Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy  Ceana Nezhat, M.D., Jennifer Cho, M.D., Vadim Morozov, M.D., Patrick Yeung, M.D.  Fertility and Sterility  Volume 91, Issue 6, Pages 2714-2719 (June 2009) DOI: 10.1016/j.fertnstert.2008.03.073 Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 1 Flow diagram for study. Fertility and Sterility 2009 91, 2714-2719DOI: (10.1016/j.fertnstert.2008.03.073) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 2 Visceral slide technique. Ultrasound images demonstrating the movement of abdominal viscera, or the visceral slide, during induced inspiration and expiration. An area of bowel is identified at time A and moves to time B with deep inspiration. The distance traveled is visually over 1 cm. Fertility and Sterility 2009 91, 2714-2719DOI: (10.1016/j.fertnstert.2008.03.073) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 3 PUGSI technique. (A) Normal PUGSI. Ultrasound visualization of the needle point is seen right underneath the peritoneal lining (thin arrow). The saline injection is visualized briefly on the left image at the dashed arrow. The fluid pocket disperses and is not seen a few seconds later in the right image. (B) Abnormal PUGSI. Ultrasound images of the same area before the saline injection, with the needle identified at the arrow (far left). Saline is then injected and a fluid pocket is visualized (middle). This fluid pocket does not disperse and persists with inspiration and expiration (far right). Fertility and Sterility 2009 91, 2714-2719DOI: (10.1016/j.fertnstert.2008.03.073) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 4 Adhesions. (A) Filmy adhesions in patient with normal visceral slide and normal PUGSI. (B) Obliterating adhesions in patient with normal visceral slide and abnormal PUGSI. Fertility and Sterility 2009 91, 2714-2719DOI: (10.1016/j.fertnstert.2008.03.073) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions