Bladder Adhesions Research Articles

Paramedian access to the pelvis as a strategy in patients with bladder adhesions to the abdominal wall.

Paramedian access to the pelvis as a strategy in patients with bladder adhesions to the abdominal wall.

BLADDER INFLATION PRIOR TO CESAREAN SECTION CAN PREVENT BLADDER INJURY IN HIGH RISK PATIENTS

This study aimed to evaluate the effectiveness of inflating the urinary bladder immediately before cesarean section (CS) in reducing the chances of bladder injury in high-risk patients. This was a prospective randomized controlled trial. The study was conducted in Obstetrics and Gynecology Ward 8, Jinnah Postgraduate Medical Centre (JPMC) Karachi, from April 06, 2021 to September 30, 2021. Three hundred twenty-eight pregnant women who delivered by cesarean section and had one or more risk factors for urinary tract injury were recruited. The women were divided into two groups: Group A underwent bladder inflation using a triple-way Foley catheter before CS, while Group B served as the control group without bladder inflation with a Foley catheter before CS. In this study, urinary bladder injury was found in 5.5% of women in Group A who had bladder inflation, while 12.2% of women in Group B without bladder inflation had bladder injury. The efficacy in Group A and B was 94.5% and 87.8%, respectively. The results showed a significant association between the study group and urinary bladder injury (p=0.032). The study significantly reduced urinary bladder injuries, surgery time, blood transfusion, and hospitalization. Inflating the urinary bladder before cesarean section should be used to prevent bladder injury in women with risk factors for dense bladder adhesion.

Laparoscopic Wedge Resection of a Cesarean Scar Ectopic Pregnancy at Nine Weeks Gestation

<h3>Study Objective</h3> To demonstrate an approach to laparoscopic wedge resection of a cesarean scar pregnancy (CSP). <h3>Design</h3> Video abstract. <h3>Setting</h3> Tertiary care Centre. <h3>Patients or Participants</h3> This case is of a 40-year-old G6P3, with 3 prior cesarean sections who was referred with a possible ectopic pregnancy at 8+3 weeks gestation after presenting with cramping and irregular bleeding. Following admission to hospital, transvaginal ultrasound revealed a CSP and a type 1 placenta percreta with no bladder involvement. The patient wished for fertility-sparing management which was planned to include pre-operative intragestational methotrexate and uterine artery embolization followed by laparoscopic wedge resection. Before pre-operative interventions could be done, the patient experienced acute vaginal bleeding and she was taken urgently for surgical management. <h3>Interventions</h3> Laparoscopic wedge resection of the CSP. <h3>Measurements and Main Results</h3> Laparoscopy revealed bladder adhesions high over the lower uterine segment and the CSP. Wedge resection of the CSP was successfully achieved with restoration of normal anatomy using a systematic approach to lysis of adhesions as well as intraoperative vascular control using dilute vasopressin and pre-emptive skeletonization of the uterine vessels. Surgical blood loss was 100mL. There were no intraoperative or postoperative complications, and the patient was discharged home post-operative day 1. The patient's beta HCG levels returned to normal within one month. <h3>Conclusion</h3> CSPs account for approximately 4% of all ectopic pregnancies. Management is individualized and often requires a multi-modal approach. This case demonstrates a safe and successful approach to fertility-sparing laparoscopic wedge resection.

Dissection Techniques for Dense Adhesions between Uterus, Bladder, and Anterior Abdominal Wall

<h3>Study Objective</h3> The objective of the video is to serve as a teaching tool in order to demonstrate surgical techniques to aid in adhesiolysis of dense adhesions between the uterus, bladder, and anterior abdominal wall. <h3>Design</h3> This video first outlines the medical and surgical history relevant for the patient. The surgical techniques used in the video are then listed prior to the narrated video of the adhesiolysis. <h3>Setting</h3> The surgical video was recorded during a robotic assisted laparoscopic total hysterectomy, bilateral salpingectomy, and cystoscopy. <h3>Patients or Participants</h3> The video includes one patient. The primary surgeon is a minimally invasive gynecologic surgeon. A minimally invasive gynecologic surgery fellow assisted with this surgery as well as a urologist. <h3>Interventions</h3> A robotic assisted laparoscopic total hysterectomy, bilateral salpingectomy, and cystoscopy was performed during the surgery. <h3>Measurements and Main Results</h3> Adhesiolysis was safely performed. A cystoscopy at the end of the procedure demonstrated no injury to the bladder as well as bilateral jets. The patient recovered well postoperatively with no complications. <h3>Conclusion</h3> This video demonstrates surgical techniques for management of dense bladder adhesions which can be used in a wide variety of surgical scenarios.

