Case Report
Cystosufflation to Prevent Bladder Injury during Single Incision Laparoscopic Management of an Incisional Ventral Hernia
Ross O. Downes*
Department of General Surgery, Doctors Hospital, Bahamas
*Corresponding author: Ross O. Downes, Department of General Surgery, Doctors Hospital, Nassau, Bahamas
Published: 27 Aug, 2018
Cite this article as: Downes RO. Cystosufflation to Prevent
Bladder Injury during Single Incision
Laparoscopic Management of an
Incisional Ventral Hernia. World J Surg
Surgical Res. 2018; 1: 1049.
Abstract
Background: Scarless/single-incision laparoscopy is becoming popular but still faces much criticism.
The technique aims to reduce the risk of trocar-induced organ injury in the patient with previous
abdominal surgery. We examine the application of this technique combined with cystosufflation in a
patient with bladder herniation through an incisional ventral hernia. Thiscase presentation outlines
our experience using this method with initial evaluation of the safety, feasibility, and benefits of this
procedure.
Methods: We examine the account of the Single incision laparoscopic repair of an incisional hernia
containing the urinary bladder. To perform the operation, a 2.5 cm linear left flank incision was
made and the single port platform utilized. Carbon dioxide insufflation of the bladder was utilized
to define its boundaries and accomplish safe adhesiolysis during the procedure.
Results: The procedure was completed safely without any adverse outcomes.
Conclusion: Our lateral approach technique combined with cystosufflation is effective in identifying
a plane between the bladder and organ structures/dense adhesions of the anterior abdominal wall
especially in women who have undergone gynecological procedures.
Keywords: Laparoscopy; Single incision; Single port; Sncisional hernia; Urinary bladder; Cystosufflation; Carbon dioxide
Introduction
The prevalence of laparoscopic surgery has increased rapidly in recent years with newfound
enthusiasm. Yet still laparoscopic procedures still only accounts for 30% of surgical cases done
[1]. The most common abdominal surgery in women is cesarean section [2]. Hysterectomy is also
commonly performed. These gynecological and obstetric procedures make subsequent laparoscopic
procedures difficult. Multiple obstetric and gynecological procedures may result in thick and dense
adhesionsbetween the uterus, bladder and other abdominal organs, which obscures the dissection
plane [2]. Incisional hernia occurs in approximately 20% of cases [3]. Hernial contents usually
include omentum and intestine. Herniation of the urinary bladder is less common. Therefore,
adhesions post pelvic surgery can increase the difficulty of laparoscopic surgery. Laparoscopic
surgery is not contraindicated in patients who have undergone several cesarean sections or
hysterectomy [4]. However, more caution is exercised in the patient who has a history of several
previous abdomino-pelvic surgeries [4]. Adhesion characteristics (location, density and extent)
have no direct correlation with the history of previous abdominal surgery and radiological studies
performed as pre-surgical work-up [5].
In this case report, we look as a female who presents with herniated bladder through an incisional
hernia who underwent single port laparoscopic repair. We used the technique of cystosufflation to
safety accomplish bladder resection and feasibility of this surgical technique in women with anterior
wall adhesions after gynecological procedures who develop incisional hernia.
Case Presentation
We present a case of incisional hernia containing the urinary bladder. Our patient was a 55-yearold
who hadno chronic illness. She had Cesarean sections x 2 and a hysterectomydone via a midline
incision 10 years ago. She presented to the emergency department with a history of abdominal pain
of 12 hr duration that was gradual in onset, beginning periumbilical
then migrating to the suprapubic region. The pain did not radiate
but was associated with urinary frequency and dysuria. She notes
that her urinary symptoms were long standing and intermittent
but had increasingly gotten worse and associated with a progressive
protrusion on the abdomen. Her urinalysis was negative.Initial
examination revealed a well-hydrated patient with blood pressure
of 130/84 and pulse rate of 86 beats/min. Abdomen was non-tender,
the previous scar was noted with a protrusion at its center. Vaginal
examination revealed no cervical excitation tenderness or adnexal
fullness. Her laboratory results were all normal. She had a CT scan of
the abdomen that showed a midline incision hernia. The image shows
multiple hernia defects with the urinary bladder herniated into one of
the defect (Figure 1). There was no evidence of strangulation noted.
A clinical diagnosis of incisional hernia was made and referred
to surgical clinic. She was seen and assessed and asingle port
laparoscopic hernia repair was advised.She was taken to surgery and
had an uneventful postoperative recovery. The patient was discharged
in 1 day. The patient a full recovery with resolution of her symptoms
and no residual herniation.
Figure 1
Surgical Technique
Patient was placed in a supine position with arms placed to the
sides. The surgeon was on the patient’s left and the assistant to the
right of the patient. A television monitor and the insufflator system
Karl Storz HD were placed to the right hip of the patient. A 16 French
Foley’s catheter was inserted. A 2.0 cm vertical left flank incision
was made and directed down into the peritoneum. The peritoneal
cavity entered and an Applied Medical single port Gel Point platform
introduced. The GelPOINT™ advanced access platform enables a
single incision approach by facilitating triangulation of standard
instrumentation through a single incision.
Prior to insufflation, a 10/12 mm trocar and 2 mm × 5 mm trocars
were then inserted through the GelPOINT™ cap in a triangular fashion
and then engaged on the base. The platform was positioned to place
the 10/12 mm port at the 12 o’ clock with other ports at 5 o’ clock
and 7 o’clock respectively. We used a standard length 5 mm 30°
laparoscope placed in the 5 o’ clock position. A straight grasper was
used for lateral retraction at 7 o’ clock and 12 o’ clock was used as the
working port. After pneumoperitoneum established using 15 mmHg,
a Swiss cheese type incisional midline hernia was identified.
