Extraperitoneal cystotomy after laparoscopy. A case report

Area of Science:

• Urology
• Minimally Invasive Surgery
• Gynecologic Surgery

Background:

• Laparoscopic surgery presents unique risks, including potential bladder injury during difficult entry and dissection.
• Preperitoneal dissection in laparoscopic procedures requires a high index of suspicion for bladder wall disruption.
• Standard diagnostic methods may fail to detect extraperitoneal bladder injuries during laparoscopic surgery.

Observation:

• A 136-kg patient undergoing laparoscopically assisted vaginal hysterectomy experienced difficult entry due to abdominal wall distortion.
• Extraperitoneal dissection was necessary, and gross hematuria was noted post-procedure.
• Methylene blue instillation did not reveal transvaginal or intraperitoneal leakage, indicating an extraperitoneal injury.

Findings:

• An anterior cystotomy (bladder injury) was identified via extraperitoneal laparoscopic inspection.
• The bladder injury was successfully repaired endoscopically.
• This case highlights the limitations of conventional diagnostic techniques for extraperitoneal bladder injuries.

Implications:

• Inadvertent bladder injuries during laparoscopic surgery, especially with difficult entry, pose significant risks.
• Extraperitoneal bladder injuries may not be detected by standard diagnostic maneuvers.
• Laparoscopic repair of bladder injuries is a viable and effective option in select cases.
• Understanding potential mechanisms for vesicoabdominal trocar fistulas is important for surgical safety.