Total hysterectomy with lysis of omental and bladder adhesions via VNOTES technique

Total hysterectomy with lysis of omental and bladder adhesions via VNOTES technique

Sophisticated Dissection without Monopolar Scissors

<h3>Study Objective</h3> To demonstrate how the bipolar method allows for pinpoint dissection with minimal thermal spread in a variety of challenging operative scenarios in gynecology. <h3>Design</h3> Case presentations. <h3>Setting</h3> Urban general hospital in Japan. <h3>Patients or Participants</h3> From December 2018 to April 2021, we performed 485 robotic surgeries using the double bipolar method in a variety of procedures such as hysterectomy for benign pathology, robotic sacro-colpopexy and para-aortic and pelvic lymphadenectomy for cervical and endometrial cancer. <h3>Interventions</h3> Pinpoint dissection in the case of severe Douglas Pouch adhesion or bladder adhesion, transperitoneal lymphadenectomy and extraperitoneal para-aortic and pelvic lymphadenectomy and nerve-sparing radical trachelectomy is a great advantage. These challenging procedures require the elucidation of fine structures and well as accurate separation of adhered organs. The double bipolar method is accurate, powerful and efficient with minimal thermal spread. <h3>Measurements and Main Results</h3> Only one patient who had extensive adhesion due to previous surgery required surgery from postoperative peritonitis. All other patients recovered quickly and without complications. <h3>Conclusion</h3> Monopolar scissors are a standard robotic equipment, used by the majority of surgeons. Although monopolar scissors allow for good quality dissection, thermal spread is always a concern. The thermal spread is known to be source of intraoperative complications and reducing this problem is an important concern. As a result, we implemented the double bipolar method. Not only because of its pinpoint accuracy, but also because the cutting mechanism has minimal thermal spread which is desirable especially when dissection ultra-fine structures.

Minimally Invasive Approach to Pelvic Arteriovenous Malformation (AVM) Refractory to Embolization

Study Objective To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Design Case report. Setting Single center academic institution. Patients or Participants A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Interventions Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Measurements and Main Results Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. Conclusion In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization. To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Case report. Single center academic institution. A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization.

VNOTES Lateral Window Approach to Hysterectomy in a Case with Previous History of Multiple Surgeries Resulting in Keloid Scars and Enlarged Uterus with Dense Bladder Adhesions

To demonstrate transvaginal natural orifice transluminal endoscopic surgery (vNOTES) lateral window approach to hysterectomy in a case with a history of multiple surgeries resulting in keloid scars and enlarged uterus with dense bladder adhesions. Stepwise demonstration of the technique with narrated video. A minimally invasive gynecologic surgery department of tertiary care private hospital. A 43-year-old female presented with menorrhagia and dysmenorrhea in the last 8 months. She had a history of undergoing cesarean section twice and an open appendectomy. These surgeries had resulted in keloid scar formation. She was very anxious about keloid formation and desired to avoid abdominal scars. Examination and transvaginal ultrasound revealed enlarged uterus with multiple fibroids. The largest intramural fibroid measured 11×9.4 cm. vNOTES hysterectomy with the following key strategies was performed: (1) anterior colpotomy with bilateral lateral window dissection, (2) posterior colpotomy with opening of posterior peritoneal pouch, (3) application of wound retractor and vNOTES glove port, (4) continued dissection of lateral window aiding to the completion of hysterectomy, (5) uterine rotation maneuver aiding to bladder adhesiolysis, and (6) transvaginal retrieval of specimen and closure of colpotomy. vNOTES is a feasible method of approaching lateral window dissection in scarred uteri. It allows safe dissection and bladder adhesiolysis. It allows excellent visualization of all pedicles and safe hysterectomy for large uteri. Hysterectomy for adherent uteri can be performed by vNOTES.

