Study Review of the bladder injuries Inn laparoscopic assisted vaginal hysterectomy

Introduction

bladder injury is a very serious complication of lap assisted vaginal hysterectomy
Method retrospective analysis

Type of operative procedure

laparoscopic assisted vaginal hysterectomy laparoscopically assisted vaginal hysterectomy performed using three symptoms signs port of bladder injury during surgery as a balloon distension of the urinary catheter bag with gas or CO2 emissions of a clear liquid in the surgical management of hematuria of bladder injury during surgery cause of the injury bladder perforation trocar primary and secondary. Hasson open technique of laparoscopy can reduce three types of injury and the third 0.2 second trocar must be inserted under vision before surgery increases the risk of cystostomy in advertentie by placing traction on the bladder near the navel, or because adherence to place it in the way of the secondary trocar. in addition to the previous surgery can cause the formation of adhesions Obliterator the position of the bladder can grip in the cervicovaginal junction after a previous cesarean section and extend the commitment of the bladder- beyond the lower uterine segment. Another cause of mechanical injury. scissors or sharp dissection of adhesion or seen near the lady of the bladder may be the adhesion of the surgery prior infection on the intestine, appendix and peritonitis.

thermal injuries

excessive bleeding may be responsible for bladder thermal necrosis. use cautry pole near the surface of the bladder should be avoided. Vesico vaginal can occur after laparoscopic surgery that uterus is detached from the bladder using unipolar or bipolar coagulation cautry excessive heat can be responsible for bladder necrosis thermal thermal necrosis may be apparent only in post-operative period at a VVF occurs .. – Fistulas can also occur if the bladder is taken when the vagina is sutured underneath.

Injection of methylene blue

via a bladder catheter will be consistent with the diagnosis of vesico-vaginal fistula. P. IV retrograde cystography should also be made to the revaluation through

Presentation

injury of the bladder

minimize injury of the bladder in patients with previous cesarean Tran intervention side of the vagina should be used to enter the anterior cul-de-sac during laparoscopic hysterectomy interfacial side window of the space vesico vaginal aware first opened. Injury management Veress needle trocar. Can be managed with catheter madness for a week with no complications later. Injury to the bladder during laparoscopic assisted vaginal hysterectomy is small and charge at some distance from the bladder trigone it can be removed laparoscopically in two layers closer delayed absorbable suture material and check that the bladder is sealed to Water injection of 300 ml of methylene blue by the bladder catheter.

out bladder injury 4-7 of 1000

Subscribe to recognize

intraopeartive bladder injury, including more

1. catheter bag during insufflation of CO2

2. bladder appears to be driven by the accessory trocar as it is advanced through the abdominal well

3. blood in urine

drainage of urine

4. trocar incision accessories

5. Post operative urinary retention

6. Post operative signs of peritonitis

7. Leakage of indigo carmine to the injured site

Prevention

Insertion injury of the bladder is secondary trocar under direct vision.

1. bladder separated from the lower uterine segment using dissection never dissect the bladder altogether

2. Make sure that the bladder is not within the saving laparoscopic stapling device before firing.

3. Avoid excessive electro surgery around the bladder

Treatment

1. Repair depends on whether the damage is thermal or mechanical

2. if damage is at the base of the dome of the bladder

3. Close trine to injury and ureteral opening

Treatment

diagnosed at the time of surgery. Injury to the bladder dome can be repaired in a simple two layer PDS C. Is layer must be continuous mucous layer containing muscle. The instillation of indigo carmine to facilitate identification of the limits of laparoscopic bladder repair of vesico vaginal if submitted after the surgery is done after 12 weeks. Vesicovaginal space was developed both bladder vaginal bladder were closed separately with the vagina with vicryl PDS. Peritoneal flash was used to separate the vesico vaginal area and sutured with vicryl. Abdominal approach should be used for the following.

