Minimizing bladder injury in laparoscopically assisted vaginal hysterectomy among women with previous cesarean sections

Background: This study demonstrated a method to prevent bladder injury during laparoscopically assisted vaginal hysterectomy (LAVH) to patients with vesicocervical adhesion after previous cesarean deliveries. Methods: Between July 2004 and July 2005, 50 women with vesicocervical adhesion who had given birth by cesarean delivery underwent LAVH. To minimize the chance of bladder injury, transvaginal lateral intervention was used to enter the anterior cul-de-sac during laparoscopic intrafascial hysterectomy. The lateral windows of the vesicocervical space were opened first. Usually, the potential spaces lateral to the adhesions could be developed easily by blunt finger dissection. Once adequate lateral spaces were created, an index finger was swept medially to define the margin of the midline adhesions secondary to the cesarean delivery scar. Under direct vision and finger guidance, the dense adhesions were dissected with more confidence and safety. Subsequently, the bladder was pushed gently aside to avert unexpected tearing or injury along the intrafascial hysterectomy. Because the vesico-uterine fold had been cut open previously under laparoscopy, the anterior cul-de-sac could be entered without much resistance. Results: The average age of the patients was 45 ± 7 years, and the extirpated uterine weight was 323 ± 170.8 g (range, 85-730 g). Intraoperatively, the mean operation time was 124.6 ± 28.5 min (range, 80-235 min), and the average blood loss was 79.1 ± 47.8 ml (range, 20-250 ml). The mean intramuscular meperidine requirements were 1.2 ± 0.8 ampules (range, 0-2 ampules) (1 ampule = 50 mg), and the average hospital stay was 3.2 ± 0.9 days (range, 2-5 days). Of these 50 patients, 24 (48%) had one, 22 (44%) had two, and 4 (8%) had three previous cesarean deliveries. No bladder injury occurred among the patients, and there was no other complication. Conclusion: Transvaginal lateral intervention may help to minimize bladder injuries during LAVH for patients with previous cesarean deliveries.