56 Aborted laparoscopic cerclage due to adhesive disease after recent cesarean section

The primary goal is to demonstrate the difference in tissue healing and adhesion formation over weeks to months after a laparotomy and to understand its impact on the feasibility of surgery. Our video is a case study of a patient's elective laparoscopic surgeries following a classical cesarean delivery. The patient, a 32-year-old G4P0130, was referred to MIS faculty by MFM for placement of a laparoscopic cerclage after classical cesarean section at 23 weeks due to cervical insufficiency. The video clips were taken in the operating room during planned procedures: laparoscopic cerclage placement at 7 weeks and 7 months following classical cesarean section. Laparoscopic cerclage was initially attempted at 7 weeks postoperative from classical cesarean section but was aborted due to dense, edematous pelvic adhesions and extreme tissue friability with ultimate concern for creating a cystotomy if the surgery had been completed. Laparoscopic cerclage was then planned for 7 months postoperative from classical cesarean section. The adhesive disease during the laparoscopic cerclage placement at 7 months postoperative from classical cesarean section was significantly improved. Findings were notable for resolved prior bowel adhesions and a well-healed classical cesarean hysterotomy defect. There were minor bladder adhesions to the uterus that were safely dissected using the Harmonic scalpel, and the laparoscopic cerclage was able to be placed in standard fashion in an overall uncomplicated procedure. Although more research is needed to study the ideal time for reoperation in setting of elective surgery after a laparotomy, our case study demonstrates the significant difference in tissue adhesions and feasibility of surgery when performing an elective surgery after a longer time interval.

Urinary bladder injury during cesarean delivery: risk factors and the role of retrograde bladder filling.

Urinary bladder injury during cesarean delivery is an uncommon complication with substantial maternal morbidity. The aim of this study was to identify possible risk factors for bladder injury during cesarean delivery and to describe the role of retrograde bladder filling in the assessment of bladder wall integrity. A retrospective cohort study at a large tertiary referral center. Women who underwent cesarean delivery between 2003 and 2017 were included. Women diagnosed with urinary bladder injury were compared to women who did not have such injuries. Data retrieved included demographic characteristics, general medical history, obstetric history and intra-partum and intra-operative data. Information regarding use of retrograde bladder filling intra-operatively was retrieved as well. During the study period, 21,177 cesarean deliveries were performed of which 68 (0.3%) cases of urinary bladder injury were identified. Two-thirds of injuries were located at the urinary bladder dome with the remaining third located at the posterior bladder wall. Most injuries were formed during uterine incision extension (60.0%) followed by peritoneal entry (22.0%). Following uni- and multivariate analyses, three parameters remained independent risk factors for bladder injury: urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of the uterine incision extension. In 15.4% of cases in which retrograde bladder filling was utilized following bladder repair, leakage of fluid was evident. Urinary bladder adhesions, failed vacuum attempt prior to cesarean delivery and size of uterine incision extension are independent risk factors for urinary bladder injury during cesarean delivery.

Cesarean scar perforation in laparoscopic hysterectomy for endometrial cancer: a case report

Perioperative complications tend to increase when performing hysterectomy in patients with a history of caesarean section. Therefore, the laparoscopic hysterectomy procedure requires careful consideration. Herein, we report the case of a patient with a history of caesarean section who underwent total laparoscopic hysterectomy for endometrial cancer. A 59-year-old woman was diagnosed with stage IA endometrial cancer preoperatively, and she underwent laparoscopic hysterectomy, bilateral adnexectomy, and pelvic lymphadenectomy. During these procedures, the bladder was observed to tightly adhere to the scar of a previous caesarean section, and the uterine was perforated due to detachment near the uterus to avoid damage to the bladder. After 2 years, there were no symptoms of recurrence. Our findings further demonstrated that bladder adhesions should be considered in laparoscopic surgery for patients with endometrial cancer who have a history of caesarean section.

