whereas that for ureteral trauma nears 0.3 per 1000 cases (Giingordiik, 2010; Oliphant, 2014; Rajasekar, 1997). Bowel is damaged in about 1 in 1000 cesarean deliveries (Silver, 2006).
Bladder laceration most commonly occurs during blunt or sharp dissection in the vesicouterine space to create the bladder lap, during peritoneal cavity entry, and during hysterotomy (Phipps, 2005; Rahman, 2009). Risks are prior cesarean delivery; emergency cesarean delivery; comorbid adhesive disease; cesarean hysterectomy, especially cases with morbidly adherent placenta; and surgery in second-stage labor compared with irst-stage (Alexander, 2007; Silver, 2006; Yossepowitch, 2004).
Bladder injury is typically identified intraoperatively, and initially, a clear-luid gush or the Foley bulb may be seen. If cystotomy is suspected, it can be conirmed with retrograde instillation of infant formula or methylene-blue-stained saline through a Foley catheter into the bladder. Leakage of opaque milk or methylene blue aids in identiication of the laceration as well as delineation of its borders. The dome is lacerated in 95 percent of cases, and injuries at the trigone form the remainder (Phipps, 2005).
Prior to cystotomy repair, ureters are examined, and surveillance for urine jets from each oriice follows. This can be done directly through the cystotomy, if at the dome, or through a separate diagnostic extraperitoneal or retropubic cystotomy, if injury nears the trigone. Jet visualization can be assisted by 50 mg of methylene blue administered intravenously.
Once ureteral patency is conirmed, the bladder may be closed with a two-or three-layer running closure using a 3-0 absorbable or delayed-absorbable suture (Fig. 30-22). he first layer inverts the mucosa into the bladder. The bladder is then illed with a marker luid to demonstrate integrity of the repair. Leaking defects can be closed with interrupted reinforcing stitches. Subsequent layers reapproximate the bladder muscularis. Postoperative care requires continuous bladder drainage for 7 to 14 days to permit healing and minimize the risk of fistula formation. U ropathogen prophylaxis during this drainage is not required. Also, cystourethrography need not be routinely performed prior to catheter removal for a simple, �ingle laceration (Davis, 1999).
FIGURE 30-22 Cystotomy repair, A. The primary layer inverts the bladder mucosa with running or interrupted sutures of 3-0 delayedabsorbable or absorbable suture, B. Second and possibly a third layer approximate the bladder muscularis to reinforce the incision closure.
Larger lacerations in or near the trigone require careful attention. Specialists may be consulted, and in preparation, ureteral stents can be assembled. In these cases, ureteral oriices are directly inspected to document jets from both. If not seen, then stents may be passed through the cystotomy and into each oriice to conirm patency. Once this is confirmed, repair should not disrupt the ureteral orifices, and stents may remain to ensure ureteral patency.