Deep endometriosis of the bowel poses unique management and operative challenges. We outline a technique of an anterior rectal resection using the intraluminal (circular) stapler.
We also review the components and use of the intraluminal stapler and discuss appropriate patient selection for this procedure.
University of Calgary
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Video Transcript: Approach to the Difficult Laparoscopic Hysterectomy Bladder Adhesions
This is a presentation of the University of Ottawa’s minimally invasive surgery programme. This is an educational video, in a series of videos, concerning the surgical approach to the difficult laparoscopic hysterectomy. In this video, we will overview our approach to difficult bladder adhesions.
Injuries to the bladder are among the most common type of injuries at laparoscopic hysterectomy, with an incidence of 0.4% to 1.3%. The increased risk of bladder injury is highlighted in a recent Cochrane review, demonstrating an increased risk of urinary tract injury of laparoscopic hysterectomy compared to the abdominal or vaginal approach. Despite these findings, good surgical technique and experience can reduce the risk of bladder injury.
We highlight six steps to managing the difficult bladder at a hysterectomy.
Step One: Anticipate Potential Difficulties Preoperatively
A careful history and preoperative evaluation can help prepare the surgeon for potential difficulties with bladder dissection. Previous cesarean section and other laparotomies are the two greatest risk factors for bladder injury. This 35-year-old patient is undergoing a total laparoscopic hysterectomy.
She has had multiple previous surgeries, including bilateral renal transplantation. This current surgery is complicated by severe endometriosis and findings of a tightly adherent bladder to the anterior aspect of the uterus.
Step Two: Develop The Paravesical Space
Key to the safe dissection of the difficult bladder is the development of the paravesical space. Knowledge of anatomy is important in this process. The paravesical space is bordered anteriorly by the pubic symphysis, mediately by the obliterated umbilical artery, laterally by the obturator internus muscle, and posteriorly by the cardinal ligament.
Safe dissection of the bladder begins with careful dissection of the paravesical space. Here, on the patient’s right side, the paravesical space is carefully being developed. Planes are avascular, and the majority of the dissection is carried out bluntly. Similar dissection and development of the paravesical space are carried out on the patient’s left-hand side.
Step Three: Dissect The Bladder Flap Lateral To Medial
This patient has had two previous cesarean sections and has symptoms of significant abdominal pain. The uterus is densely adherent to the anterior abdominal wall, and the location of the bladder is unclear. An attempt to dissect these dense adhesions directly would place this patient at increased risk of bladder injury.
Instead, we revert to our basic principle of developing the paravesical spaces bilaterally and dissecting the bladder in a lateral to medial direction. With careful lateral to medial dissection, the uterus is mobilized off of its dense attachments to the extra-abdominal wall, and the safety of the bladder is ensured. With the uterus freed, we ensure that the paravesical spaces have been well developed bilaterally. Once again, careful lateral or medial dissection of the remainder of the bladder flap is carried out.
Step Four: Optimize Visualization and Anatomic Relationships
Optimal visualization at laparoscopic hysterectomy requires the active participation of a vaginal assistant [unclear] the uterus, with special attention on pushing the uterus in a cephalic direction. In this manner, the bladder can be safely dissected, and a total laparoscopic hysterectomy can be carried out.
Step Five: Consider Alternative Management
This third patient, again, has dense bladder adhesions from multiple previous cesarean sections. The paravesical spaces are developed bilaterally, with proper lateral to medial dissection of the bladder. A vaginal assistant optimizes the anatomical relationship, pushing the uterus in a cephalic direction.
In cases where dense bladder adhesions persist, alternative options should be considered. These options include conversion to laparotomy, LAVH, or in this case, subtotal hysterectomy.
Step Six: Identify and Repair An Injury
A bladder injury at laparoscopy can easily be identified as CO2 gas flowing from the abdomen through the bladder and into a Foley bag. Other methods to identify injury include cystoscopy and retrograde filling of the bladder with methylene blue. If a bladder injury is recognized, it can be repaired immediately without an increase in patient morbidity.
To conclude, these six key steps can be carried out routinely at laparoscopic hysterectomy. With experience, these principles can allow the surgeon to proceed safely and confidently with difficult bladder adhesions.