1736 Novel Approach to Repair of Laparoscopic Cystotomy

Abstract

Video Objective This video aims to demonstrate an interesting incidental cystotomy created laparoscopically during a total hysterectomy, demonstrate best practices for repair techniques, and review relevant anatomy. Setting Our patient is a 47 year old G7P3223 with a prior surgical history of 4 cesarean sections, who presents for total laparoscopic hysterectomy and bilateral salpingectomy as definitive treatment for abnormal uterine bleeding (AUB) due to leiomyomas. The surgery takes place at a large tertiary medical center. During creation of the colpotomy, a through and through anterior cystotomy and a partial thickness posterior cystotomy is incidentally created. Illustrations of relevant anatomy demonstrate how the colpotomy is created and which areas of the bladder need to be repaired. Interventions The extent of the cystotomy is assessed by guiding the laparoscope into the bladder via the cystotomy. The ureteric orifices are found to be intact bilaterally. The repair is then performed laparoscopically. First, the partial thickness posterior cystotomy is repaired in two layers. The first layer is a running non-locking stitch that is started in an inside-to-out followed by an outside-to-in fashion, allowing the knot to be buried below the mucosa. The second layer is an imbricating baseball stitch burying the mucosal layers. Next, the anterior full thickness cystotomy is repaired in two running non-locking layers burying all knots outside the bladder to prevent a nidus for stone formation and other complications. The bladder is backfilled to assure a water tight seal and the hysterectomy is continued. Conclusion Our video demonstrates an interesting cystotomy that involves both the anterior and posterior walls of the bladder and evaluation of the trigone from the abdominal side. It summarizes and illustrates best practices for bladder injury repair laparoscopically and relevant anatomy. Finally, it reviews necessary intraoperative care after repair, including retrograde filling of the bladder and cystoscopy, and postoperative care.