The bladder may be lacerated during a hysterectomy, pelvic prolapse repair, or other pelvic surgery. A bladder cystotomy can occur during transvaginal, transabdominal, or laparascopic surgery and the principles of repair are the same. Prompt recognition and repair of a bladder laceration typically allows healing without sequelae.
1. Carefully dissect the vaginal epithelium away from the tissue around the site of the laceration. The goal of dissecting the vaginal wall free from the tissue around the injury is to expose an area of detrusor large enough to allow for careful inspection of the injury and a multilayered closure. If the laceration is anywhere near the intramural course of the ureters, then indigo carmine should be administered intravenously and cystoscopy performed to observe ureteral efflux. In the case of a large laceration, cystoscopy may prove difficult as too much of the instilled fluid may escape via the laceration. If the bladder cannot be distended prior to repair of the laceration, then cystoscopy should be repeated after completion of the bladder repair.
1. Dissect any overlying tissue or fat away from the detrusor muscle around the site of the laceration. If there is any concern regarding additional areas of bladder injury, then an anterior vertical cystotomy should be performed to allow for thorough bladder inspection. The same anterior cytostomy can be used to inspect the bladder trigone and observe the ureteral orifices for efflux if there is a concern for ureteral injury. If there is no suspicion for another bladder injury, then the primary laceration can be closed without further inspection.
2. Repair of the bladder injury can begin once the laceration is well visualized and the surrounding detrusor muscle is exposed. There are multiple techniques for repair but most include a multilayered approach.
3. Start by closing the bladder mucosa with a running 3-0 absorbable suture such as chromic or Vicryl (do not use permanent suture) (Figure 37-1A). Once that is completed, close the detrusor layer with a running locking 2-0 Vicryl suture (Figure 37-1B). Next, fill the bladder with saline via a Foley catheter to make sure there are no significant areas of leakage at the suture line. If there are, reinforce that area with interrupted 2-0 Vicryl sutures to ensure a watertight seal. If the repair is in close proximity to the ureters, it may be useful to perform cystoscopy and observe for ureteral efflux to ensure that the ureters were not obstructed during the repair—this is more typical during a vaginal approach.
4. For most bladder repairs, it is satisfactory to leave just a transurethral catheter. If there is excessive bleeding within the bladder, one may consider leaving a suprapubic tube as well. No perivesical drain is required if the bladder repair is watertight or if the repair is performed transvaginally. However, if the repair is tenuous or if the tissue quality is poor, then one should consider a perivesical Jackson–Pratt (JP) or other closed suction drain.
The length of postoperative catheterization depends on the location and nature of the injury. Extraperitoneal dome cystotomies that are small such as a TVT perforation may not require postoperative bladder drainage. Larger extraperitoneal dome cystotomies should be drained for one to three days. Cystotomies in the bladder dome that are intraperitoneal should be drained for five to seven days. Injuries to the bladder trigone should be drained for 7 to 14 days and complex injuries may require drainage as long as 21 days. If the bladder repair was characterized by good exposure and a watertight closure, a cystogram is not necessary prior to catheter removal. If the repair was tenuous, then one should consider a cystogram to rule out residual extravasation prior to catheter removal.
The ureter courses through the pelvis in relatively close association to a number of gynecologic structures. It may be injured in any type of gynecologic or pelvic reconstructive procedure. The most important step to prevent injury is to identify the ureter and remain cognizant of its course during the operation. An unrecognized ureteral injury often occurs when the surgery becomes challenging due to bleeding and other intraoperative difficulties.
The preoperative assessment should determine whether or not a patient has two functioning kidneys. One should ask the patient about prior kidney surgery and inquire about any flank or abdominal scars seen on physical examination. Nothing wastes time like waiting for ureteral efflux in a patient who had a prior nephrectomy.
Ureteral injury is a well-known complication of a wide range of gynecologic and pelvic reconstructive procedures. The possibility of a ureteral injury should be reviewed with the patient and documented in the informed consent.
There is some debate about the utility of “prophylactic stents” placed before incision to facilitate identification of the ureters intraoperatively. The general consensus is that they do not decrease the risk of ureteral injury but they do aid in recognition of a ureteral injury. However, there may be unique cases where a particular surgeon might find them helpful. Ureteral stents can easily be placed at the start of the case by a urologist or by the gynecologist if he or she is familiar with stent placement.
If in doubt as to whether the ureter has been injured or if one does not feel comfortable repairing a ureteral injury, then the next step is to obtain an intraoperative urology consult.