Approach to Difficult Bladder Dissection during Laparoscopic Hysterectomy

Study Objective This video describes and demonstrates various techniques for approaching difficult bladder dissection during laparoscopic hysterectomy. Design N/A Setting The techniques and surgeries demonstrated in this video were performed on patients undergoing laparoscopic hysterectomy in an academic tertiary care center. The patients had surgical histories predisposing them to difficult bladder dissection at the time of laparoscopic hysterectomy. These techniques can be used individually or in combination with each other in order to ensure successful bladder dissection. Patients or Participants N/A Interventions Four techniques for successful bladder dissection are reviewed in this video. The first technique involves backfilling the bladder with lactated ringers in order to help delineate the boundaries of the bladder and avoid inadvertent injury. A second technique involves first approaching the bladder laterally in order to find a surgical plane for adhesiolysis, followed by further dissection cephalad towards the dome of the bladder. Lateralization of the uterine arteries prior to bladder dissection is described in the third technique. Finally, the last technique involves first creating posterior colpotomy and carrying the incision anteriorly in order to help delineate normal anatomical markers. Measurements and Main Results N/A Conclusion Total laparoscopic hysterectomy can be safely completed in the presence of dense bladder adhesions through four techniques described above.

Relationship between C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) with gall bladder adhesion on cholecystectomy at Abdul Wahab Sjahranie Hospital, Samarinda

Background: The conversion from laparoscopic cholecystectomy to open cholecystectomy often results from pericholecystic Adhesion. Pericholecystic Adhesion is a result of cholecystitis in the case of cholelithiasis. C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) can be increased in cholecystitis and used as a predictive factor for the degree of difficulty in laparoscopic cholecystectomy. This study aims to determine the relationship between CRP and ESR with gall bladder adhesion on cholecystectomy at Abdul Wahab Sjahranie Hospital, Samarinda.Method: A cross-sectional study was conducted among 61 respondents who underwent a cholecystectomy surgery at Abdul Wahab Sjahranie Hospital Samarinda during July-September 2019. Parameters assessed in this study were Gender, diagnosis, CRP, ESR, age, hemoglobin, leukocytes count, platelet count, and the relationship between CRP and ESR value with the pericholecystic adhesions. Data were analyzed by SPSS version 22 for Windows. Results: Most of respondents were female (70.5%), followed by cholelithiasis (73.8%) as primary diagnosis, no Pericholecystic Adhesions found (68.9%), CRP level &lt; 23 mg/dl (77.0%), and ESR level ≥ 11 mm/hour (78.7%). In addition, the average age of respondents was 48.44±10.85 years old, followed by the hemoglobin level (12.43±1.77 g/dL), leukocytes counts (9,439.67±3,719.37/µl), and platelet counts (319,295.08 ± 90,587.59/ µl). CRP level had a significant relationship to the occurrence of pericholecystic Adhesion (OR: 75.400; 95%CI: 7.991-711.441; p=0.000).Conclusion: It can be concluded that there was a relationship between CRP and ESR with the occurrence of pericholecystic Adhesion. However, based on multivariate analysis, CRP was more significant compared to ESR on the occurrence of pericholecystic Adhesion.

83: Technique for retrograde robotic hysterectomy for management of dense bladder adhesions

The primary objective is to show a technique for performing retrograde dissection of densely adherent bladder from anterior uterine wall during robotic-assisted laparoscopic hysterectomy. Many women who undergo hysterectomy have a history of prior cesarean sections, which can result in dense anterior uterine adhesions. Significant adhesions between uterus and bladder create a challenge for safe completion of hysterectomy without injury to lower urinary tract. Here, we show a technique for performing a retrograde hysterectomy in which all major blood supply to the uterus is sealed and the colpotomy completed prior to bladder adhesiolysis. Furthermore, we show a technique for retrograde dissection of the bladder from uterine wall starting inferiorly at the level of the cardinal ligaments and working superiorly towards the fundus of the uterus. With this technique, there is early control of vascular supply thus decreasing intraoperative blood loss, direct visualization of ureters thus decreasing risk of injury, and a 360-degree access to bladder adhesions once colpotomy is complete in order to safely perform adhesiolysis. We show dissection of the pararectal and paravesical spaces, bilateral ureterolysis, and sealing of uterine artery at its origin. Performing a retrograde hysterectomy allows early control of blood supply, constant visibility of ureters, and access to inferior bladder adhesions. Performing a retrograde dissection of the bladder can decrease risk of injury to lower urinary tract. These techniques can be used to safely perform robot-assisted laparoscopic hysterectomy in patients with dense uterine adhesions to the bladder.

