Incidental Cystotomy and Proctotomy Case File

Incidental Cystotomy and Proctotomy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 31

A 43-year-old African American woman presents with a history of anemia from heavy menstrual bleeding not responsive to hormone therapy. She had a bilateral tubal ligation (BTL) at the time of her second cesarean section. She is not interested in any therapeutic procedure that cannot guarantee

her that she will not bleed again in the future. She is otherwise in good health. On physical examination, she has a uterus that is at the upper limits of normal size, and some leiomyomata are palpable on examination. The estimated weight of the uterus is 250 g. Ultrasound of the uterus shows slight enlargement, and some leiomyomata, the largest of which is 2 to 3 cm in size. The patient opts for vaginal hysterectomy, and the chief resident is assigned to the case. After making a 180-degree incision around the anterior portion of the cervix, the resident encounters a fibroid and has some difficulty gaining access to the peritoneal cavity anteriorly, and clear, slightly yellow liquid exits the operative site. The fluid is slightly blood tinged. The resident quickly extends the incision around the posterior aspect of the cervix, and tries to force the duckbill retractor into the posterior cul-de-sac. A watery, foul-smelling, brown substance coming from the region of the posterior cul-de-sac is encountered.

➤ What are the most likely diagnoses?

➤ How would you confirm the diagnoses?

➤ What is the best therapy?

ANSWERS TO CASE 31:

Incidental Cystotomy and Proctotomy

Summary: A 43-year-old woman with two prior cesareans and small fibroids presents for vaginal hysterectomy. While making the incision around the cervix, the surgeon encounters a yellow liquid anteriorly and a watery, brown substance coming from the posterior cul-de-sac.

➤ Most likely diagnoses: Incidental cystotomy and incidental proctotomy.

➤ Confirmation of diagnoses: Instill sterile milk into the bladder and see if it exits the wound anteriorly; place a gloved finger in the rectum and see if the finger is visible through the proctotomy site.

➤ Best therapy: Immediate operative repair of both the injury to the bladder and to the rectum.

ANALYSIS

Objectives

1. Know the approximate potential rates of bladder and bowel injury.
2. Consider what can be done at the time of vaginal hysterectomy to diminish the potential for injury to the bowel and bladder.
3. Become familiar with the most common type of injuries to occur when performing a vaginal hysterectomy.
4. Learn how to repair injuries to the bladder and rectum that may occur during the course of vaginal hysterectomy.

Considerations

This 43-year-old woman had both incidental cystotomy and proctotomy. Prompt identification of the injuries is important with repair. The bladder injury should be delineated and it should be assured that the laceration is sufficiently far from the ureteral orifices. An injury too close to the ureters can

lead to stricture and obstruction. Laceration to the rectum likewise must be recognized. Typically, the rectum will be injured below the peritoneal reflection and can be repaired with a double layer closure. The exception is for a significant amount of devitalized tissue, cancer, or prior irradiated tissue.

Fortunately, injury to the bladder and to the bowel is relatively uncommon in vaginal hysterectomy. Injury to the ureter is distinctly rare in vaginal hysterectomy and will not be discussed further. While some studies fail to distinguish a significant difference in complication rates attributable to the route of hysterectomy, most studies indicate that the incidence of any injury with vaginal hysterectomy (VH) is less than that with either total abdominal hysterectomy (TAH) or with laparoscopically assisted vaginal hysterectomy (LAVH). Difficulty in performing a VH is more likely to result in injury to either the bladder or the bowel. Careful case selection is helpful in avoiding the vaginal route if the risk of potential complication is felt to be unacceptably high. The experience of the operating gynecologist is a major determinant in deciding whether to attempt a challenging vaginal case. While the percentages of hysterectomy done worldwide via the vaginal route are felt by most authorities to be too low, it is better to err on the side of caution and avoid the vaginal route if the risk of injury is deemed to be unacceptably high, or refer the patient to a more experienced gynecologic surgeon if the reasons for taking the vaginal route are compelling.

In the case cited above, the history of cesarean sections increases the risk for bladder injury, and, if the uterine fibroids are occluding the posterior culde- sac, rectal injury is a distinct possibility.

The potential for rectal injury is also increased by adhesions resultant of endometriosis, history of pelvic inflammatory disease, prior pelvic surgery, or any other process, which may compromise or obliterate the posterior cul-de-sac.

APPROACH TO

Bladder and Bowel Injuries

DEFINITIONS

CYSTOTOMY: Surgical entry into the bladder.

PROCTOTOMY: Surgical entry into the rectum.

