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Unrecognized Bladder Perforation During Operative Laparoscopy
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
Unrecognized Bladder Perforation During Operative Laparoscopy Vincent Patrick Lamaro, MRANZCOG, Jonathan David Broome, MRCOG, and Thierry Georges Vancaillie, M.D., FRANZCOG Abstract During operative laparoscopy in a 42-year-old woman, 12-mm trocar lacerations occurred through anterior and posterior walls of the bladder but were not recognized. This case demonstrates important issues related to predicting, avoiding, detecting, and treating bladder trauma associated with laparoscopic surgery. It also indicates that some classic warning signs of accidental cystotomy may be absent or delayed in appearance. (J Am Assoc Gynecol Laparosc 7(3):417–419, 2000)
CT). The right infundibulopelvic ligament was isolated and ligated with extracorporeal knots with 2-0 polyglycolic acid suture. After division of the infundibulopelvic ligament, it was further secured with an 0-Polysorb Surgitie (U.S. Surgical Corp.). Using electrosurgery the right adnexa was dissected from the pelvic sidewall before being removed through the suprapubic port. The rectus sheath in the umbilical and suprapubic incisions was closed with 1-0 polyglycolic acid sutures. One hour postoperatively the woman had heavily blood-stained urine. An intravenous urogram was reported as normal, and the catheter was removed after 48 hours when the urine was clear. The woman was able to void spontaneously and was discharged. Over the next 5 days she went to two different emergency departments because of bladder pain and hematuria. She was presumed to have, and was treated for, a urinary tract infection. The patient was reviewed in our unit 5 days later with acute urinary retention. She had hematuria, and examination showed a small hematoma beneath the suprapubic incision. Ultrasound findings were consistent with blood clots in the bladder. At cystoscopy the clots were evacuated. Healing entry and exit
Bladder trauma is the most common complication of open abdominal surgery. Its frequency in laparoscopic surgery is higher still, and the ability to detect intraoperative trauma may be lower than desired.1 Whereas various clinical signs indicate bladder perforation at laparoscopic surgery and are watched for, absence of such signs does not necessarily exclude the injury. Case Report A year before coming to our institution, a 42-yearold woman had undergone total abdominal hysterectomy and left salpingo-oophorectomy, followed 3 months later by laparoscopic division of adhesions and drainage of a left ovarian cyst. Now, she underwent laparoscopic right salpingo-oophorectomy because of chronic right-sided pelvic pain. A 12-gauge indwelling catheter was inserted with some difficulty after urethral dilatation. Pneumoperitoneum and laparoscopic entry were achieved in the left upper quadrant. Extensive adhesions involving omentum and anterior abdominal wall were divided before inserting a 10-mm umbilical port and 12-mm suprapubic Versaport (U.S. Surgical Corp., Norwalk,
From the Department of Obstetrics and Gynaecology, University New South Wales, Kensington, Royal Hospital for Women, Randwick NSW, Australia (all authors). Address reprint requests to Dr. V. P. Lamaro, Department of Endo-Gynaecology, Royal Hospital for Women, Barker Street, Randwick, NSW, Australia 2031; fax 02 9382 6758. Presented at the 28th annual meeting of the American Association of Gynecologic Laparoscopists, Las Vegas, Nevada, November 8–11, 1999. Accepted for publication March 14, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2000, Vol. 7 No. 3 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
417
Unrecognized Bladder Perforation During Operative Laparoscopy Lamaro et al
The fact that this patient went to two emergency departments added to the delay in diagnosis of the injury. Hematuria and bladder pain were thought to be secondary to a urinary tract infection, and the diagnosis of clot retention secondary to expulsion of a rectus sheath hematoma into the bladder was made only once the women returned to our unit. Conservative treatment was deemed to be all that was required at that stage. The bladder should always be inspected before inserting a pelvic secondary port, looking particularly for adherence to previous surgical scars, distortion of usual bladder margins, presence of bladder wall disease such as endometriosis, and presence of urachal sinus congenital anomalies.1 When location of the superior margin of the bladder edge is uncertain, retrograde filling of the bladder with saline may help delineate the vesicoperitoneal reflection; bladder contents must be redrained before inserting the trocar. Adhesions involving bladder peritoneum are best dealt with by inserting a 5-mm lateral port and carefully dissecting the bladder free. Cystoscopy has a role in cases where uncertainty exists regarding passage of a trocar or difficult surgical dissection around the bladder. Endoscopic suturing would have been appropriate treatment had this injury been detected at initial surgery.7 This case reminds us of the importance of being vigilant with surgical technique no matter how routine. It illustrates that classic signs such as hematuria and CO2 in the catheter bag may be absent in the presence of bladder perforation. It reinforces the need to investigate gross postoperative hematuria in the absence of intraoperative signs, and reminds us that a normal radiology report may not equal a normal set of films.