Fine needle holders and pickups will be needed for ureteral manipulation and Potts scissors are useful for ureteral spatulation. An endoscopic attempt at ureteral stenting will require a rigid cystoscope, a guidewire, and double J stent.
Based on the nature, degree, and location of the ureteral injury, one must decide what approach to take to repair the injury.1
Obstruction from tension: For example, kinking of the ureter after a stitch is placed into the distal uterosacral ligament—in this case just removing the suture is likely to resolve the obstruction.
Ligation of ureter: Simply removing the suture may be sufficient. Many would likely place a ureteral stent (cystoscopically) for a few weeks to prevent any stricturing of the ureter.
Crush injury: Remove what was crushing the ureter and place a ureteral stent (cystoscopically).
Mild thermal injury: Treat as a crush injury (place stent). The area may look healthy at the time of surgery but then necrose over the ensuing days.
Ureteral laceration:
Small clean partial laceration of the ureter can be primarily repaired.
Place stent over a wire—this can be done either cystoscopically or via the laceration; make sure not to make the injury worse when trying to place stent.
Carefully reapproximate the lacerated edges of the ureter with a single layer of interrupted 4-0 Vicryl. Handle the ureter gently and just place a few sutures—placing too many sutures during the reapproximation may compromise tissue quality and perfusion to the area of repair.
Significant ureteral injury or complete transaction usually requires ureteral reimplantation. The majority of gynecologic ureteral injuries occur in the distal ureter. In such cases, the ureter can usually be directly implanted into the bladder in a tension-free manner. If the ureter does not easily reach the bladder, then an alternate technique should be employed to allow the bladder to reach the ureter. These techniques include a psoas hitch of the bladder or a Boari flap.
Ureteral dissection: Carefully dissect the ureter free from the site of injury to a proximal level that will allow it to reach the bladder in a tension-free fashion. Leave as much tissue on the ureter as possible, as stripping off the adventitia may remove the blood supply to the ureter, leading to ischemia and stricture formation. Handle the ureter gently with fine instruments and ensure that the ureter reaches the bladder without tension. If you can easily see the edge of the distal segment of ureter (the portion that will be left behind), then tie it off with a free tie. If it is difficult to find or tie off, then leave it alone.
Spatulation of the ureter: Cut the injured distal edge of the ureter at a 45° angle and then spatulate the proximal edge of the previous incision to leave a wide open ureteral end (Figure 37-2A). This spatulation step is done to increase the diameter of the anastomosis and allow plenty of room to reimplant and suture the ureter without causing stricturing.
Reimplantation: Find an area of the dome of the bladder that the ureter reaches easily. Incise 3 cm of detrusor muscle in a transverse direction. Incise the distal 1 to 2 cm of mucosa within that incision. Bring the spatulated ureteral end to the mucosal defect. The reimplantation is started with a 4-0 Vicryl stitch to reapproximate the proximal portion of the spatulated ureter and the proximal edge of the mucosal defect. A few more interrupted 4-0 Vicryl sutures are placed to sew the rest of the ureteral edge to lay flat on the mucosa (Figure 37-2B and C). Some favor interrupted mucosal sutures, while others do a running closure. Either way, it is important that the closure be watertight and without undue ischemia. About half way through closure, place a wire up the ureter and pass a stent over the wire; then remove the wire and place the distal end of the stent in the bladder. The mucosal closure can then be completed after placement of the stent. Loosely reapproximate the detrusor over the distal 1 cm of the reimplantation site with interrupted 3-0 Vicryl sutures (Figure 37-2D). Do not be aggressive with this step since “tight” sutures here can cause ureteral obstruction.
Leave drains: Place a JP or other closed suction drain in pelvis. Leave a Foley catheter in the patient to drain the bladder and prevent any strain on the reimplant site.
FIGURE 37-2
Ureteroneocystotomy. A. Spatulate the ureter. B. Ureteral reimplantation. An incision is made in the dome of the bladder. The surgeon determines the best location for tunneling of the proximal spatulated urethra. C. Ureteral reimplantation. Once the ureter has been tunneled through bladder detrusor muscle, the orifice is sewn to the bladder mucosa using delayed absorbable suture. Ureter stent is then placed. D. Reimplanted ureter.
Days four to five—Remove JP drain as long as daily output is less than 150 mL. If the daily output is higher than that, send the fluid for a creatinine level. If it is just peritoneal fluid, the creatinine level should be similar to the serum creatinine level (0.5–1.4 mg/dL) and the JP drain can be removed. If it is elevated, it likely indicates that the fluid is urine or has some urine within it and that the repair has not yet sealed. In such a situation the JP should be left in place but taken off suction until the output diminishes.