CLINICAL APPROACH TO BLADDER INJURY

The best solution regarding injuries to the bowel and bladder is to avoid them in the first place. Hemostasis and some hydrodissection are extremely beneficial in gaining access to both the anterior and posterior cul-de-sacs. The scalpel incision on the anterior cervix should be about 2.0 to 2.5 cm above the plane of the exocervix, and perpendicular to the long axis of the cervix. The incision is extended into a level of cervical tissue that permits easy index finger dissection of the outer layers of the uterine tissue upward in a cephalic direction. Dissection laterally on both sides of the anterior aspect of the cervix facilitates placement of a small Deaver type of retractor in the midline, which retracts the cut tissue cephalad. Placing the tip of the Metzenbaum scissors firmly into the tissue and opening both blades of the scissors laterally will usually expose the anterior peritoneal fold. The index finger of the nonscissor operating hand feels the distinctly “slippery” consistency of the anterior peritoneal fold as it slides back and forth between the surgeon’s index finger and the underlying firm tissue of the anterior cervico-uterine junction. This peritoneal fold is distinctly visible at this point and should be grasped with tissue forceps, lifted slightly ventrally, and then incised sharply with Metzenbaum scissors in a line directly parallel to the long axis of the cervix. This should gain direct access into the anterior cul-de-sac, and a Heaney retractor should be placed into this opening. Clearly visible contents of the abdominal cavity and the lack of visible urine confirm entry into the correct plane.

A review of the literature reveals multiple rates of bladder injury in the performance of VH. The bladder is most likely injured when the surgeon is attempting to gain entry into the anterior cul-de-sac. The other potential for bladder injury happens as part of anterior vaginal wall repair with placement

of a suture into the bladder as part of a plication stitch. This is best avoided by keeping the stitch lateral enough to avoid the bladder and by being alert for blood in the urine immediately following placement of these stitches. Bladder injury rates range from 0.2 to 10 per 1000 surgeries.1 A history of prior cesarean increases the odds ratio for bladder injury to 2.04 (95% CI: 1.01-4.1, P = 0.46) for all types of hysterectomies.2 Other historical events which have been shown to increase the risk for bladder injury include prior pelvic surgery, and obesity is shown to be problematic in some series but not

in others. Nulliparity and nondescent of the uterus increase the potential for bladder injury, but neither of these are absolute contraindications to the vaginal route. Concurrent surgery for incontinence increases the risk for bladder injury, increasing from 3.1% in VH cases without repair to 12.5% where repair was performed. Cystoscopy can also occur during cesarean (Figures 31–1 and 31–2).

Women who sustain injuries to the bladder experience longer operating times, greater blood loss, longer hospital stays, greater postoperative morbidity, more febrile morbidity, and longer use of catheter drainage of the bladder. The vast majority of bladder injuries sustained at VH can be managed vaginally without resorting to laparotomy.

The technique of repair of the bladder injury involves placing two or three layers of absorbable suture, size 3-0, initially using the mucosal layer for approximation and hemostasis, and then a horizontal mattress layer to provide strength and to imbricate the mucosal layer closure. A third layer of interrupted mattress sutures may be indicated in especially large injuries, burying the initial submucosal muscular layer. The integrity of the closure should be tested by filling the bladder with milk via a catheter at the conclusion of the repair, and the catheter needs to remain in place for 5 to 7 days postoperatively, with appropriate antibiotic coverage to avoid urinary tract infection from the indwelling catheter.

Vesicovaginal fistula is a potential complication following cystotomy, but the likelihood of that happening is only in the range of 10%. The risk is significantly higher in those cases in which the bladder injury is not recognized

Figure 31–1. Bladder is repaired in two layers. First layer is mucosa. (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics, 23rd ed.New York:McGraw-Hill, 2010.)

at the time of the initial surgical procedure. A recent study using diagnostic cystourethroscopy after all TAH, VH, and LAVH cases in the series determined that only 35.3% of bladder injuries were detected prior to cystoscopy, and the authors suggest that the routine use of cystoscopy should be considered at the conclusion of all types of hysterectomy.3 “Cystoscopy should be performed intraoperatively to assess for bladder or ureteral damage after all prolapse or incontinence procedures during which the bladder or ureters may be at risk of injury.”4

Figure 31–2. Bladder is repaired with second layer. (Reproduced, with permission, from Cunningham FG, Leveno KJ,Bloom SL,et al. Williams Obstetrics, 23rd ed.New York: McGraw-Hill, 2010.)

CLINICAL APPROACH TO BOWEL INJURY

Many of the principles that apply to avoiding bladder injury also apply to prevention of injury to the rectum. Hemostasis and hydrodissection beneficially provide visibility for entry into the posterior cul-de-sac. However, in contrast to entry into the anterior cul-de-sac, lateral dissection is not helpful when entering the posterior cul-de-sac. Tissue forceps grasp the uterine border of the incised vaginal mucosa in the midline and pull it away from the cervico-uterine junction at a 90-degree angle, making a “tent” in the mucosa and underlying peritoneum. Mayo scissors are placed directly on top of the tissue forceps, at about a 45-degree angle, and an incision is made directly into the “tent” created by the tissue forceps. If the initial incision does not provide entry into the peritoneal cavity, pick up the tissue deeper again in the site of the initial incision and repeat the incision in the same tissue plane. Using the scissor tips to “open and spread” the tissue is not helpful in gaining entry posteriorly. If unable to gain entry at this point, stay close to the uterus and continue dissection posteriorly toward the top of the uterine fundus until entry can be gained into the cul-de-sac. It is better to make incisions into the posterior uterus than into the bowel.