1. Inadequate exposure due to secondary or retracted fistula in a narrow vagina.

2. Close to the ureter fistula

3. multiple fistulas

4. Associated bladder pelvic pathology should be anticipated before surgery

Technical

New

A new technique for dissecting the bladder laparoscopically was detected by James Cook University Hospital during Laparoscopic-assisted vaginal hysterectomy in the department of minimally invasive surgery. 130 LAVH were reviewed bladder was dissected laparoscopically with a metal catheter was used identification to stretch the edge of the bladder and a sponge forceps was inserted to mark the site virginal scissors monopalar Colpotomy earlier were used to open virginal there was a 0.7% bladder injury was immediately recognized and repaired with laparoscopic intra corporeal knot average operating time was 198.7 minutes recorded mean hospital stay was 2.7 days with the range of 2 to 5 days dissecting the bladder laparoscopically adds 5 to 10 minutes of operating time, but significantly facilited identify appropriate plan, it is easy technique to learn and teach is associated with minimal complications with no increase in the incidence of injury bladder dysfunction or injury to the bladder by laparoscopy is rare, and said al reported 1.6% incidence of serious urinary complications after major surgery? Majority being laparoscopic bladder perforation or fistula, there are four cases of injury of the bladder in a series of 900 laparoscopic hysterectomies for three of the woman was gone within 2 or 3 c sections are women in the vaginal hysterectomy are likely to be injured if they had bladder previous section C. In this study, these reports 130 consecutive LAVH bladder and ureter were dissected vaginal pouch then opened laparoscopically. This technique was originally designed for the woman who had previous C section in which the bladder was adherent and difficult to identify and dissect vaginal technique was later adopted in all cases because it is ed to be easier and more safe and vaginally this technique was used in 130 LAVH performed at the James Cook Hospital technique was used in all patients the same technique of high pressure input OT 25 mm Hg using 3 ports in addition to 10 mm umbilical trocar 5 mm port inserted under direct vision in the right iliac fossa and left later to deep epigastric vessels and are inserted one above pubically. Bipolar diathermy and scissors were used to secure lower pedicles, but not including two round ligaments uterine vessels were secured with bipolar diathermy of the peritoneum was dissected from a round ligament on the other side. A metal catheter was then inserted into the catheter tip was so turned up pupil was reported to stretch the bladder pillars bladder was dissected with scissors with monopolar catheter in place. Sponge forceps was then pushed into the vagina to the anterior fornix to stretch the vagina and mark the location of colpotomy monopolar scissors were used to open the vagina and the use of cutting diathermy and shooting just before contact with the vaginal tissues have achieved significant hemostasis without bleeding vagina opened in layers until the sponge clamp was achieved, which was pushed into the area and the blade wide open stretch procedure colpotomy was completed vaginally. A Wertheim retractor was placed into the bladder to protect the uterine vessels were first fixed with forceps and secured with vicryl followed by the cardinal and utero sacral ligaments and intra-peritoneal drain and urinary catheter to date following results of 130 patients 12 had C sections mean operative time was 98.7 minutes. There was a bladder injury that was recognized immediately and repaired with laparoscopic intra-corporeal knots. Cystoscopy was performed to ensure the appropriate remedy bladder and to exclude other injuries. Patients have a urinary catheter for 7 days at follow-up 6 months after surgery she was well without residual bladder dysfunction.

It is difficult to detect the incidence of injuries of the bladder with laparoscopic surgery , especially in general LAVH GILMOUR et al (9) reported that the major gynecological surgery of the incident bladder injury varies from 0 2 -19.5 / per thousand, with over all frequencies from 2.6 per thousand based on medlinereach for all reports from 1996 to 1998. The found a higher incidence of bladder injury during routine cystoscopic was playing with range from 0 to 29.2 and on all frequencies of 10.4 miles. Author notes that only 51.6% of bladder injuries were identified and managed intraoperatively. Ostrzenski et al (10) reported the overall incidence of bladder injury during the laparoscopic procedure ranged from 0.022% to 8.3% of cases. These injuries most frequently occurred during LAVH. With electro surgical dissection instruments leading cause of injury. Intraoperative diagnosis of bladder injury was made in 53.24% of bladder injuries all cases, the bladder dome structure is the most commonly injured. Less than half the 29.87% of bladder injuries were corrected laparoscopically. Trauma in this series occurred when the bladder catheter was pushed into the bladder wall and punched through. The injury was immediately identified and successfully repaired laparoscopically without permanent residual bladder dysfunction. Catheters used metal to stretch the bladder to help identify the limits to the bladder and pillars. Which greatly facilitate the recognition, in which to dissect the bladder and release especially in patients with extensive dissection of the scars should be taken up one believes that the bladder has been completely freed from the vagina and use sponge forceps to stretch the vaginal wall clearly marks the location for colpotomy. Further studies are needed to get more a more accurate estimate of the trauma of the bladder. Cystoscopy was not performed routinely, except bladder injury was suspected indigo carmine was injected intravenously a few minutes before cystoscopy. Some authors recommend the routine use of cystoscopy with prior hysterectomy due to the high incidence of bladder lesions undetected Vakili at al (11) recently reported an incident of 4.8% of injuries during hysterectomy and urinary so concluded that routine cystoscopy should be considered. Harkki-Siren et al (12) have reported complication rates of laparoscopic procedure for miles, but a major complication rate of 10 per thousand in laparoscopic surgical complications by 19 percent% in these major serious injury was ureteric 46% had intestinal lesions. They found that 75% of the major complications have been associated with LAVH and commented that many of them may be due to the technique that the uterine vessels were coagulated and cut by laparoscopy 86% of the time and try to get vessels of the uterus with diathermy or staples can cause significantly more ureteral injury (13). In this series no ureteral injury that stopped laparoscopic dissection above uterine vessel and the procedure was then completed vaginally. A recent systematic review and meta-analysis of randomized controlled trials comparing vaginal and abdominal LAVH was published by Johnson et al (14). They reported a significant increase in urinary tract lesions for laparoscopic compared with abdominal hysterectomy odd ratio 2.6 to 95% is no significant difference when comparing the laparoscopic hysterectomy over vaginal or laparoscopic compared LAVH. In this series has opted for LAVH Visco et al reported 2.6% of LAVH damage to the urinary tract occurred in a total of 2998 cases. Evaluate study published by Ginny et al (17) reported bladder injury 2.1% in laparoscopic hysterectomy compared to 1% in abdominal hysterectomy. Comparison of laparoscopic hysterectomy and bladder injury vaginal has been reported at 0.9% and 1.2% respectively. Incidence of injuries of the bladder in the series Gasser was 0.7% lower due to the ease of identifying and dissecting the bladder.