Day ten—Remove Foley catheter.
Six weeks—Perform cystoscopy and remove stents. Alert patients to inform you if they develop any flank pain on the side of the injury.
Three months—Obtain renal ultrasound to make sure no hydronephrosis has appeared.
One year—Repeat renal ultrasound.
Box 37-1 Master Surgeon’s Corner
Ureteral injury can be recognized by direct visualization of ureteral injury, lack of efflux on cystoscopy, development of hydroureteronephrosis, or extravasation of urine into the peritoneal cavity visualized after intravenous indigo carmine administration.
If ureteral injury is suspected, the level of injury can be confirmed after inability to pass a guidewire or ureteral stent cystoscopically or fluoroscopically with extravasation of contrast after retrograde administration of radiopaque contrast.
If there is tension on the repair during ureteral implant surgery, the ureteroneocystotomy can be augmented by stitching the bladder to the ipsilateral psoas muscle (psoas hitch) or forming a bladder tube flap (Boari flap) that reaches the distal ureteral end.
Bowel injury is a rare complication of pelvic reconstructive surgery but can occur with the abdominal, laparoscopic, or vaginal approaches. Intraoperative recognition and repair is essential in order to avoid the potentially devastating sequelae of peritonitis, abscess, and sepsis that can be associated with delayed recognition. Other potential sequelae of small bowel injury include fistula, prolonged ileus, and bowel obstruction. Potential mechanisms of injury include laceration, perforation, thermal or burn injury, crush with associated ischemic injury, and mesenteric/vascular injury. It is important to be cognizant of the mechanisms of injury as they will dictate the management approach. Tears that involve only the serosa can typically be managed with simple interrupted sutures or imbrication using a Lembert-style repair. Small serosal tears may require no treatment. Intramural hematomas will usually heal spontaneously and do not typically require intervention. Full-thickness defects will require either a primary repair or resection and primary anastomosis depending on the nature and extent of the injury. A mesenteric vascular injury will require careful inspection of the bowel to assess for viability. All bowels with compromised vasculature will require wide resection with primary anastomosis of the viable bowel. When a bowel injury occurs because of trocar injury, whether laparoscopic or from a sling or prolapse mesh device, it is prudent to leave the trocar in position until the full nature of the injury is known as it is much easier to identify the location of the injury with the trocar in place. Ileostomy is rarely, if ever, required to manage an intraoperative small bowel injury.
Bowel injury is an uncommon but well-described complication of a wide range of gynecologic and pelvic reconstructive procedures. The possibility of an injury to the small and large bowel should be reviewed with the patient and documented in the informed consent.
Intravenous antibiotic prophylaxis is recommended to prevent infection for most pelvic reconstructive surgery. Historically, mechanical bowel preparation has often been recommended prior to laparoscopic or open pelvic reconstructive procedures. However, there are little data to support this practice.2
If one is in doubt about the appropriate approach or one does not feel comfortable repairing a small bowel injury, then the next step is to obtain an intraoperative surgical consult.
Lacerations of less than half the circumference of the small bowel without associated vascular or thermal injury may be repaired primarily without bowel resection.3,4
Isolate and expose injury—Identify and adequately expose the bowel injury. The small bowel should be inspected throughout its entirety to ensure that all injuries are located (eg, “run the bowel”). Isolate the site of injury with noncrushing bowel clamps or Babcock clamps to prevent further spillage of bowel contents. The mesentery should be inspected for any vascular compromise. Any active mesenteric bleeding should be controlled by isolation and ligation of individual vessels rather than by mass ligation of the mesentery, which can produce ischemia.
Repair of enterotomy—Although single-layer closure has been described, we prefer a two-layered closure. It is essential that the edges of the repair be viable; any devascularized or nonviable tissue should be debrided. The first layer of closure can be performed with simple interrupted sutures or a running suture of 3-0 or 4-0 absorbable suture material incorporating all layers. The closure should run perpendicular to the direction of the bowel (transverse closure), regardless of the direction of the tear (Figure 37-3). This layer is then buried by an interrupted longitudinal mattress stitch through the seromuscular layer using 3-0 delayed absorbable suture or silk. The reason for the direction of closure is to prevent stricture formation at the site of the repair, as longitudinal closure can cause narrowing of the lumen. The integrity of the repair may be assessed by milking small bowel contents across the line of repair and observing for leakage.
Irrigate the area copiously.
