Intraoperative ultrasound poses challenges for surgery and radiology

The elderly patient was a major donor to the hospital. Intraoperative ultrasound revealed an unexpected liver lesion. Color Doppler showed vascularity. If the lesion was a cancerous tumor, the entire liver would need to be removed, the surgeon told radiologist Dr. Stephen Horii. Only histology would reveal actual pathology.

What did Horii recommend?

Horii told the surgeon the chances were it was a tumor, and the organ was removed. Subsequent histology confirmed the pathology, but the decision was an example of the pressure and complications associated with intravascular ultrasound scans, said Horii, a professor of radiology and clinical director of the Medical Informatics Group at the University of Pennsylvania, during a presentation Thursday.

Unscheduled intraoperative ultrasound is highly disruptive to both the surgery and radiology departments. The need arises suddenly and usually involves a delay in surgery, which can be both clinically and economically costly (some estimates place the cost of the surgical unit at $1 per second). It so disrupts plans at the radiology department that it must sometimes be denied.

The challenges posed by intraoperative ultrasound have prompted attempts to find ways to document the process and look for improvements, but this has proved difficult.

"I didn't realize how complex this was until I had to diagram it," Horii said.

He showed several pages of diagrams exploring the process and the decisions involved. Even then, Horii admitted that some of the boxes in the flow charts he developed proved too complex to expand. The challenges were daunting:

• involvement of teams from both the surgical and radiology departments

• need to scrub in for the radiologists

• introduction of nonsterile monitors into the surgical suite

• difficulty in reading the ultrasound images on screens that may be as far as eight feet away

Besides the disruption in workflow, one of the big issues for radiology is reimbursement. An intraoperative ultrasound may be billed the same as a less complex procedure such as imaging a biopsy. One solution emerged at Penn: Radiologists were credentialed in surgery and listed as surgical assistants, and they thus could collect a higher fee.

Another option is to have surgeons do their own intraoperative ultrasound scans, but many lack the training or inclination to acquire it, Horii said. Still, when the intraoperative scan is needed, it usually is very important, changing plans or management about a third of the times it is used.