There was omentum and bowel herniated through some of the
defects. The urinary bladder was also noted to be herniated with
its margins ill-defined. With the use of LigaSure™ the bowel and
omentum were dissected out and reduced. Intermittent carbon
dioxide insufflations of the bladder was used to identify its margins
and subsequently dissected freed. There was also noted to be a
non-absorbable suture through the dome of the bladder from the
abdominal wall closure. After extensive adhesiolysis was preformed
and the margins of the hernia defect defined, a large 20 cm × 25
cm oval laparoscopic mesh was placed and tacked to the anterior
abdominal wall. The Gel Point was removed and patient sent to the
recovery room.
Discussion
Women who have undergone cesarean section and hysterectomy
are likely to have anterior wall adhesions [6]. This makes laparoscopy
difficult because the port-placement cannot be established properly
due to adhesions. Thus the single port approach with a flank incision
is ideal in these patients. The reported incidence of bladder injury
during laparoscopic incisional hernia repair is 2% [7]. With bladder
herniation present the incidence of iatrogenic injury is likely to be
higher. During repair, the fear is that the bladder may be damaged
during dissection. Previous caesarean surgery, multiple fibroids
and severe endometriosis are predisposing factors for urological
misadventures [7]. Cystosufflation is a novel technique that allows
the margins of the bladder to be identified decreasing injury during
laparoscopy. Injury can also be identified at the time of surgery.
Early bladder injury recognition does not increase post-operative
morbidity when repaired during the same laparoscopic procedure
[8]. Cystosufflation is well tolerated by patients and can reliably
prevent iatrogenic cystotomy [5].
Anterior wall adhesions should be anticipated in patients who have
undergone cesarean section if the uterine cervix is found be located
much superior to its normal location during pelvic examination
[5]. This finding presumably holds true for patients with cervical
preserving hysterectomy. Generallaparoscopic principle dictate, the
umbilical trocar is inserted first to establish pneumoperitoneum.
This is made difficult because midline adhesions commonly occur
in women post obstetric and gynecological procedures. Laparoscopy
in such women is safer and more effective when pneumoperitoneum
is established with first trocar in the upper left quadrant/flank
considered virgin territory. Our technique describes using a single
left flank incision, which places port platform in a safe zone. Ancillary
trocars are eliminated. Sufficient adhesiolysis can be performed to
secure adequate visual field for safe mesh placement. Mesh placement
during repair may be difficult when the fascial defect extends towards
the pubis [3]. Cystosufflation is used to carefully divide the adhesions
between the bladder and anterior wall which dissectionaccomplished
using laparoscopic scissors with monopolar coagulation.
Cystosufflation is accomplished by insertion a Foley’s catheter and
connecting it to standard Carbon Dioxide insufflator. No special
tubing is required. The bladder is repeatedly distended and deflated
in an effort to define its margins and allow proper visualization. If the
bladder fails to properly distend, then troubleshooting of the system
is done. Once the system is properly functioning; a bladder injury
suspected. Hematuria may also raise the suspicion of bladder injury.
We previously described this technique, where pneumoperitoneum
is created and adhesiolysis is performed from a lateral approach [10].
We believe there are multiple advantages of this surgical technique.
First, because initial entry is in the lateral aspect of the abdomen,
any damage to organs adhered to anterior wall can be avoided and
a pneumoperitoneum can be easily created. Anterior wall adherence
occurs between intra-abdominal structures (the urinary bladder in
this case) and peritoneum. The combination of the lateral approach
and cystosufflation decreases difficulty in locating bladder boundaries
covered by dense adhesions. The area can be dissected quickly and
safely, decreasing the risk for undesirable bleeding and perforation of
urinary bladder that could occur during adhesiolysis.
Bladder wall adhesion is an unavoidable side effect in patients
who have undergone cesarean section [11]. In our case the scenario
is compounded by hysterectomy and the fact bladder now herniates
through an incisional hernia. We also note the presence of a nonabsorbable
suture through the dome of the bladder than seemed to be
part of the fascial closure.
We therefore propose our approach when performing incisional
hernia repair in women who have undergone hysterectomy
previously. We hypothesize that bladder adhesionsare more severe
in patients who have undergone hysterectomy via midline incision
versus a pfannenstiel incision. It is still necessary to be as cautious
during adhesiolysis of the anterior wall adhesions in a patient with
a pfannenstiel incision. Nevertheless, if the boundary of the bladder
is obscure we recommend employing cystosufflation using carbon
dioxide to distend the bladder through a Foley catheter during the
laparoscopic procedure to check the border [5].
The factors to consider and be duplicated are techniques to create
pneumoperitoneum and adhesiolysis. It is vital to make first entry in
the left flank, not through the umbilicus, to make pneumoperitoneum.
Abdominal insufflation is more difficult using the conventional means
because of preexisting dense anterior wall adhesions. The distance
from the anterior abdominal wall adhesions to the laparoscope is also
important. If the telescope is placed via a traditional umbilical port
while performing adhesiolysis, organ structures may be too close to
peritoneum, which restricts the field of action, and prove too difficult
for adequate dissection. It is easier to perform adhesiolysis of the
anterior wall adhesions in the lateral flank. The single port platform
is inserted using an open technique, which is safer and avoids placing
an umbilical port and supplementary ports. It does not lead to major
changes in the surgical view and the skilled laparoscopic surgeon
easily corrects small discrepancies.
In conclusion, our lateral approach techniques creating a
pneumoperitoneum, combined with cystosufflation to dissect a plane
between the bladder/organ structures and dense adhesionsof the
anterior abdominal wall are effective especially in women who have
undergone gynecological procedures.
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