Occult bladder injury after laparoscopic appendicectomy

Abstract

SUMMARYMinimally invasive procedures have revolutionised surgery by reducing pain and the length of hospital stay for patients. These are not simple procedures and training in laparoscopic surgery is an arduous process. Meticulous preparation prior to surgery is paramount to prevent complications. We report a rare complication involving a 35-year-old patient who underwent a laparoscopic appendicectomy for a perforated appendix. Two days after surgery the patient experienced redness and swelling in the lower abdominal region and oliguria. A delayed computer tomography (CT) scan revealed contrast leakage around the bladder spreading within the peritoneal cavity consistent with an intraperitoneal bladder perforation. She underwent urinary catheterisation for 6 days. A follow-up CT cystogram showed no evidence of leakage into the peritoneal cavity. This case highlights the need for thorough preparation prior to laparoscopic surgery and careful manipulation of instruments during routine procedures to minimise the risk of serious patient complications such as the aforementioned. BACKGROUND

Bladder injury in a child during laparoscopic surgery

“…Laparoscopic appendicectomy is currently one of the most commonly performed paediatric surgical procedures; its growing popularity over open appendicectomy is due to reported reduced length of hospital stay, shorter recovery time, and relative cosmesis of scars [4]. However, laparoscopic surgery is associated with a 0.2% risk of intraabdominal injury, most commonly during use of bladed or blunt trocars to insert ports [5]. Intestinal injury is the most common, followed by vascular injury [4, 5].…”

“…However, laparoscopic surgery is associated with a 0.2% risk of intraabdominal injury, most commonly during use of bladed or blunt trocars to insert ports [5]. Intestinal injury is the most common, followed by vascular injury [4, 5]. Bladder injury is estimated to occur in approximately 0.3–0.5% of adult laparoscopic appendicectomies [1].…”

“…The use of a suprapubic port in laparoscopic appendicectomy is common, and is most likely to cause the bladder injury. This risk can be reduced by catherisation of the bladder prior to placement of ports [1, 5]. An ‘in/out’ technique of catheterization is often utilized safely.…”

“…Bladder injury in laparoscopic surgery may be intra-peritoneal or extra-peritoneal. Intraperitoneal injuries may be immediately apparent, such as when using sharp dissection inside the abdomen, or delayed such as rupture of an occult injury caused by thermal dissection of a nearby structure [5]. These usually require operative repair.…”

“…A cystogram is the diagnostic investigation of choice. Other imaging modalities include ultrasound, which would demonstrate large fluid collections, and computerized tomography (CT) [1, 5]. Small extraperitoneal injuries can be managed conservatively with catheterization of the bladder for 5–7 days along with broad spectrum antibiotics.…”