2019 Volume 35 Issue 2 Pages 262-269
Damages in the urinary system are complications to be avoided in total laparoscopic hysterectomy (TLH). In this case reported at this time, we were not aware of bladder injuries in the operative field but were able to recognize the damages with expansion of a closed urinary drainage bag. She was 48 years old with four pregnancies and two childbirths, and had a past health history of Caesarean section by longitudinal incision in the lower abdomen at ages 18 and 26, abdominal myomectomy at age 19, and surgery to remove the remaining gauze at the time of myomectomy. She visited the clinic with a menorrhagia, abnormal vaginal bleeding, and difficulty in urination as main complaints resulting in TLH with the diagnosis of multiple uterine myoma. Intraoperative findings presented omental adhesion to the abdominal wall in a wide range, and the anterior wall of the uterus strongly adhered to the abdominal wall as well. As a result, the bladder was sandwiched between the abdominal wall and uterine cervix, and the posterior wall of the bladder was further presenting adhesion to the anterior vessels of the right parametrium. Sudden expansion of the closed urinary drainage bag was pointed out by the anesthesiologist while the bladder adhesion was detached. When the detached surface of the bladder was confirmed, a small 8mm tear was discovered and repaired with a double-layer closure. While confirming the mucosal surface with cystoscopy, routine TLH continued to be performed. Cystography was performed on the eighth day after surgery, and no leak to the abdominal cavity was confirmed and she was released from the hospital.
Bladder injuries are diagnosed with severe urinary hemorrhage and urine leakage to the abdominal cavity, while intraoperative cystoscopy is also considered as effective for diagnosis. However, intraoperative diagnosis is difficult if the damaged site is very small and delayed injuries due to heat damage may occur; therefore it is impossible to understand all bladder injuries with intraoperative cystoscopy. Under such limited circumstances, bladder injuries were successfully recognized with expansion of the closed urinary drainage bag in our case. For this reason, paying attention to expansion of the closed urinary drainage bag during surgery is considered as a simple and effective tool not to overlook bladder injuries. We hope to be able to catch complications in the future, while considering to temporarily increase the abdominal air pressure after detachment of bladder adhesion in the case of TLH to determine whether or not expansion of the closed urinary drainage bag can be a method to confirm bladder injuries.
