Ultrasound-Guided Interventions 
Vallery Logedi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
 
Ultrasound-guided biopsy, drainage or drain 
placement is the most advanced form of surgeon-
performed ultrasound. The surgeon must have 
excellent technical understanding and skill in order 
to place the tip of a needle into a structure, seeing it 
continuously to avoid injury to surrounding 
structures. This is an advanced skill requiring 
proficiency and understanding of ultrasound. See 
Introduction to  Ultrasonography for more details.  
 
In general, any probe can be used for an 
ultrasound-guided intervention. However, the depth 
of the structure in question determines which probe 
should be used. The linear (vascular) transducer, 
with frequencies of 5 - 7.5mHz, shows detail at 
depths up to 6 cm and should be used for venous 
catheterization. It can also be used for breast or neck 
mass biopsy. The curved (abdominal) transducer, 
with frequencies of 2.5 - 3mHz, shows detail up to 
18cm. This should be used for drainage of intra-
abdominal abscess or liver biopsy.  
 
It is important to remember what an 
ultrasound probe shows, and what it doesn’t. The 
image from an ultrasound probe is two-dimensional, 
like a “cross section” of the tissue immediately 
beneath the probe. If the needle is completely within 
the flat plane of tissue beneath the probe, all of it will 
be seen. If the needle merely passes through the plane 
of tissue in one place, it will be seen as only a dot. If 
the needle is parallel to, but not passing through, the 
plane of the tissue underneath the probe, it will not 
be seen at all. These last two situations should be 
avoided as much as possible, because the sharp tip of 
the needle is unseen by the operator.  
 
 
 
 
Correct technique. The needle is completely within the two-
dimensional plane. It is seen by the ultrasound, including the 
tip which can be seen as it advances.  
 
 
Incorrect technique: The path of the needle is not aligned with 
the plane of the ultrasound. Only the part of the needle that 
passes through the plane of the ultrasound can be seen 
(represented by a Red dot in the drawing and a White dot on 
the ultrasound image.) The tip of the needle, unseen, may be 
perforating another structure.  
 
 
Incorrect technique: The needle is parallel to the plane of the 
ultrasound, but not within the plane. The needle cannot be seen 
at all; its tip may be perforating another structure. All above 
ultrasound images courtesy of Dr Bruno Di Muzio, from the 
case https://radiopaedia.org/cases/31841?lang=us  
 
Ultrasound-Guided Interventions 
Vallery Logedi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Ideally, for intra-abdominal interventions a 
CT scan is done first. The images are then used as a 
reference for surgical planning; probe placement can 
be guided by palpable landmarks such as the costal 
margin or the iliac crest. If CT is unavailable, the 
surgeon must use fixed intra-abdominal landmarks 
for reference while examining the anatomy with the 
ultrasound probe. Landmarks include the liver, the 
kidneys, the diaphragm, the bladder (or the Foley 
catheter balloon) and the retroperitoneal vessels. The 
bowels themselves, being compressible and mobile, 
are not useful as landmarks.  
 
The most feared complication of any 
ultrasound-guided intervention is iatrogenic injury to 
surrounding structures. In the neck, the vessels of the 
carotid sheath as well as the trachea and esophagus 
are at risk. In the abdomen, the operator must avoid 
injury to the bowels, the great vessels, and the larger 
vessels within the liver. In general, the liver is a 
friend to the interventionist, because it is easy to 
visualize and relatively safe to pass a needle through. 
Drainage of subphrenic or para-duodenal abscesses, 
as well as percutaneous cholecystostomy, all involve 
passing a needle through the liver to get to the 
pathology. Coagulation must be adequate; the 
International Normalized Ratio (INR) should be less 
than 1.6.  
Ultrasound-guided abscess aspiration can be 
performed with nothing more than an ultrasound and 
a long enough needle. Core needle biopsies need 
only 
an 
ultrasound 
and 
biopsy 
equipment. 
Interventions such as abscess drainage require some 
specialized equipment, at minimum a central line kit 
with a guidewire and a needle. Once the guidewire is 
placed within the structure, other interventions can 
be done over the wire using the Seldinger technique 
(described elsewhere in this Manual.)  
Dedicated sterile ultrasound probe covers are 
available commercially in high-resource settings. 
We demonstrate here a technique for making your 
own ultrasound probe cover using a sterile surgical 
glove and a sterile towel.  
 
Ultrasound-guided interventions are done in 
the following steps: 
● Position the patient, ultrasound and surgeon 
● Perform ultrasonography to plan the  approach 
● Anesthetize under ultrasound guidance 
● Pass the needle tip into the structure of interest 
● Perform the intervention (biopsy, aspiration, 
catheter placement) 
 
Steps: 
1. The first step will usually include any workup or 
preoperative considerations. In the case of an 
ultrasound-guided liver biopsy as shown below, 
that would include checking for a normal 
hemoglobin, platelet count, prothrombin time 
and INR. 
2. Local anesthesia alone is adequate for such 
procedures in cooperative patients.  
3. First the patient is positioned. Visualize the mass 
to be biopsied with ultrasound before the site is 
cleaned and draped. For ergonomic purposes it is 
important to ensure that the ultrasound machine 
is placed opposite the biopsy site and by 
extension, the surgeon. 
4. The site is cleaned and draped. There is usually 
no need for full drapes as field sterility is 
adequate 
 
Patient positioned for an ultrasound-guided intra-abdominal 
mass biopsy.  
 
5. Local anesthesia is injected around the biopsy 
site. Alternatively, local anesthesia can be 
injected while visualizing the mass in step #3 
above.  
6. An extra sterile towel or small drape is laid across 
the field as shown in the image below. This will 
Ultrasound-Guided Interventions 
Vallery Logedi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
be used to cover the ultrasound probe cable and 
ensure sterility. The probe is placed in a sterile 
glove containing ultrasound gel and then 
wrapped in the towel. 
 
