Clinical Review

Injury-free vaginal surgery: Case-based protective tactics

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A strategy for avoiding, recognizing, and repairing injuries intraoperatively—and averting litigation



CASE 1 Gush of fluid during dissection

A 55-year-old woman with 2 prior cesarean deliveries and stage III uterovaginal prolapse (primarily apical) is now undergoing transvaginal hysterectomy and prolapse repair. During sharp dissection of the bladder off the lower uterine segment, a gush of clear fluid washes over the area of dissection.

What steps would you take to achieve the best possible clinical outcome for this woman?

If a patient sustains a urinary tract injury, she is 91 times more likely to sue her surgeon than a patient who has a different complication or problem at gynecologic surgery.1 Yet, despite a surgeon’s best efforts, injury can occur. If it does, the best approach is immediate recognition and repair.

Primary prevention—including identifying the ureters—and intraoperative repair is the easiest, most successful, least morbid approach, compared to postoperative management. And probably less likely to lead to a lawsuit.2

As always, our main goal in any preventive effort is the best possible patient care and clinical outcomes, and diligent, careful surgical technique is the best protection on all counts. Every vaginal surgeon should have a consistent strategy for preventing, indentifying and managing intraoperative injuries to the urinary tract and bowel.

This article discusses potential injuries to the lower genitourinary and gastrointestinal tracts separately.

Vulnerable anatomy is a given

The ureters are injured in up to 2.4% of vaginal surgeries,4 and gynecologic surgery accounts for as much as 52% of inadvertent ureteral injuries.5 The bladder and bowel can also sustain injuries, in up to 2.9% and 8% of cases, respectively.3,6

Mechanisms of injury can include bladder perforation7 (and, rarely, small bowel perforation8) during placement of bladder neck and midurethral slings, transection of the bladder or ureter during vaginal hysterectomy, and ureteral kinking or obstruction during vaginal hysterectomy and vault suspension.4,9

The rectum can sometimes be perforated during posterior colporrhaphy or perineorrhaphy.6

Risk factors

For intraoperative bladder injury: prior anterior colporrhaphy, cesarean delivery, or incontinence surgery.

For injury to the rectum: prior posterior vaginal wall surgery and defects in the distal rectovaginal septum.

For injury to the small bowel: enterocele.

Women with surgically induced or suspected congenital anatomic anomalies (eg, ureteral reimplantation, ectopic kidneys or ureters, suprapubic vascular bypass grafts) require evaluation to establish the location of these anatomic variants with respect to the planned area of surgical exploration.

Most gyn surgical injuries involve the urinary tract

The urethra and a substantial portion of the posterior bladder rest on and are supported by the anterior vaginal wall. In women with an intact uterus, the posterior bladder wall also rests on the anterior lower uterine segment.

In women with a uterine scar, the bladder wall itself can sometimes be scarred down to the anterior lower uterine segment. This scarring occurs when the lower uterine scar becomes adherent to the posterior bladder wall during wound healing. Unrepaired or delayed repair to bladder injuries in these areas may lead to fistula formation.

Prior anterior colporrhaphy is associated with scarring between the bladder and anterior vaginal walls and can increase the risk of bladder injury during vaginal surgery.

Risks during sling procedures

Intraoperative injuries to the bladder dome and bladder neck are most common during urethral and bladder-neck sling procedures. During these procedures, prevent injury by keeping the passing tip of the sling-insertion device (eg, trocar or other passing instrument) clear of the urethra and bladder neck, and perform cystourethroscopy during each pass to identify any perforation of the bladder or urethra.

When perforation occurs, inspect the ureteral orifices thoroughly and document prompt efflux from both. If the orifices are freely effluxing and the remainder of the bladder mucosa is intact, withdraw the perforating instrument, pass it through again, and repeat cystoscopy to confirm that there is no new perforation.

Perforations to the bladder dome usually heal spontaneously in the postoperative period, with no need for extended bladder drainage. Perforations at the lateral or anterior bladder neck will also heal spontaneously.

Injuries to the posterior bladder wall and trigone


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