wounds were identified in the dome and base of the bladder, respectively, and ureteral orifices were uninjured. The woman was discharged with a 16-gauge indwelling catheter with free drainage for 10 days. At review 6 weeks postoperatively, she had no urinary symptoms and the suprapubic hematoma had resolved. Discussion Bladder trauma associated with advanced laparoscopic surgery has a reported frequency of 0.02% to 8.5%,1,2 averaging about 1.5% in a unit such as ours.3 Electrosurgical dissection was reported to be the leading technique causing injury, followed by blunt dissection of the bladder and trocar insertion.1 Factors predisposing to such injury include history of surgery (up to 70% of patients), pelvic adhesions, endometriosis, patient obesity,4 complex surgery,5 and poor surgical technique. As many as half of these injuries occur while inserting trocars,2 illustrating the importance of safe insertion technique. Draining the bladder by urethral catheterization before any pelvic procedure, no matter how minor, is mandatory. Preoperative voiding does not guarantee bladder emptying, and manual examination is notoriously unreliable in detecting bladder enlargement.6 This patient had undergone both laparotomy for hysterectomy and laparoscopic division of adhesions. She had extensive anterior abdominal wall adhesions and, in retrospect, superior displacement of the bladder. Failure to follow safety rules such as fully delineating bladder anatomy and inserting the suprapubic trocar perpendicular to the skin rather than obliquely, may have played a role in the initial injury. Hematuria, intraperitoneal bleeding, and CO2 distending the catheter bag often signify bladder injury, signs that were absent in this woman. The presence of the trocar through the bladder walls probably maintained a degree of hemostasis and barrier to passage of CO2. It was not until 1 hour postoperatively that gross hematuria was noted. At that time it was thought that initial attempts at catheterizing this patient, followed by urethral dilatation and recatheterization, may explain this finding. However, as a precaution, an intravenous urogram was ordered, which was reported as normal. Retrospective review of these films shows that the indwelling catheter was not clamped off, with contrast medium free to fill the catheter tubing and bag without causing bladder distention and contrast leakage.