Ultrasound probe covered with gel and placed inside a sterile 
glove 
 
 
Green towel for wrapping probe cable (within the Red line) 
 
 
Probe, manipulated by the operator holding the sterile glove, is 
placed on the extra towel 
 
 
The towel is closed brought together and wrapped over the 
probe and wire. 
 
 
Probe secured within the towel using gauzes. The same effect  
can be achieved using sterile adhesive tape, penetrating towel 
Ultrasound-Guided Interventions 
Vallery Logedi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
clips or hemostats to keep the towel closed over the probe and 
wire. 
 
7. After confirming the site of the mass to be 
biopsied, a stab incision is made over the site in 
the area that was anesthetized. The core biopsy 
needle is inserted under ultrasound guidance. 
Intervention such as biopsy or aspiration is 
performed. On completion, the site is cleaned and 
dressed. 
 
Biopsy in progress. The same operator holds both the probe and 
the needle. This allows both structures to be manipulated 
together so that the needle stays in the plane of visualization.  
 
 
Another example of the correct technique for biopsy: The same 
operator holds both the needle and the ultrasound probe, 
allowing both to be manipulated simultaneously so that the 
needle stays within the plane of visualization of the probe.  
 
Biopsy in progress. Note that the machine is placed opposite 
the patient from the surgeon, so that the ultrasound image can 
be seen without the surgeon having to rotate their body or neck.  
 
Pitfalls 
● As stated earlier, it is important to familiarize 
yourself with the ultrasound machine and to 
ensure visualization of the needle at all times to 
avoid injury to other structures. 
● Biopsy within the liver can lead to injury to the 
vascular or biliary structures, leading to an 
arteriovenous or arterio-biliary fistula. Proper 
technique and avoidance of large vessels is 
crucial 
to 
prevent 
this 
life-threatening 
complication.  
● Be aware that as the patient breathes, the liver 
moves and your target may move out of the plane 
of visualization. Advance the needle with the 
respiratory cycle, or ask the patient to hold their 
breath.  
● As you gradually become facile with this 
technique, you will be able to place the tip of the 
needle within increasingly smaller objects. Start 
with large targets. 
 
Ultrasound-Guided Interventions 
Vallery Logedi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Guide: Gelatin Model for Practicing Ultrasound-
Guided Interventions 
 
There are special motor skills for handling 
the needle and the ultrasound probe simultaneously, 
keeping the needle in the field of view while 
advancing it through tissue. It is best to acquire these 
skills on a realistic model rather than on a living 
human being. We have developed the following 
technique for teaching this skill, using pieces of soft 
fruit suspended in gelatin.   
 
We usually have ultrasound practice sessions 
of 1-2 hours each, with about 3-4 stations. We obtain 
several ultrasound machines at once from various 
hospital departments, and hire people to allow their 
necks and abdomens to be ultrasounded. Trainees 
then rotate through stations practicing their 
ultrasound skills. This gelatin biopsy model is one of 
the stations.  
 
The gelatin biopsy model must be prepared 
several days in advance, as it entails at least two 
cycles of curing the gelatin in layers, so that the 
“tumors” are suspended within the gelatin.  
1. Obtain packets of gelatin, either plain or 
flavored, as available.  
 
An example of gelatin available in a local market.  
 
2. Obtain a bowl with a round shape. Line the inside 
of the bowl with butter or grease. This will make 
the gelatin and plastic wrap easier to remove 
from the bowl once it is cured.  
3. Line the inside of the bowl with plastic wrap, 
which will serve as a protective “skin” over the 
gelatin when you are performing ultrasound.  
4. Using hot water, make enough gelatin to fill the 
bowl halfway. Use double the strength specified 
by the manufacturer’s instructions. Place the 
bowl in a refrigerator and allow it to harden 
overnight.  
5. Once the gelatin has hardened, place pieces of 
fruit in the bowl. Use soft, non-round pieces such 
as slices of banana or mango, or sections of 
orange or tangerine. Round fruit like cherries or 
grapes will roll around on the surface of the 
hardened gelatin and collect all together in one 
side of the bowl. Hard fruit like slices of apple 
will be more difficult to pass a needle through.  
6. Another variation includes a balloon filled with 
milk, to simulate an abscess to be aspirated. You 
can use a central line kit to practice placing a 
catheter within the abscess using the Seldinger 
technique.  
7. Make enough double-strength gelatin to fill the 
bowl the rest of the way. Pour it over the fruit 
pieces, assuring that they remain in place and do 
not “clump” together in one corner of the 
mixture. Return the bowl to the refrigerator 
overnight.  
8. Gently remove the gelatin and plastic wrap from 
the bowl by placing a plate over the top of the 
bowl and inverting it. You may need an assistant 
for this step, depending on the size of the bowl. 
The plastic wrap should easily separate from the 
bowl because of the butter or grease you applied. 
If this does not happen, pour a small amount of 
hot water over the outside of the bowl.  
9. Apply ultrasound gel to the plastic wrap on the 
surface of the gelatin and practice visualizing the 
fruit with the ultrasound. Then, practice passing 
the needle into the gelatin while visualizing the 
needle entirely with the probe.  
Ultrasound-Guided Interventions 
Vallery Logedi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Using an ultrasound probe in one hand and a biopsy needle in 
the other, the operator can easily practice the skill of 
visualizing the entire needle and advancing it safely within the 
gelatin.  
 
Vallery Logedi, MBCHB 
AIC Kijabe Hospital 
Kenya 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
January 2023 
