7783 Approach to a Difficult Bladder Flap during Laparoscopic Hysterectomy

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<h3>Study Objective</h3> Present a systematic approach to dissecting a difficult bladder flap during a laparoscopic hysterectomy. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Cesarean section is the most commonly performed operating room procedure in the United States. Previous cesarean section significantly increases the risk of bladder and urinary tract injuries during laparoscopic hysterectomy. Long-term complications associated with bladder injury include bladder and ureteral fistulae, renal failure, infection, and death. <h3>Patients or Participants</h3> Patients with previous cesarean sections undergoing laparoscopic hysterectomy. <h3>Interventions</h3> The key principles for safe and effective dissection of a difficult bladder flap during a laparoscopic hysterectomy include: • Use of gentle interrogative blunt dissection to identify the endopelvic fascia and creation of a tunnel inferior to the adhesions and posterior to the bladder using the low and lateral approach • Ligation of the uterine blood supply prior to addressing the difficult bladder flap • Backfilling the bladder to delineate its borders • Managing any bleeding early to prevent tissue staining • Once the uterine blood supplies are controlled, serially thinning and separating the bladder flap adhesions close to the uterine serosa and mobilize the bladder below the colpotomy cup <h3>Measurements and Main Results</h3> The patients recovered well without any postoperative complications. <h3>Conclusion</h3> C-sections can produce significant midline scarring which increases the risk of bladder injury during laparoscopic hysterectomy. Techniques to address a difficult bladder flap during laparoscopic hysterectomy include gentle interrogative blunt dissection and a low and lateral approach, backfilling the bladder, and using sharp dissection to serially thin and separate adhesions close to the uterine serosa.