Extraperitoneal cystotomy after laparoscopy. A case report.

BACKGROUND: Difficult laparoscopic entry with preperitoneal dissection may disrupt the bladder wall without intraperitoneal or transvaginal evidence of injury. A high index of suspicion must be maintained. CASE: A laparoscopically assisted vaginal hysterectomy was performed on a 136-kg, 43-year-old nullipara with a fibroid uterus and pelvic endometriosis. Open laparoscopic entry was impeded by a distorted abdominal wall, necessitating infraumbilical, extraperitoneal laparoscopic dissection. Following an uncomplicated laparoscopically assisted vaginal hysterectomy, gross hematuria was evident. Intravesically instilled methylene blue would not leak transvaginally or intraperitoneally. Extraperitoneal prevesical laparoscopic inspection demonstrated an anterior cystotomy that was repaired endoscopically. CONCLUSION: This report highlights the potential dangers of inadvertent vesical injury in the laparoscopic patient with difficult entry as well as the failure of traditional transvaginal or transabdominal diagnostic maneuvers to reliably identify extraperitoneal bladder injuries. The report also suggests a mechanism by which surgically inapparent vesicoabdominal trocar fistulas may form and confirms that bladder injuries, in selected patients, can be safely and effectively repaired laparoscopically.