İntraperitoneal Polipropilen Mesh Kullanımına Bağlı Adezyonların Proflaksisinde Chitin Materyalinin Etkisi

Purpose/Aim: Polypropylene mesh is the most applied and used material in the repairing of the abdominal wall. The purpose of this study is the evaluation of the efficiency of chitin, an anti-adhesive mucopolysaccharide, coated polypropylene mesh and liquid chitin on the formation of adhesion induced by polypropylene mesh.Materials and Methods: Thirty male Wister Albino rats were divided into 3 groups randomly. In Group A, the abdominal defect was closed only by polypropylene mesh, in Group B, polypropylene mesh with liquid chitin was used and in Group C, chitin film was applied to the inner side of the polypropylene mesh that was attached to the abdomen. Separation of polypropylene meshes from the fascia, location and shape transformation of them, existence of foreign body granuloma between the material and abdominal structures, rupture pressure of the material and the other morbidities were observed and evaluated.Results: There was adhesion with omentum in all groups. In Group A, liver adhesion was detected in 7 cases and small intestine adhesion was detected in 3 cases. The thickness of adhesion was measured as 19.25 mm and rupture pressure was measured as 2.57 kg. In Group B, there was small intestine adhesion in all cases and bladder adhesion was detected in 2 cases. The thickness of adhesion and rupture pressure was measured on an average as 37.52 mm and 2.42 kg respectively. Similar to Group B, in Group C, there was small intestine adhesion in all cases. Moreover, there was bladder adhesion in 4 cases, pancreas adhesion in 1 case and large intestine in 1 case. The thickness of adhesion and rupture pressure was measured on average as 46,14mm and 1.97 kg respectively. The number and thickness of the adhesion were statistically much more observed in Group A according to/in comparison to Group B and C statistically p

Transurethral Removal of Perforated Intrauterine Device

Video Objective To describe the management of a perforated IUD into the bladder, with removal of a fractured arm via a transurethral approach. Setting 36yo G1P1 with expired ParaGard IUD in place who experienced spontaneous detachment of the IUD strings with attempted removal in the office. Pelvic ultrasound showed evidence of one IUD arm perforating the bladder, which was also confirmed on office cystoscopy. She was scheduled to undergo attempted hysteroscopic IUD removal, but also consented for laparoscopy as she desired a permanent sterilization procedure. Interventions Cystoscopy was first performed, confirming one arm of the IUD perforating the bladder dome. Laparoscopy was performed, noting the incidental finding of the second IUD arm perforating the uterine fundus. Adhesions between the fundus, bladder dome, and omentum were noted. Hysteroscopy was performed in attempt to remove the IUD while under laparoscopic guidance. With traction on the IUD body, the IUD was partially removed, but one of the arms was noted to have fractured off. Laparoscopically, it was evident the arm perforating the fundus remained in situ. While attempting to remove the fractured arm via laparoscopy, the arm spontaneously retracted into the myometrium. Bilateral salpingectomy was performed for permanent sterilization. The bladder adhesion was divided and the cystotomy from the perforated arm was repaired. Repeat hysteroscopy was performed but the fractured arm was not visualized. Repeat cystoscopy revealed the fractured arm free within the bladder. The arm was removed transurethrally with a cystoscopic grasper. Conclusion When planning surgery to remove a perforated IUD, a surgeon must consider and be prepared to perform multiple approaches for removal in the event of IUD fracture.

Robot Assisted Laparoscopic Hysterectomy with Fetus in-situ for Placenta Percreta in Second Trimester

Video Objective To describe a technique of robotic-assisted laparoscopic hysterectomy of a second trimester gravid uterus with placenta percreta Setting A step-by-step explanation of the surgery using video (instructive video). Interventions In this video, we describe the surgical approach opted for this patient desiring pregnancy termination and no desire for future fertility. Minimally invasive surgery was recommended considering decreased blood loss, postoperative pain and hospital stay. Also considering her prior surgical history, the laparoscopic approach would offer better visualization for lysis of adhesions. Intraoperatively, the uterus was found to have adhesions anteriorly to the abdominal wall as well as bladder adhesions to the lower uterine segment. Generalized increased vascularity was observed. The blood supply from the utero-ovarian and the uterine vessels were tackled prior to releasing the adhesion of the anterior wall of the uterus to the anterior abdominal wall. The lower uterine segment was adherent to the bladder, thereby the lateral approach was used to enter the paravesicular space to create a bladder flap to mobilize the bladder inferiorly. An End to End (EEA) sizer was used to identify the colpotomy site. The cardinal ligament were coagulated and transected to lateralize the paracervical tissue. The colpotomy was then performed and the specimen was then exteriorized intact vaginally. The vaginal cuff was then closed in a continuous fashion using 0-VLoc. Estimate blood loss was 300mL. Postoperatively, patient was hemodynamically stable, and post-operative labs were found to be within normal limits. Patient was discharged in stable condition on post-operative day one. Conclusion Robot assisted hysterectomy is feasible and superior to open approach in a patient with a second trimester pregnancy complicated by placenta percreta with completion of child bearing.

