In this month’s issue, two systematic reviews and meta-analyzes

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examine the use of ultrasound beyond its basic utility as a diagnostic tool. Limperg et al. demonstrate that ultrasound, as surgical planning tool, can reliably ensure the absence of intra-abdominal wall adhesions when evaluating the visceral lamina, giving surgeons the confidence to safely enter an adhesion-free area laparoscopically

. Liu et al., on the other hand, show the value of ultrasound as a treatment delivery tool guide the administration of microwave ablation (MWA) to symptomatic fibroids

. While the studies examine quite distinct concepts, they point to a similar sentiment: ultrasound is becoming more and more and inextricably linked with the modern practice of gynecologic surgery. Although we may be many years away from this, but universally I think we are approaching the era of gynecological surgeon sonographer. Simplified, this is a minimally invasive gynecological surgeon who has clinical expertise in performing and interpreting gynecological ultrasound for diagnostic and management purposes. Although this is an unusual combination of skills in various parts of the world, particularly in North America, the number of gynecological sonographer surgeons continues to increase and the landscape of gynecology is changing as that we know him.

Establish a connection with the Limperg et al. to study

, it is the dual nature of the ultrasound gynecological surgeon that will allow the optimal performance of an intraoperative evaluation of the transabdominal ultrasound visceral blade and the subsequent safe placement of the trocar. We can observe the same principles in endometriosis surgery, where the International Deep Endometriosis Analysis (IDEA) group encourages the identification of surgical complexity in a non-invasive manner through disease mapping, allowing optimal triage of patients. depending on the complexity and precise surgical planning.

. The IDEA group recommends a test similar to that of the evaluation of the visceral lamina; the uterine “slip sign” is a dynamic ultrasound test that assesses obliteration of the recto-uterine pocket. A negative sliding sign, equivalent to an obliterated recto-uterine pouch, is a clear indication that the surgery will be complex and should only be undertaken by a surgeon with advanced skills. Likewise, the sliding sign may be useful beyond endometriosis surgery and applied preoperatively in all patients who are scheduled to undergo hysterectomy for a prediction of similar surgical complexity.

. The ideal person to perform these ultrasounds is the ultrasound gynecological surgeon because of the unique dynamic nature of ultrasound compared to other imaging modalities. In general, it is more surgically relevant to collect subtleties in real time – the what, where, why, how much, surrounding structures / pathologies, etc. – than simply reading a result presented on a report as a present / absent dichotomy. Although difficult to quantify and certainly not something evaluated in the literature, I think it is more informative to visualize the anatomy / pathology on ultrasound yourself, giving an independent interpretation (on the understanding of the patient in front of you and the clinical scenario) versus reading a report prepared by someone else.

The nature of this editorial limits a comprehensive review of the literature, but we can trace it back to ultrasound-guided gynecologic surgery when Coccia et al. published what may have been the first exclusively ultrasound guided hysteroscopy in 1996

. More recently, JMIG has published papers describing ultrasound-guided procedures, including discharge of cesarean pregnancies and reoperation after failed endometrial ablations. A personal philosophy is to minimize gynecological surgeries and procedures performed blindly. The ability to use ultrasound guidance in difficult hysteroscopies has made it possible to complete many cases to achieve the desired outcome that would otherwise have been incomplete or worse, prone to complications. In the office, performing an ultrasound just before inserting the intrauterine device for a visual assessment of size, orientation and any disturbing objects (eg fibroids) optimizes placement. With the availability and ease of use of ultrasound overcoming procedural blindness, why would we want to continue working in the dark?

In addition to what is presented here, there are other advantages of integrating ultrasound into the modern practice of gynecology, by gynecological sonographer surgeons, beyond the scope of this editorial. I hope that future gynecologists can acquire training in gynecological ultrasound in residency and scholarship programs, obtaining the professional title of gynecological surgeon sonographer. Until then, we need to make progress in learning the best we can – from existing sonologists, radiologists, sonographers – how to interpret images acquired by others, how to perform small but useful components of ultrasound (for example, sliding sign) and how to maximize the potential of ultrasound to optimize the clinical management of our patients.