References 1. Ostrzenski A, Ostrzenska KM: Bladder injury during laparoscopic surgery. Obstet Gynecol Surv 53(3): 175–180, 1998 2. MacCordick C, Lecuru F, Rizk E, et al: Morbidity in laparoscopic gynecological surgery: Results of a prospective single-center study. Surg Endosc 13(1):57–61, 1999 3. Saidi MH, Sadler RK, Vancaillie TG, et al: Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 87(2):272–276, 1996
418
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
4. Mendoza D, Newman RC, Albala D, et al: Laparoscopic complications in markedly obese urologic patients (a multi-institutional review). Urology 48(4):562–567, 1996
6. Greig JD, Mahadaven M, John TG, et al: Comparison of manual and ultrasonographic evaluation of bladder size in patients prior to laparoscopy. Surg Endosc 10(4):432–433, 1996
5. Mirhashemi R, Harlow B, Ginsburg E, et al: Predicting risk of complications with gynecologic laparoscopic surgery. Obstet Gynecol 92(3):327–331, 1998
7. Taskin O, Wheeler JM: Laparoscopic repair of bladder injury and laceration. J Am Assoc Gynecol Laparosc 2(2):227–229, 1995
419
The Journal of the American Association of Gynecologic Laparoscopists
Unrecognized Bladder Perforation During Operative Laparoscopy Vincent Patrick Lamaro, MRANZCOG, Jonathan David Broome, MRCOG, and Thierry Georges Vancaillie, M.D., FRANZCOG Abstract During operative laparoscopy in a 42-year-old woman, 12-mm trocar lacerations occurred through anterior and posterior walls of the bladder but were not recognized. This case demonstrates important issues related to predicting, avoiding, detecting, and treating bladder trauma associated with laparoscopic surgery. It also indicates that some classic warning signs of accidental cystotomy may be absent or delayed in appearance. (J Am Assoc Gynecol Laparosc 7(3):417–419, 2000)
CT). The right infundibulopelvic ligament was isolated and ligated with extracorporeal knots with 2-0 polyglycolic acid suture. After division of the infundibulopelvic ligament, it was further secured with an 0-Polysorb Surgitie (U.S. Surgical Corp.). Using electrosurgery the right adnexa was dissected from the pelvic sidewall before being removed through the suprapubic port. The rectus sheath in the umbilical and suprapubic incisions was closed with 1-0 polyglycolic acid sutures. One hour postoperatively the woman had heavily blood-stained urine. An intravenous urogram was reported as normal, and the catheter was removed after 48 hours when the urine was clear. The woman was able to void spontaneously and was discharged. Over the next 5 days she went to two different emergency departments because of bladder pain and hematuria. She was presumed to have, and was treated for, a urinary tract infection. The patient was reviewed in our unit 5 days later with acute urinary retention. She had hematuria, and examination showed a small hematoma beneath the suprapubic incision. Ultrasound findings were consistent with blood clots in the bladder. At cystoscopy the clots were evacuated. Healing entry and exit
Bladder trauma is the most common complication of open abdominal surgery. Its frequency in laparoscopic surgery is higher still, and the ability to detect intraoperative trauma may be lower than desired.1 Whereas various clinical signs indicate bladder perforation at laparoscopic surgery and are watched for, absence of such signs does not necessarily exclude the injury. Case Report A year before coming to our institution, a 42-yearold woman had undergone total abdominal hysterectomy and left salpingo-oophorectomy, followed 3 months later by laparoscopic division of adhesions and drainage of a left ovarian cyst. Now, she underwent laparoscopic right salpingo-oophorectomy because of chronic right-sided pelvic pain. A 12-gauge indwelling catheter was inserted with some difficulty after urethral dilatation. Pneumoperitoneum and laparoscopic entry were achieved in the left upper quadrant. Extensive adhesions involving omentum and anterior abdominal wall were divided before inserting a 10-mm umbilical port and 12-mm suprapubic Versaport (U.S. Surgical Corp., Norwalk,
From the Department of Obstetrics and Gynaecology, University New South Wales, Kensington, Royal Hospital for Women, Randwick NSW, Australia (all authors). Address reprint requests to Dr. V. P. Lamaro, Department of Endo-Gynaecology, Royal Hospital for Women, Barker Street, Randwick, NSW, Australia 2031; fax 02 9382 6758. Presented at the 28th annual meeting of the American Association of Gynecologic Laparoscopists, Las Vegas, Nevada, November 8–11, 1999. Accepted for publication March 14, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2000, Vol. 7 No. 3 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
417
Unrecognized Bladder Perforation During Operative Laparoscopy Lamaro et al
The fact that this patient went to two emergency departments added to the delay in diagnosis of the injury. Hematuria and bladder pain were thought to be secondary to a urinary tract infection, and the diagnosis of clot retention secondary to expulsion of a rectus sheath hematoma into the bladder was made only once the women returned to our unit. Conservative treatment was deemed to be all that was required at that stage. The bladder should always be inspected before inserting a pelvic secondary port, looking particularly for adherence to previous surgical scars, distortion of usual bladder margins, presence of bladder wall disease such as endometriosis, and presence of urachal sinus congenital anomalies.1 When location of the superior margin of the bladder edge is uncertain, retrograde filling of the bladder with saline may help delineate the vesicoperitoneal reflection; bladder contents must be redrained before inserting the trocar. Adhesions involving bladder peritoneum are best dealt with by inserting a 5-mm lateral port and carefully dissecting the bladder free. Cystoscopy has a role in cases where uncertainty exists regarding passage of a trocar or difficult surgical dissection around the bladder. Endoscopic suturing would have been appropriate treatment had this injury been detected at initial surgery.7 This case reminds us of the importance of being vigilant with surgical technique no matter how routine. It illustrates that classic signs such as hematuria and CO2 in the catheter bag may be absent in the presence of bladder perforation. It reinforces the need to investigate gross postoperative hematuria in the absence of intraoperative signs, and reminds us that a normal radiology report may not equal a normal set of films.
