Management of complications

Question 1

Rate of serious complications at the time of laparoscopy?

When are they most likely to occur?

Answer 1

1-2/1000

50% at time of entry

Question 2

Rates of injury at laparoscopy:

• Bowel
• Urological
• Vascular

Answer 2

Bowel injuries 0.6-1.4/1000

Urological injuries 0.3-1/1000

Vascular injuries 0.1/1000

Question 3

Urinary tract complications

• Which type of injury most common?
• What increases the risk?
• Most common sites of bladder injury?

Answer 3

Bladder injury is more common than ureteric injury

Prior surgery increases the risk

Common sites of bladder injury:

• 95% are at the dome of the bladder
• 5% are at the trigone,

Question 4

Most common times to injure the bladder at CS?

Answer 4

• creation of the bladder flap 43%,
• peritoneal entry 33%,
• uterine incision or delivery 24%

Question 5

Most common ways to injure bladder at laparoscopy?

Answer 5

Most common operative injury mechanisms:

1. Mechanical or electro-thermal trauma
   Entry with suprapubic port, adhesiolysis , thermal injury during dissection of bladder from uppercervix or vagina. OR during resection of endometriotic implants
2. Devascularisation or denervation of autonomic pelvic plexus controlling normal voiding function
3. Accidental placement of an intravesical suture or staple

Question 6

Features that diagnose/suggest bladder injury?

Answer 6

• Distension of foley bag with gas instead of urine
• Visualisation of foley catheter balloon
• Intraperitoneal leakage of methylene blue

Post op

• Hematuria
• Post op oligouria or anuria
• Increased output through surgical drains

Question 7

Intraoperative diagnosis of bladder injury?

Answer 7

Methylene blue in 200-500mls of NaCl 0.9% into the bladder via catether and observe

Cystoscopy- ureteric jets (easier with dye in the bladder) or bladder injury

Question 8

Post op assessment of bladder injury?

Answer 8

FBC and urea, creatinine and electrolytes (may be normal though)
Urinalysis

If high drain output: send fluid to lab for creatinine measurement

Post-op if bladder injury suspected then USS is a good initial test assess for hydronephrosis or exclude a retroperitoneal collection. CT follows this with renal contrast to perform IVU

Question 9

Treatment of bladder injury?

Answer 9

Cystoscopy and visualisation of bladder neck and urethral orifices to identify extent of injury

Cystotomies <1cm can also be conservatively managed

Intra-peritoneal injuries: need operative exploration and repair

Injury to dome (away from trigone) Simple bladder closure is in 2 layers using absorbable sutures e.g. 3/0 Vicryl Rapide , tension free ‘oppose don’t necrose’. Test with methylene blue

Injury to trigone- check for ureteric injuries

Consider leaving drain in

Keep IDC for 7-10 days, perform cystogram to ensure healing

The bladder will reepithelialize within three to four days and regains its normal strength after 21 days

Question 10

Outcomes after bladder injury

Answer 10

Good after simple closure, “ bladder is forgiving”

Long term complications: fistula formation, urinary incontinence, bladder instability

Patients with prior radiation and inflammatory bowel disease are at increased risk of entero vesical fistula formation after bladder injury

Question 11

Describe the course of the ureter

Answer 11

Ureters enter the pelvis at the pelvic brim and cross from lateral to the common iliacs to medial to the ovarian vesels.

Descend into the pelvis within the ureteric fold which is attached to the medial leaf of the broad ligament and the lateral pelvic sidewall.

The ureter is located on the medial leaf of the broad ligament and courses under the uterine artery. Prior to any surgical manipulation, it usually lies 2 cm lateral to the uterus, but may be nearer. The ureter must be identified before clamping and cutting the uterine artery to avoid injury.

Just inferior to the cervical os the ureter passes under the uterine arteries and enters the posterior bladder close to the anterolateral vaginal fornix

Question 12

Common sites of ureteric injury

Answer 12

1. At the pelvic brim when ligating the IP ligament
   - during ligation of IP ligament ureters run medial to the ovarian vessels esp if there is a large ovarian /paraovarian cysts, residual or ovarian remnant syndrome
2. Ligation of the uterine artery (most common)

at the base of the broad ligament where it passes underneath uterine arteries)

3. closure of the angles of the vaginal cuff

• At the vaginal angles at the conclusion of hysterectomy, where it can be incorporated into haemostatic sutures
• When clamping pedicles around a cervical or broad ligament fibroid

4. When clamping pedicles around a cervical or broad ligament fibroid as the ureter could be anterior, lateral, or posterior to the fibroid depending on the tissue distortion

Question 13

Most common mechanisms of ureteric injury (6)

Answer 13

6 most common operative ureteral injury mechanisms:

1. Crushing
2. Kinked or ligated with a suture
3. Transsecton (partial or complete)
4. Angulation of the ureter with secondary obstruction
5. Ischaemia from ureteral stripping or electrocoagulation
6. Resection of a segment of ureter

Question 14

Intraoperative investigations if ureteric injury suspected

Answer 14

• IV indigo carmine - enables structures of the urinary tract to be seen in the surgical field, and demonstrate if there is a leak
• Careful inspection of the urinary tract and dissection of the ureters to assess the anatomical course and integrity
• Intraoperative ureteral catheterization
  Cystoscopy to look for jets followed by retrograde ureteropyelography to localise a ureteric lesion- extravasation of contrast confirms a ureteric injury
  retrograde ureteral dye injection