ENDOUROLOGY & LAPAROSCOPY

Laparoscopic management of intraperitoneal bladder rupture secondary to blunt abdominal trauma using intracorporeal single layer suturing technique
Kim FJ, Chammas MF Jr, Gewehr EV, Campagna A, Moore EE
From the Division of Urology, Department of Surgery, Denver Health Medical Center and University of Colorado Health Sciences Center, Denver, Colorado, USA.
J Trauma. 2008; 65: 234-6.

• Background: Since Parra reported the first case of laparoscopic repair of bladder rupture caused by nonlaparoscopic injury to the bladder in 1994, several case reports have demonstrated the feasibility of this reconstructive surgical technique. We report the series of six patients that underwent laparoscopic repair of intraperitoneal bladder rupture (LRIB) because of blunt trauma using a single layer suturing technique. To our knowledge, this is the first series of LRIB reported secondary to blunt abdominal trauma.
• Methods: From January of 2002 through June of 2006, a total of 139 patients were identified in our trauma registry with bladder ruptures secondary to abdominal blunt trauma. Among them 111 (79.8%) patients had associated pelvic injury. Seventy-one patients underwent surgical exploration and open bladder repair. Six cases were managed with laparoscopic technique. Patients were positioned in supine position and a three port-technique (5 mm, 10 mm, and 12 mm) was performed using the intracorporeal single layer suturing with a 3.0 Vycril (UR-6 needle). A close system Jackson-Pratt drain was placed in the retropubic space to monitor possible urine extravasation.
• Results: The mean age of the patients was 47.3 years old (18-74 years). There were three female and three male patients. The average operation time was 43 minutes (31-75 minutes), mean length of bladder tear was 6.37 cm (5.3-7.7 cm), mean estimated blood loss was 16.6 cc (10-35 cc) and mean follow-up was 25.5 months (20-28 months). Two patients underwent combined orthopedic procedures. Computerized Tomography (CT) cystogram was performed between 5 days and 7 days after surgery with no signs of leakage in all patients.
• Conclusion: LRIB perforation because of blunt abdominal trauma using single layer intracorporeal suturing technique is a minimally invasive alternative to open surgery in well selected patients with no other intrabdominal injuries or intracranial pressure issues, offering faster recovery and better cosmetic results.
  
  
• Editorial Comment
  This retrospective study demonstrated the development of minimally invasive laparoscopic surgery in trauma, especially for the bladder. This manuscript brings new concepts and changes in old “dogmas” such as, bladder repair in 2 layers, use of supra-pubic urine diversion, and use of minimally invasive approach to trauma. At Denver Health Medical Center, a level 1 trauma center, pioneering studies such as gastro-intestinal anastomosis performed in 1 layer demonstrated efficacious repair and gave birth to the similar concept of repair for the bladder. As stated in this study, the large number of trauma patients allowed the development of new minimally invasive techniques, i.e.; among the 111 patients with pelvic injuries during a period of less than 5 years, only 6 patients were able to benefit from this minimally invasive approach to repair the bladder. The authors emphasize the specific indications and selection of patients and contra-indications, such as, associated head trauma that may not allow the insufflation pressures or the “light” Trendelenburg position.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu