LAUSR

Video Objective The purpose of this video is to demonstrate the technique for laparoscopic repair of an intraoperative cystotomy, at the time of total laparoscopic hysterectomy. Setting In the particular case presented in this video, a large paracervical fibroid distorts the anatomy of the lower uterine segment. While developing the bladder flap, an inadvertent cystotomy 4 centimeters in diameter is created, immediately identified, and subsequently repaired laparoscopically by standard surgical guidelines. The risk of a urinary tract injury during laparoscopic hysterectomy ranges from 0.735-1.8%; the risk of a bladder injury is three times more likely than that of a ureteral injury. A number of patient characteristics increase the risk of an injury, including endometriosis, a history of cesarean sections, and large fibroids that distort uterine anatomy. Urinary tract injuries that go unrecognized at the time of surgery are associated with increased postoperative morbidities, specifically hospital readmission, sepsis, and fistula formation. Interventions The cystotomy repair is demonstrated in standard fashion after completion of the hysterectomy and confirming the injury does not involve the trigone. Bladder dome injuries greater than 1 centimeter require primary repair, which should be completed in 2 layers with delayed absorbable suture. The first layer opposes the edges of the bladder mucosa and muscularis and the second layer closes the bladder serosa. Following repair, the bladder is retro filled with normal saline to ensure a watertight closure. Imbricating sutures can be utilized on the serosa to enhance closure as necessary. A cystoscopy confirms intact repair and bilateral ureteral efflux. An indwelling foley catheter is maintained for 1-2 weeks postoperatively. Conclusion Recognition and repair of a bladder injury at the time of original surgery optimizes patient outcomes. A two layer closure using excellent tissue reapproximation is essential for ideal wound healing.