Densely adherent bladder can be found in cases of previous caesarean section [1, 2] and in those patients with the history of having undergone cervicopexy. One often encounters an advanced bladder while doing an LSCS in a patient of previous caesarean delivery(s). But if the lower segment is well formed at the time of repeat caesarean, it is usually not a problem opening the uterovesical fold and pushing the bladder down. The tissue edema actually helps the obstetrician get the right plane. The problem of separating the bladder is usually encountered when performing hysterectomy in cases of previous LSCS, endometriosis, PID, and malignancy.

In such situations, always use sharp dissection (the golden rule!) and stay close to the specimen. Feel the bulb of Foley catheter time to time and use it as a landmark. Hold a small bit of tissue with a blunt forceps, cauterize, and then cut the charred band using tissue cutting scissors. Try to go in this way as below as possible. Forcibly pushing the bladder down with a “peanut” or with a sponge on holder is strongly discouraged; it can traumatize the bladder and also cause profuse bleeding. One must remember that descending branch of the uterine artery, which supplies the cervix and vagina, can get traumatized leading to profuse hemorrhage. The vesical venous plexus can also get traumatized and bleeding from these vessels is very difficult to control. So the rule of the thumb is hold a small bit of tissue with fine tip forceps, cauterize, and cut close to the specimen. If bleeding starts, put a mop and give gentle pressure and begin dissection from another point. If there is a lot of bleeding, maybe one is not in the correct plane. Is the dissection going into the substance of the cervix? Consider this possibility.

When using cautery near the base of bladder or near any vital structure, it is important to cauterize as “touch and go.” This is because the tissue damage extends beyond the area of visible charring. The electrocautery settings have to be checked; it is advisable to keep it low. Should sparking occur or if dense charring of tissues noted, then immediately lower the electrocautery settings. Should profuse bleeding occur, then it may be advisable to do a bilateral internal iliac artery ligation than apply cautery or take deep stitches near the base of bladder. A mop can be placed on the bleeding area and the round ligaments divided (the round ligaments would have already been divided when one is opening the uterovesical fold, but if one wants to quickly access the internal iliac artery to ligate it to control pelvic hemorrhage, then one might have to divide the round ligaments again a bit laterally). The folds of the broad ligament should be separated, and the bifurcation of the common iliac artery located. The internal iliac artery is the medial branch of the common iliac artery.

Bladder injury can occur if precautions are not taken. Bladder can be injured as a result of excessive use of cautery or inadvertent stitches in the base of bladder. Injuries can also happen during sharp dissection, but in injuries due to sharp dissection, the edges are neat and clean and are easier to repair. And the injuries are almost always detected on table. But in case of injury due to excessive use of cautery or inadvertent stitches, the injury becomes evident after the devitalized tissues have sloughed away and a vesicovaginal or a ureterovaginal fistula has developed. The repair is complicated by the fact that the tissues are edematous and the edges are irregular.

If the base of bladder, trigone, or the ureter is involved, the repair requires a urologist. Rent in the base of bladder is not as simple as a rent in the dome of bladder. Ureteric orifices can get included during closure, further complicating the situation.

One may encounter a situation where one cannot clearly make out the cervicovaginal junction anteriorly. In such situations, try the posterior technique. Skeletonize the uterine arteries and ligate them. Now divide the uterosacral ligaments which are attached to the cervix at 5 o’clock and 7 o’clock positions separately, not including the Mackenrodt’s ligaments. Open the fold of peritoneum below the cervix posteriorly, and open the vagina posteriorly. Hold the cervix with an Allis forceps and deliver the cervix into the pelvis. Ask the assistant to give upward traction to the specimen. Gently do sharp dissection and free the cervix from the vaginal attachments all around. Close the vagina making sure the bladder is not included in the vault sutures. If bladder injury is suspected, check the color of urine. Do retrograde filling of bladder with saline stained with methylene blue and see if any part of the bladder is included in the vault sutures. If methylene blue stained saline is seen pouring into the pelvis, then it is certain that there is a bladder rent.

Now let us study a series of photographs which illustrate how one must proceed with the dissection in a case of densely adherent bladder.

Sharp Dissection to Push the Bladder Down (Fig. 6.1a–i)

The dissection begins by holding the uterovesical fold with a forceps and cauterizing it (Fig. 6.1a). There could be vessels underneath, and incising the fold can lead to bleeding which can obscure the operating field. In the above case, the bladder is quite below. Locating the inflated bulb of Foleys catheter will confirm the position of the bladder.

The uterovesical fold has been opened and the dissection has begun (Fig. 6.1b), and it is clear that bleeding can be expected. Hold a small fold of tissue with a forceps and cauterize it. And then cut the cauterized tissue. Proceed little by little.

Remain close to the specimen throughout the procedure (Fig. 6.1c).

Sharp dissection has started in the midpoint (Fig. 6.1d). Bleeding has also started. Using sponge on holder to push the bladder down will lead to a lot of bleeding which can be difficult to control. In those cases where there is a history of LSCS delivery, the bladder may be densely adherent in the midline, and it might be easier to begin the dissection a bit laterally, more toward the uterines, where the uterovaginal fold may not have been opened during the LSCS.

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