The rate of urinary tract injury during hysterectomy is described anywhere from 0.2% to 1.6%. In a recent systematic review of the literature by Wang et al., bladder injury has been shown to be three times higher than ureteral injury. This is most often due to lysis of adhesions or bladder dissection during laparoscopic surgery. There are several risk factors that have been identified to increase the risk of bladder injury during laparoscopic surgery, including a history of prior surgeries and endometriosis. The objective of this video is to demonstrate different techniques to assist with difficult bladder dissection during laparoscopic hysterectomy. The first technique is the traditional lateral to medial bladder dissection with concomitant use of the bladder backfill to better demonstrate surgical planes. We will demonstrate our use of a metal Foley catheter stylet to assist with difficult bladder dissection. And lastly, we will demonstrate how to use an identified cystotomy to your surgical advantage. We begin by identifying pertinent anatomical landmarks. Adhesions can significantly distort normal anatomical planes. Here we demonstrate traditional techniques, including lateral to medial bladder dissection using a combination of blunt dissection and electrosurgery to open the parabasical space and skeletonize the uterine pedicle. The bladder is backfilled with approximately 150 cc's of normal saline to assist in identification of its borders in order to perform further dissection in this plane. The same technique is used to open the right parabasical space. We have begun to restore our anatomical planes. This allows us to continue safe dissection along the adhesions at the level of the vesicle uterine fold. After the bladder is fully mobilized, it is again backfilled to verify integrity. Dense adhesions may be encountered from the uterus to the anterior abdominal wall after multiple surgeries as seen in this patient. Another technique that can be useful when encountered with obliterated anatomical landmarks is the use of a metal stylet that can be inserted into the Foley catheter. This stylet can be manipulated by a surgical assistant to distinguish anatomical borders. After careful dissection of the uterus from the anterior abdominal wall using electrosurgery, the stylet is again used to safely complete the remainder of the bladder dissection. We then perform both backfilling of the bladder and cystoscopic evaluation to verify bladder integrity and bilateral ureteral efflux. If asystotomy is encountered, it may be used to guide the remainder of the bladder dissection. Loparoscopic closure of the cystotomy is done only after the bladder dissection is completed. Cystotomy repair is performed using absorbable suture in two layers. Again, it is important to test the bladder integrity and ureteral efflux prior to completion of the procedure. Desai et al. showed a 31% increase in the rate of total laparoscopic hysterectomy in the U.S. from 2007 to 2012. The potential morbidity from lower urinary tract injury makes practicing appropriate bladder dissection a key surgical technique for laparoscopists to master. We hope our video has demonstrated an array of techniques to assist with difficult bladder dissection that can be incorporated into your surgical practice. For more information, visit www.fema.gov

bladder dissection

laparoscopic hysterectomy

urinary tract injury

bladder injury

risk factors