If bowel injury is suspected, place a gloved finger into the rectum and see if rectal injury can be confirmed. If there is bowel injury, obtain visualization with enough dissection to see the extent of the injury and then approximate the mucosa with a running stitch of 3-0 absorbable suture. The muscularis is closed with interrupted inverting mattress sutures of 3-0 absorbable suture.

Bowel injuries are less common than bladder injuries. Large series reported an incidence of bowel injury with vaginal hysterectomy of 0.5%, with almost all occurring at the point of entry into the posterior cul-de-sac.1 Rectovaginal fistula is a rare complication of this injury, as most are detected and repaired immediately and successfully. After the patient sustains a bowel injury, she should be kept on a liquid diet until bowel function returns and then on a lowresidue diet for the following week. Judicious use of stool softeners and laxatives is indicated until recovery is complete.

CONCLUSION

Blanket recommendations regarding when or if to call a consultant urologist for bladder injury or a surgeon for bowel injury are challenging and obviously depend on the extent of the injury and the experience of the operating gynecologist. If the injury appears straightforward, the repair goes smoothly, and if the bladder or the bowel appears intact following repair, then consultation may not be required. If the limits of the injury are not easily delineated, the integrity of the repair cannot be confirmed, or if the degree of confidence in the result is less than satisfactory, then ask for help. Patients with chronic diseases of the urinary tract or of the intestinal tract which would predispose such a patient to a complicated recovery even without unintentional injury should definitely be evaluated intraoperatively by urology or surgery as needed. Community practice and standards of course also play an important role.

Comprehension Questions

31.1 Which of the following surgical approaches for hysterectomy is associated with the overall lowest incidence of bladder injury?

A. Abdominal hysterectomy

B. Laparoscopic hysterectomy

C. Vaginal hysterectomy

31.2 If incidental cystotomy is noted at the time of vaginal hysterectomy, which of the following should be the approach?

A. The location of the injury should be ascertained regarding the distance from the ureteral orifices.

B. The vaginal approach should be abandoned, and the case converted to an abdominal procedure.

C. The patient should undergo an intravenous pyelogram to assess the renal function.

D. A suprapubic catheter should be placed in the bladder.

ANSWERS

31.1 C. Vaginal hysterectomy results in the lowest incidence of bladder injury compared to all other surgical approaches.

31.2 A. Upon recognition of a bladder injury, its extent and location, especially with respect to the ureteral orifices, should be established. This assessment will indicate whether the bladder can be closed with a simple two layer closure or will require possible ureteral surgery and/or stents.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Early detection, preferably intraoperatively,of injury to the bowel or bladder will allow for immediate repair and greatly reduce the risk of significant harm to the patient, and to the reputation of the surgeon (Level B).

➤ Infiltration of the cervix with a mixture of 1% lidocaine and 1:100,000 epinephrine or 0.5% lidocaine and 1:200,000 epinephrine prior to the circumferential incision around the cervix will provide excellent hemostasis and allow for better visualization of anatomic landmarks and the potential to avoid injury (Level B).

➤ Using the more dilute solution will allow for instillation of a greater volume of fluid, and the principle of hydrodissection may create easier planes for entry into the anterior and posterior cul-de-sacs (Level C).

➤ The use of sterile milk to see the injury to the bladder may be preferable to the use of indigo carmine or methylene blue dyes, as both dyes tend to stain the tissue and may make visualization of the tissue to be repaired more difficult (Level B).

➤ When repairing injuries to the bladder, sutures should be tied such that the knot is outside of the bladder mucosa to avoid the potential for the knotted suture to cause bladder stones (Level C).

➤ When repairing rectal injuries, tie the suture such that the knot is inside of the rectal lumen, allowing the suture to slough into the bowel when healing is complete and the suture dissolves (Level B).

➤ If your surgical procedure results in an injury to the bowel or bladder, do not describe this as “inadvertent” in your written or dictated operative report. Synonyms for “inadvertent” include “careless” and “inattentive.” Do not put yourself in the position of having to explain this wording in a deposition or trial for medical malpractice (Level C).

REFERENCES

1. Mathevet P, Valencia P, Cousin C, Meiller G, Dargent D. Operative injuries during vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2001;97:71-75. 

2. David-Montefiore E, Rouzier R, Chapron C. Surgical routes and complications of hysterectomy for benign disorders: a prospective observational study in French university hospitals. Hum Reprod. 2007;22:260-265. 

3. Vakili B, Chesson R, Kyle B, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol. 2005;192:1599-1604. 

4. American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin No. 85. Obstet Gynecol. 2007;110:717-730. 

5. Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol. 1998;92:113-118. 

6. Rooney C, Crawford A, Vassallo B, Kleeman S, Karram M. Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? Am J Obstet Gynecol. 2005;193:2041-2044. 

7. Carley M, McIntire D, Carley J, Schaffer J. Incidence, risk factors, and morbidity of unintended bladder or ureter injury during hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13:18-21. 

8. Dorairajan G, Rani P, Habeebullah S, Dorairajan L. Urological injuries during hysterectomies: a 6-year review. J Obstet Gynaecol Res. 2004;30:430-435. www.BookOfLinks.

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