Repair of Advertent and Inadvertent Cystotomy
Opening and Closing the Bladder
When performing abdominal surgery, the surgeon may encounter pelvic pathology that involves the lower urinary tract. The gynecologist should be comfortable with performing a cystotomy to assist in dissection of the bladder off pelvic organs such as the uterus or possibly off the back of the symphysis pubis in cases of retropubic urethropexy. Also, when ureteral injury has potentially occurred, it is reasonable to make a high cystotomy to assess ureteral patency. Making an incision into the urinary bladder is best done high up in the extraperitoneal portion of the dome of the bladder. An easy way of doing this is to mobilize the balloon of the Foley catheter up into the dome of the bladder (Fig. 88–1), go to the extraperitoneal portion of the dome of the bladder, and using cautery or a knife incise down onto the balloon until the bladder is penetrated (Figs. 88–2 and 88–3). Through a 4- to 5-cm incision in the dome of the bladder, one can assess the inside of the bladder for any potential suture penetration or injury and can visualize the ureteral orifices to ensure ureteral patency (Fig. 88–4). Also, if indicated, a ureteral stent or pediatric feeding tube can be passed in a retrograde fashion (Fig. 88–5). Ureteral stent placement may be very helpful when pelvic pathology such as endometriosis, pelvic inflammatory disease, or a pelvic mass distorts or involves the pelvic ureter. To close the bladder, delayed absorbable 3-0 sutures are utilized. The author prefers to use chromic catgut suture as it does not tear through the tissue and its short time of absorption will never allow stone formation. The first layer is a continuous suture that approximates the vesical mucosa (Figs. 88–6 and 88–7). A second layer is then placed to imbricate the muscular portion of the wall of the bladder over the mucosal closure (see Figs. 88–7 and 88–8). This is usually performed with a 3-0 absorbable suture in a continuous or an interrupted fashion.