If one is careful, one can easily avoid bladder injury by obeying the principles mentioned above. This study Gasser describe the dissection of the bladder laparoscopically adds 5-10 minutes running time. The use of the catheter with metal in order to identify the margin of the bladder and the stretching of the plane of the bladder pillar are easily recognizable. Using forceps sponge clearly m arks the vagina and therefore the site colpotomy. It is a technique easy to learn and adopt especially in patients with c previous section. Incident of the bladder is low key advantage in facilitating bladder dissection when there is a significant bond. The technique is associated with a low incidence of injury of the bladder.

Reference

1) Schutz K, M Possover, Merker A, Michels W, Schneider A (2002) Prospective randomized comparison of laparoscopically assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of uterus weighing> 200g. Surg Endosc 16: 121-125.

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3) A Zapico, P Fuentes, Grasse, Arnan F, J Otazu, Cortes-Prieto J (2005) laparoscopically assisted vaginal hysterectomy over abdominal hysterectomy in stages I and II endometrial cancer: Data operating, monitoring, and survival, Gynecol Oncol 98: 222-227.

4) Harkki-Siren P, Kurki T (1997) An analysis at the national level of laparoscopic complications. Hynecol Obstet 89: 108-112

5) Harkki-Siren P, Sjoberg J, Titinen A (1998) Urinary tract injuries after hysterectomy, Obstet Gynecol 92: 113-118

6) Ostrzenski A, Ostrzenska KM (1998) for bladder injury during laparoscopic surgery, Obstet Gynecol Surv 53: 175-180

7) Rooney CM, Crawford, BJ Vassallo, Kleeman SD, Karram MM (2005) is a previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-control study, Am J Obstet Gynecol 193:2041-2044

Armenakis NA, Pareek G, Fracchia JA (2004) Iatrogenic bladder perforations: long-term follow-up of 65 patients. J Am Coll Surg 198: 78-82

9) Matheved P, Valencia P, Cousin C, Mellier G, Dargent D (2001) injury to run for a vaginal hysterectomy, Europ J Obstet Gynecol Repord Biol 97: 71-75

10) & Berek Novak Gynecology (2007) Lippincott Williams & Wilkins, Philadelphia, 14th ed, pp 805-811

11) Vessy M, Villard-Mackintosh L, McPherson K, Coulter A, Yeates D (1992). The epidemiology of hysterectomy: finding in a large cohort study. Br J Gynaecol Obsted 99: 402-407

hysterectomies

12) Cosson M, E Lambaudie, Boukerrou M, Querleu D, G Crépin (2001) Vaginal, laparoscopic or abdominal bisorders benign: immediate and early postoperative complications. Eur J Obstet Gynecol Reprod Biol 98: 231-236

13) Sheth SS, Malpani AN (1995) vaginal hysterectomy following previous cesarean section. Int J Gynecol Obsted 50: 165-169

14) Hsu WC, Chang WC, Huang SC, Torng P, Chang DY, Sheu BC (2006) Visceral sliding technique is useful for detecting abdominal adhesion and preventing laparoscopic surgical complications. Gynecol Obstet Invest 62: 75-78

15) Chang WC, Huang SC, Sheu BC, Chen C, Torng PL, Hsu WC, Chang DY (2005) Transvaginal hysterectomy or laparoscopically assisted vaginal hysterectomy for uterine nonprolapsed. Obstet Gynecol 106: 321-326

16) Chang WC Torng PL, Hunag SC, Sheu BC, Hsu WC, Chen RJ, Chow SN, Chang DY (2005) laparoscopically assisted vaginal hysterectomy with uterine ligation artey through retrograde umbilical ligament tracking. J Minim Invasive Gynecol 12: 336-342

17) Aronson MP, Bose Tm (2002) pre-operative bladder injury in pelvic surgery. Clin Obsted Gynecol 45: 428-438

18) Neumann G, Raswmussen KL, Lauszus FF (2004) Intraoperative bladder injury during hysterectomy for benign lesions. Acta Obstet Gynecol Scand 83: 1001-1002

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