wounds were identified in the dome and base of the bladder, respectively, and ureteral orifices were uninjured. The woman was discharged with a 16-gauge indwelling catheter with free drainage for 10 days. At review 6 weeks postoperatively, she had no urinary symptoms and the suprapubic hematoma had resolved. Discussion Bladder trauma associated with advanced laparoscopic surgery has a reported frequency of 0.02% to 8.5%,1,2 averaging about 1.5% in a unit such as ours.3 Electrosurgical dissection was reported to be the leading technique causing injury, followed by blunt dissection of the bladder and trocar insertion.1 Factors predisposing to such injury include history of surgery (up to 70% of patients), pelvic adhesions, endometriosis, patient obesity,4 complex surgery,5 and poor surgical technique. As many as half of these injuries occur while inserting trocars,2 illustrating the importance of safe insertion technique. Draining the bladder by urethral catheterization before any pelvic procedure, no matter how minor, is mandatory. Preoperative voiding does not guarantee bladder emptying, and manual examination is notoriously unreliable in detecting bladder enlargement.6 This patient had undergone both laparotomy for hysterectomy and laparoscopic division of adhesions. She had extensive anterior abdominal wall adhesions and, in retrospect, superior displacement of the bladder. Failure to follow safety rules such as fully delineating bladder anatomy and inserting the suprapubic trocar perpendicular to the skin rather than obliquely, may have played a role in the initial injury. Hematuria, intraperitoneal bleeding, and CO2 distending the catheter bag often signify bladder injury, signs that were absent in this woman. The presence of the trocar through the bladder walls probably maintained a degree of hemostasis and barrier to passage of CO2. It was not until 1 hour postoperatively that gross hematuria was noted. At that time it was thought that initial attempts at catheterizing this patient, followed by urethral dilatation and recatheterization, may explain this finding. However, as a precaution, an intravenous urogram was ordered, which was reported as normal. Retrospective review of these films shows that the indwelling catheter was not clamped off, with contrast medium free to fill the catheter tubing and bag without causing bladder distention and contrast leakage.
References 1. Ostrzenski A, Ostrzenska KM: Bladder injury during laparoscopic surgery. Obstet Gynecol Surv 53(3): 175–180, 1998 2. MacCordick C, Lecuru F, Rizk E, et al: Morbidity in laparoscopic gynecological surgery: Results of a prospective single-center study. Surg Endosc 13(1):57–61, 1999 3. Saidi MH, Sadler RK, Vancaillie TG, et al: Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol 87(2):272–276, 1996
418
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
4. Mendoza D, Newman RC, Albala D, et al: Laparoscopic complications in markedly obese urologic patients (a multi-institutional review). Urology 48(4):562–567, 1996
6. Greig JD, Mahadaven M, John TG, et al: Comparison of manual and ultrasonographic evaluation of bladder size in patients prior to laparoscopy. Surg Endosc 10(4):432–433, 1996
5. Mirhashemi R, Harlow B, Ginsburg E, et al: Predicting risk of complications with gynecologic laparoscopic surgery. Obstet Gynecol 92(3):327–331, 1998
7. Taskin O, Wheeler JM: Laparoscopic repair of bladder injury and laceration. J Am Assoc Gynecol Laparosc 2(2):227–229, 1995
419