Full-thickness small bowel injuries that are larger than 50% of the bowel circumference or injuries that include significant thermal or vascular injury should be repaired with small bowel resection and primary anastomosis. Also, if multiple enterotomies occur within a localized segment of small bowel, it is often prudent to resect the entire damaged segment rather than perform multiple primary enterotomy repairs regardless of their size. Similarly, if primary repair will result in significant narrowing of the small bowel lumen, then resection and primary anastomosis should be performed. Small bowel resection can be repaired using either an end-to-end handsewn repair or a side-to-side (functional end-to-end) anastomosis with a linear stapler; here we focus on a stapled repair.
Gastrointestinal anastomosis (GIA) and thoracoabdominal (TA) staplers are required for a stapled small bowel repair. Noncrushing bowel clamps and/or Babcock clamps are also useful.
Isolate and expose injury—Identify and adequately expose the bowel injury. The small bowel should be inspected in its entirety to ensure that all injuries are located (eg, “run the bowel”). Isolate the site of injury with noncrushing bowel clamps or Babcock clamps to prevent further spillage of bowel contents. Moist laparotomy sponges can be used to isolate the damaged bowel from the remaining peritoneal contents. The mesentery should be inspected for any vascular compromise. Any active mesenteric bleeding should be controlled by isolation and ligation of individual vessels rather than by mass ligation of the mesentery, which can produce ischemia. Direct observation of the affected bowel, Doppler ultrasound, or intravenous fluorescein can be used to determine the adequacy of blood flow to the affected small bowel. After the margins of the resection have been determined, electrocautery is used to score the peritoneum on either side of the mesentery in a V shape to encompass only vessels related to the section to be removed (Figure 37-4A).
Divide the small bowel segment—A window is made in an avascular section of the mesentery adjacent to the bowel at the site of the planned margins. Using this window, the GIA stapler is passed through on either side of the segment of bowel being divided and engaged creating two staple lines and two ends (Figure 37-4B). Typically, the 3.8 mm GIA stapler is adequate, although a larger size may be needed if the bowel is thickened. This is repeated on the other side to isolate the bowel segment to be resected.
Divide the mesentery—After the bowel is divided, the mesentery is divided using electrocautery. Lifting the small bowel, the vascular arcade of the mesentery can typically be seen by transillumination. The vascular pedicles are ligated with 3-0 absorbable suture, hemoclips, or a harmonic scalpel. The isolated segment of damaged bowel is removed.
Side-to-side anastomosis—The two segments of small bowel to be used for the anastomosis are positioned for the side-to-side anastomosis with their antimesenteric sides in contact. 3-0 stay sutures can be used to assist with orientation if needed. Adjacent corners of the staple lines are cut off and a GIA cutting stapler (60 or 80 mm) is inserted with one arm of the stapler in the distal small bowel and the other in the proximal small bowel. The stapler is engaged creating a connection with the length of the stapler between the two ends of the bowel establishing the functional side-to-side anastomosis. This internal staple line should be inspected to identify any sites of bleeding. Interrupted 4-0 sutures can be placed for hemostasis in any bleeding areas.
Close the end of the anastomosis—The open end of the anastomosis is closed by firing a TA stapler across the free ends of the joined bowel loops. The staple line can be inverted using a row of 3-0 or 4-0 interrupted Lembert sutures to ensure closure. A simple suture can also be placed at the “crotch” of the anastomosis for additional support. The integrity of the repair may be assessed by milking small bowel contents across the line of repair and observing for leakage.
Close the mesenteric defect—Large mesenteric defects should be closed with continuous or interrupted 3-0 absorbable suture.
Irrigate the area copiously.
FIGURE 37-4
Small bowel resection. A. Identify and isolate blood supply for small bowel resection. B. GIA stapler is used to divide small intestine. (Reproduced with permission from Ref.5 Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
Although once common practice, the literature does not support routine nasogastric suction after repair of a small bowel injury. Multiple randomized trials have demonstrated that routine nasogastric decompression is associated with an increased rate of pneumonia, atelectasis, and fever in the postoperative period when compared with no decompression. Moreover, nasogastric suction increases patient discomfort, sinus infection, and epistaxis. As such, nasogastric suction should not be performed routinely after small bowel resection. Patients should be monitored closely and if they develop signs and symptoms of a postoperative ileus, then selective use of nasogastric suction is warranted. As with nasogastric suction, delayed postoperative feeding after bowel resection was once common practice. Current data support early postoperative feeding even after small bowel resection. Randomized trials demonstrate similar rates of ileus, anastomotic leak, and time required for return to normal bowel function between patients receiving early feeding and those receiving delayed feeding after surgery. There is no need to continue antibiotics into the postoperative period after an isolated small bowel injury.
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