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Bowel and bladder  injuries at Hysterectomy

Shobhana Mohandas: TOGS bulletin, Vol1,No5:July 2005



Hysterectomy is one of the commonest surgeries performed by the gynaecologtist. To list all the complications with their management is beyond the scope of this bulletin. A few of the practical aspects of dealing with bowel and bladder injuries are discussed.


Bowel injuries: Bowel injuries at the time of hysterectomy may occur when there are difficult adhesions like in the case of grade IV endometriosis or post operative adhesions following previous surgery. To avoid injuring the bowel, always release simple adhesions in the periphery first. If the bowel is densely adherent to the uterus, it may be better to cut into the the uterus using a scissor near the point of  adhesion, rather than cutting at the junction of the bowel and the uterus. Pushing with a gauze in case of laparotomy or grasper at a time of LAVH may injure the  bowel. In case of inadvertent injury to rectum, confirmation can be made by  passing a flatus tube through the rectum and looking for it abdominally. Minute cuts can be detected by the following procedure : The pelvis is filled with water and an IV tube passed into the rectum and inflated with air, using a BP apparatus. Air bubbles are suggestive of injury. These maneuvers may be necessary because, in cases where bowel is liable to be injured, there is usually a lot of haemorrhage and identification of injury becomes difficult.


If a difficult dissection is anticipated deep in the pelvis, especially in cases of endometriosis, rectovaginal fistula can occur due to delayed necrosis. To prevent this, the omentum may be partially mobilized and inserted between the rectum and vagina. This will help by providing new blood supply to the devascularised area.


Repair of injuries:  If the ileum or jejunum has been injured, the site should be first dissected from surrounding  structures to make closure possible. The surgical principles involved in suturing the small bowel include maintaining an adequate blood supply, using small-guage absorbable suture material, using full-thickness pedicle, creating a watertight seal and preserving the lumen. Mesentry should be inspected to make sure there is adequate blood supply to the injured part.


In gynecologic surgery, large bowel is the one which is more liable to be injured. This always raises the possibility of colostomy. In general, repair of the colon is safe in patients with good mechanical and antibiotic bowel preparation and favorable local conditions in the pelvic. In patients who have had good bowel preparation and limited injury, two layer closure may be done. Closure should be aligned perpendicular to the axis of the bowel. Once the site and orientation of the repair have  been determined, stay sutures are placed at each angle. 3-0 polygycolic delayed absorbable suture material should be used. The sutures are placed approximately 3mm apart, with the knots tied on the outside. If a second layer can placed without compromising the diameter of the lumen , this is done with interrupted 3-0 suture.


In patients with a simple injury, unprepared bowel and gross peritoneal contamination with stool, diverting colostomy and repair should be considered. A simple loop colostomy usually accomplishes diversion of the fecal stream and may be reversed without an additional laparotomy


Bladder injuries:  Bladder  is liable to be injured in patients with adhesions like in previous caesarian section and in cases with altered pelvic anatomy as in big tumors. Just as in bowel adhesions, bladder adhesions can be prevented by use of sharp dissection instead of blunt dissection. While performing vaginal hysterectomy, it is sometimes difficult to identify the bladder in cases of procidentia. If the cervical os is visible, a dilator in the cervix and a metal catheter in the bladder will help identify the organs. A metal catheter in the bladder for all vaginal hysterectomies is ideal to prevent cutting into the bladder in the mistaken belief that it is the peritoneum. In  patients with long cervix and in vaginal hysterectomy for large uterus, if the bladder peritoneum is not easily reached, it may be prudent to start clamping the mackenrodt’s ligaments first. The uterus descends further and will bring the bladder peritoneum lower.  In fundal fibroids., the bladder peritoneum may not be visible even after mackenrodt’s, and it is the author’s practice to clamp the uterine before opening the bladder peritoneum. Usually this is necessary only in fundal fibroids.

While doing caesarian hysterectomy/ laparoscopic hysterectomy in a case with lot of adhesions, sometimes it may be difficult to know where the uterus ends and the bladder begins, as the whole area may be red and sometimes oozing. Whenever in doubt about the location of the bladder or about whether it has been injured or not,, it would be prudent to insert a Foleys catheter, and fill the bladder. A nicely filling bladder usually rules out major injuries. It also allows one to know the location of the bladder.


In case of injuries to the bladder, a two layer closure using 3-0 vicryl giving a water-tight closure is enough.


In case the bladder has been entered and closed, it is not only the expertise in closing the injury that is important, but the bladder drainage post-operatively is equally important. While a continuous urinary catheter is kept in situ  for 7-10 days , one should take care to put in a catheter with a very big opening, so that any flakes that may form are also drained.  Nurses should be instructed to constantly make sure that  the bladder is  draining, as there is a tendency for bladder mucosa to form flakes and for these flakes to go and obstruct the eye of the catheter. The pressure in the bladder that is caused as a consequence makes the suture give way.


Usually bladder injuries occur in cases where there are attempts at adhesiolysis followed by oozing\spurting, where multiple attempts have been tried at haemostasis using cautery and ligatures. The muscle layer of the bladder may be devascularised as a result, with a tendency to form fistulas. In such cases, it may be better to put in two catheters, one urinary and another suprapubic.





















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