 6 of 15 patients: the entry point was repositioned after findings consistent with intraoperative brain shift in 4, and the lesion was localized in interhemispheric corridors in 2. Post-resection iUS suspected residual tissue in 7 of 14 patients, but only 1 corresponded to residual tumor on MRI; a thin remnant on the motor cortex was not identified as suspicious for residual tumor on iUS. A new or worsened motor deficit occurred in 2 patients (13.3%); at follow-up, this was persistent at 20 months in 1 and partially improved in the other. No patient required reoperation, and there was no 30-day mortality. Conclusions: General-purpose B-mode iUS aided exposure confirmation and trajectory refinement but had limited value for excluding thin residual tumor. When functional mapping or neurophysiological monitoring is unavailable, it may provide accessible real-time anatomical guidance; however, because it lacks functional information, it should not be considered an alternative to these functional adjuncts. Full article

Two client-owned Lionhead rabbits underwent median sternotomy for mediastinal mass excision. Premedication included methadone, dexmedetomidine, and midazolam, with ketamine added for one rabbit. Anesthesia was maintained with isoflurane in oxygen and a ketamine infusion. Bilateral ultrasound-guided TTP blocks were performed at the level of the second and fifth intercostal spaces using a linear transducer and a spinal needle advanced in-plane in a lateromedial direction. Bupivacaine 0.5% was injected at a total dose of 2 mg/kg per rabbit, divided equally among four injection sites (total volumes of 0.9 mL and 1.0 mL for the first and second rabbits, respectively). Only one rabbit exhibited a brief intraoperative nociceptive response. The second rabbit developed severe postoperative respiratory compromise related to inadequate thoracic drain function and died 4 h after surgery. These cases indicate that the TTP block is technically feasible in rabbits and can contribute to intraoperative analgesia during thoracic surgery. Further studies are needed to evaluate the optimal injectate volume and its distribution, as well as the safety and efficacy of the anesthetic dose. Full article

Background/Objectives: Steatotic liver disease (SLD) is a global health priority, increasing the demand for accessible circulating biomarkers. Carboxylesterase 1 (CES1) plays a key role in hepatic lipid metabolism, but its clinical utility as a plasma biomarker remains unclear. This study aimed to validate an automated immunoassay for plasma CES1 and perform a preliminary evaluation of its diagnostic performance for hepatic steatosis quantified using advanced ultrasound. Methods: An automated ELISA for plasma CES1 was analytically validated. A preliminary clinical evaluation was performed in 95 consecutive outpatients structured to approximate a health-screening population, using ultrasound-derived attenuation coefficients (AC) to quantify steatosis. Results: The assay demonstrated robust analytical performance with intra- and inter-assay coefficients of variation < 10% and excellent sample stability. Plasma CES1 significantly correlated with AC (r = 0.585, p < 0.001), yielding an area under the receiver operating characteristic curve of 0.82 for diagnosing ultrasound-defined steatotic livers. In multivariable analysis, CES1 was independently associated with hepatic steatosis (adjusted odds ratio: 1.03 per 10 pg/mL increase, p < 0.001). Conclusions: Plasma CES1 shows strong diagnostic potential for ultrasound-defined hepatic steatosis. However, this preliminary evaluation is subject to a restricted cohort spectrum; further prospective validation in broader, unselected real-world populations is required before clinical implementation. Full article