Is laparoscopic repair reasonable?
When surgical intervention is necessary, the choice between laparoscopy and laparotomy depends on the skill and comfort level of the surgeon and the availability of instruments and support team.6,7 That said, ureteral injury is usually treated via laparotomy.1 As operative laparoscopy becomes even more commonplace, reconstruction of the urinary system will increasingly be managed laparoscopically.
Depending on the size and location of the injury, reconstruction may involve ureteral reimplantation with or without a psoas hitch, Boari flap, or primary endtoend anastomosis.8-10
CASE 2: Postoperative symptoms lead to rehospitalization
A 35-year-old patient undergoes laparoscopic ovarian cystectomy and returns home the same day. She is readmitted 72 hours later because of lower abdominal tenderness, worsening nausea and vomiting, and urine-like drainage from her midline suprapubic trocar site. Analysis of the leaking fluid shows high creatinine levels consistent with urine. The patient has no fever and is hemodynamically stable. Examination reveals a moderately distended abdomen with decreased bowel sounds. Hematuria is evident on urine analysis.
Urologic consultation is obtained, and the patient undergoes simultaneous laparoscopy and cystoscopy, during which perforation of the bladder dome is discovered, apparently caused by the mid suprapubic trocar. The bladder is mobilized anteriorly, and both anterior and posterior aspects of the perforation are repaired in one layer laparoscopically.
After continuous drainage with a transurethral Foley catheter for 7 days, cystography shows complete healing of the bladder, and the Foley catheter is removed. The patient recovers completely.
Vesical injury sometimes occurs in patients who have a history of laparotomy, a full bladder at the time of surgery, or displaced anatomy due to pelvic adhesions.11 Although bladder injury is rare, laparoscopy increases the risk. Trocars, uterine manipulators, and blunt instruments can perforate or lacerate the bladder, and energy devices can cause thermal injury. The risk of bladder injury increases during laparoscopic hysterectomy.
Be vigilant about trocar placement and dissection techniques
Accessory trocars can injure a full bladder. Injury can also occur when distorted anatomy from a previous pelvic operation obscures bladder boundaries, making insertion of the midline trocar potentially perilous (FIGURE 1). The Veress needle and Rubin’s cannula can perforate the bladder.11-13 And in the anterior cul-de-sac, adhesiolysis, deep coagulation, laser ablation, or sharp excision of endometriosis implants can predispose a patient to bladder injury.
In women with severe endometriosis, lower-segment myoma, or a history of cesarean section, the bladder is vulnerable to laceration when blunt dissection is used during laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH). A vesical injury also can occur at the time of laparoscopic bladder-neck suspension upon entry into, and dissection of, the space of Retzius.
FIGURE 1 A bladder at risk
In this patient with a previous cesarean section, the bladder is adherent to the anterior abdominal wall. Needle mapping in the conventional midline trocar position indicates that the trocar must be relocated to avoid bladder injury.
Intraoperative findings that suggest bladder injury include air in the urinary catheter, hematuria, trocar site drainage of urine, or indigo carmine leakage. Postoperative signs and symptoms include leaking from incisional sites, a mass in the abdominal wall, and abdominal swelling.
Liberal use of cystoscopy or distension of the bladder with 300 to 500 mL of normal saline is recommended whenever there is a suspicion of bladder injury, especially during laparoscopic hysterectomy or LAVH. When a trocar causes the injury, look for both entry and exit punctures, both of which should be treated.
No matter how much care is taken, some bladder injuries, such as vesicovaginal fistulae, become apparent only postoperatively. More rarely, peritonitis or pseudoascites herald the injury. Retrograde cystography may aid identification.
Treatment of bladder injuries
Small perforations recognized intraoperatively may be conservatively managed by postoperative bladder drainage for 5 to 7 days. Most other bladder injuries require prompt intervention. For example, trocar injury to the bladder dome requires one- or two-layer closure followed by 5 to 7 days of urinary drainage. (Both closing and healing are promoted by drainage.)
Laparoscopy or laparotomy? Laparoscopic repair has become increasingly common, and bladder injury is a common complication of LAVH.13,14
CASE 3: Postop pain, tachycardia
A 41-year-old obese woman undergoes laparoscopic cystectomy for an 8-cm left ovarian mass. The abdomen is entered on the second attempt with a long Veress needle. The umbilical trocar is reinserted “several” times because of difficulty opening the peritoneum with the tip of the trocar sheath. The surgical procedure is completed within 2 hours, and the patient is discharged 23 hours later.
The next day, she experiences increasing abdominal pain and presents to the emergency room. Upon admission she reports intermittent chills, but denies nausea and vomiting. She is in mild distress, pale and tachycardic, with a temperature of 96.4°, pulse of 117, respiration rate of 20, blood pressure of 106/64 mm Hg, and oxygen saturation of 92%. She also has a diffusely tender abdomen but normal blood work. Abdominal and chest x-rays show a large right subphrenic air-fluid level that is consistent with free intraperitoneal air, unsurprising given her recent surgery. Bibasilar atelectasis and consolidation are noted on the initial chest x-ray.