U nrepaired cystotomy can manifest as hematuria, oliguria, abdominal pain, ileus, ascites, peritonitis, fever, urinoma, or istula. For diagnosis, retrograde cystography or abdominal computed tomography (CT) with cystography can be used (Tarney, 2013). Cystoscopy is also an option but may require an operating room. Once identified, prompt repair is indicated (Balgobin, 2017).
hese injuries occur most oten during repair of hysterotomy extensions into the broad ligament or vagina (Eisenkop, 1982). If ureteral injury is suspected, methylene blue is administered. The pelvis is directly inspected for dye extravasation, which suggests ureteral transection. Next, brisk dye-stained urine jets are sought from each oriice to exclude ureteral kinking or ligation. Oriice viewing may be via cystoscopy, if available; through a comorbid traumatic cystotomy; or through a diagnostic cystotomy. With sluggish or absent jets, consultation with a specialist is typically requested. A ureteral catheter is irst threaded to identiY a potential obstruction site and guide ureterolysis. Kinked or ligated ureters can be relieved by release of ensnaring sutures. Crush injuries are inspected to ensure vital tissue. In these cases, stents are let to avert ureteral stricture. A Foley cath�ter remains for 7 to 10 days, and the ureteral catheters are removed via cystoscopy ater 14 days. Intravenous pyelography (IVP) is usually not necessary before removal of the stent if it was placed as a precautionary measure ater relatively minor injury (Davis, 1999).
Crush injuries with devascularization, thermal injury, or transection require more extensive repair. If a healthy-appearing ureter can be reimplanted into the bladder without undue tension, then ureteroneocystostomy is preferable. For more proximal injuries, ureteroureterostomy, psoas hitch, or Boari lap creation may be needed. An explanation of these more extensive procedures is found in Cunningham and Gistrap s Operative Obstetrics, 3rd edition (Balgobin, 2017).
Unrecognized ureteral injury can mimic those of cystotomy with the addition of possible costovertebral angle tenderness. CT urography is a preferred initial diagnostic tool (Sharp, 2016). he duration of time from injury to identification directs repair. hose identified early are often suitable for immediate repair.
Serosal tears represent weak points in the small bowel. If obstruction develops postoperatively, these weak spots may perforate, leading to peritonitis. If serosal tears are few in number, they can be oversewn with either a ine absorbable or nonabsorbable suture (Davis, 1999). More signiicant lacerations are often repaired in consultation with a general surgeon or gynecologic oncologist.
During and after cesarean delivery, requirements for intravenous luids can vary considerably. Administered fluids consist of either lactated Ringer solution or a similar crystalloid solution with 5-percent dextrose. Typically, at least 2 L is infused during surgery. Blood loss with uncomplicated cesarean delivery approximates 1000 mL. he average-sized woman with a hematocrit of 30 percent or more and with a normally expanded blood and extracellular luid volume most often will tolerate blood loss up to 2000 mL without diiculty. Unappreciated bleeding through the vagina during the procedure, bleeding concealed in the uterus after its closure, or both commonly lead to underestimation.