Laparoscopic excision of infected urachal cyst: Illustration of technique

Abstract

The urachus is a fibrous cord structure connecting the urinary bladder dome and the umbilicus.1 Persistent urachal anomalies are rare conditions which commonly present as infection. Conventional treatment is excision of the umbilicus together with the entire tract with or without a cuff of the urinary bladder.2–3 Complete excision will result in a large laparotomy wound and related short-term disadvantage. With the advance of the laparoscopic technique, more and more patients have undergone laparoscopic excisions.4–6 We herein report a case and illustrate the laparoscopic technique in the accompanying video. A 22-year-old man presented to us with a 3-day history of umbilical pain and fever and was not responding to antibiotic treatment prescribed by a private doctor. On physical examination, his umbilicus was inflamed with some pus-like discharge. Contrast computed tomography (CT) scan was carried out and findings were suggestive of infected urachus. Laparoscopic excision of the infected urachus was suggested to the patient and he agreed to the operation. The operation was carried out under general anaesthesia and the patient was placed in the supine position. A urinary catheter was inserted. One 10–11-mm camera port was inserted in the right side of the patient's abdomen at the level of the umbilicus by an open technique. Two 5-mm working ports were then inserted under laparoscopic guidance. All ports were placed at the right side of the abdomen. Thirty-degree laparoscopy was used so that it gave a clear view of the posterior surface of the anterior abdominal wall. An ultrasonic dissector was used to dissect the peritoneum around the infected urachal cyst. Further dissection was carried out along the preperitoneal plane so that the entire median umbilical ligament was dissected out. We traced down along the tract until the dome of the urinary bladder was reached. The urinary bladder was then distended with 300-mL methylene blue solution. Double clipping of the tract was applied just proximal to the dome of the urinary bladder. The whole tract was fully mobilized up to the umbilical attachment. Trans-umbilical elliptical skin incision was carried out and the tract separated from the umbilicus. The entire tract was then retrieved through the umbilical wound with a specimen bag. The umbilical fascia was closed with interrupted PDS-1 sutures and the umbilicus was reconstructed with interrupted 3-0 nylon. Other port sites and skin wounds were closed with subcuticular sutures. The patient recovered well and was discharged the next day after operation. Additional video images may be found in the online version of this article. Visit http://cshk.org/surgical_practice/multi-media_article/May_2010_issue_MM4_video.htm Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author of the article.