2878 Posterior Approach to Uterine Artery Ligation

Video Objective This video demonstrates an alternative approach to uterine artery ligation during a Robotic Assisted Total Laparoscopic Hysterectomy in the setting of an obliterated anterior cul-de-sac. Setting This a case of a 29 year old with two prior cesarean sections presenting for Robotic Assisted Total Laparoscopic Hysterectomy for abnormal uterine bleeding. Upon entry, the uterus is found to be densely adherent to the anterior abdominal wall. Interventions The uterine arteries were dissected out, desiccated, and transected from the posterior aspect of the uterus due to the limited access anteriorly secondary to bladder adhesions. Conclusion In conclusion, an obliterated anterior cul-de-sac due to previous surgeries makes it difficult to access the uterine arteries secondary to poor visualization. By approaching uterine artery ligation from the posterior aspect, one may avoid inadvertent injury to vasculature or the bladder and reduce the amount of bleeding during the bladder dissection.

Single-incision laparoscopic repair of a cesarean scar defect

To evaluate the feasibility of laparoscopic single-incision repair for a cesarean scar defect (CSD). Step-by-step explanation of surgery using an instructive video, with Institutional Review Board approval. University Hospital, Shandong Province, People's Republic of China. A 36-year-old G2P1011 woman presented with postmenstrual spotting and pelvic pain that was resistant to medical management. Transvaginal ultrasound revealed a CSD measuring 1.08 × 0.71cm with a residual myometrial thickness of 1.5mm. She desired to preserve fertility and had cosmetic concerns related to surgery. We performed single-incision laparoscopic CSD repair. After abdominal entry, the overlying peritoneum and bladder adhesion were dissected using a monopolar hook, cold scissors, and a grasper. Diagnostic hysteroscopy was performed to identify CSD boundaries. Cold scissors were used to resect the scar tissue, avoiding the use of thermal energy to prevent injury that would impair wound healing. Closure was performed using 2/0 Ethibond suture (Ethicon); the first layer was a running full-thickness vertical suture, and the second layer was a horizontal mattress suture to reduce incisional tension. Single-incision intracorporeal knot tying was successfully accomplished by forming a triangle with the straight laparoscopic forceps and the articulated instrument. Successful repair of CSD via single-incision laparoscopic surgery. Operative time was 50minutes; blood loss was 50mL. At the postoperative visit, the umbilical wound had properly healed with excellent cosmetic results. Abdominal ultrasound demonstrated that the CSD had disappeared. Cyclic menses resumed without postmenstrual spotting or pelvic pain. Our case suggests that single-incision laparoscopic repair is a feasible approach to treat CSD that can provide excellent cosmetic results. Additional studies should investigate the clinical utility of single-incision laparoscopic CSD repair in a larger sample to compare the outcomes with the vaginal and hysteroscopic approaches.

Omission of the Bladder Flap Suggests Short Term and Long Term Benefits

Background: Cesarean section is now the most common major surgical procedure performed on women worldwide. With the increasing numbers of cesarean sections, there is the need to utilize evidence based techniques to optimize outcomes and minimize complications. We hypothesize that omission of the bladder flap in both primary and repeat cesarean sections will be associated with shorter operating time without a significant increase in intraoperative and postoperative complications. Methods: 550 patients were enrolled in the study. They were randomly allocated in the 2 groups to evaluate the effects of cancelling the bladder dissection. Results: Significant reduction of the total operating time (p = 0.01), skin to delivery time (p = 0.02) and micro-hematuria (p = 0.01) in group with bladder omission. Long term result: Including more bladder adhesion and fibrosis in the cases with bladder dissection. Conclusions: Omission of the bladder dissection achieved short-term advantages as regards reduction of operating time, incision-delivery duration and decreased blood loss as well as long-term effects include different in the bladder adhesion.