Laparoscopic repair of intra-abdominal bladder perforation in preschool children.

Intraperitoneal bladder rupture is uncommon in very young children, but its incidence may increase with increasing use of seat and lap belts. To the best of our knowledge, there are no prior reports of laparoscopic repair of this injury in children. We describe two recent cases and discuss useful technical points that facilitate a successful laparoscopic repair. Both our patients were preschool age girls who sustained seat and lap belt injuries. Contrast computed tomography scan suggested a large amount of free peritoneal fluid and cystogram confirmed intraperitoneal bladder perforation (isolated injury). The injury was repaired using delayed absorbable sutures and intracorporeal suturing (continuous in 1, interrupted in 1) using a 3 port laparoscopic technique. Meticulous peritoneal lavage was carried out to minimise urinary peritonitis and the bladder as well as the peritoneal cavity were drained. Check cystograms (day 7) revealed no leaks. Young girls appear to be at risk of intraperitoneal bladder injuries following lap belt injuries. After exclusion of life-threatening injuries and concurrent abdominal injuries which need rapid control or preclude pneumoperitoneum, a laparoscopic repair can be safely performed.

INTRODUCTION

Intraperitoneal bladder perforation is a rare injury in children, which can occur as a result of compression by seat (lap) belt compression appears to have been reported as early as 1983.[1] Repair using an open surgical approach has been recommended as standard of care.[2] We report two cases of traumatic intraperitoneal rupture of the urinary bladder which were managed using laparoscopic techniques and discuss certain technical points of possible importance in dealing with this age group.

CASE REPORTS

Case 1

A 4-year-old girl, restrained in a child seat with lap and seat belts was involved in a moderate velocity motor vehicle accident. Her primary assessment suggested hemodynamic stability but significant amount of free fluid in the abdomen. Contrast computed tomography (CT) scan suggested intraperitoneal bladder rupture with no other apparent injury [Figure 1]. She underwent a laparoscopy [Figure 2] followed by repair with the insertion of a bladder catheter and an intraperitoneal Jackson-Pratt drain through the left-sided port. Repair was performed with a single layer of interrupted sutures of 4'0 Polydioxanone (PDS-II™) suture, and the repair was tested using dilute methylene blue [Figure 3]. Drain was removed and patient discharged on day 2. Catheter was removed on day 7 after a check cystogram [Figure 4].

Figure 1

Contrast computed tomography revealing an intraperitoneal bladder rupture

Figure 2

Laparoscopic view of the bladder wall defect

Figure 3

The sutured bladder at the end of the operation

Figure 4

Day 7 cystogram confirms an intact bladder (anteroposterior view)

Case 2

A 3-year-old similarly restrained girl was involved in a high-velocity motor vehicle accident. She was retrieved to a tertiary paediatric trauma centre was diagnosed to have isolated intraperitoneal rupture of the bladder on CT cystogram. This was repaired laparoscopically using a single layer of continuous 4'0 polyglactin (Vicryl™). Post-operative management was similar to case 1.

Laparoscopic technique

Our approach was to place the child supine with a screen at the foot end and another at the head end. Following peritoneal access using a 5 mm port at the umbilicus (pressure 10 mm Hg), the injury site on the bladder dome was defined followed by ergonomic placement of two working ports on either side to allow ease of intracorporal suturing. A transcutaneous traction stitch through the anterior most part of the injury was considered if the injury extended posteroinferiorly along the bladder wall. Secure repair was achieved using 4'0 polyglactin (Vicryl™) or 4'0 Polydioxanone (PDS-II™) suture on SH-1 or RB-1 needle facilitated by slight Trendelenburg tilt. The urine was aspirated from all quadrants using the second screen as a guide. A 6 Fr drain was placed retrovesically through the left sided port.

DISCUSSION

To the best of our knowledge, this is the first report, which confirms the safety and efficacy of laparoscopic management of intraperitoneal bladder injuries in children.

Intraperitoneal bladder injuries account for nearly 17% of the bladder injuries in children and there appears to be a considerable variability in the reported literature in their management. Surgery has been recommended the standard of care.[2] Despite this, only 66% of the injuries were surgically repaired. This is because there have been successful reports of conservative management of these injuries in children.[3] It is our belief that intraperitoneal bladder injuries should be surgically repaired whenever possible to reduce the morbidity associated with urinary peritonitis and reduce hospital stay. This is supported by the audit of the National Trauma Data Bank (USA), which suggests that surgical repair confers a survival advantage in children with bladder injuries.[2] Interestingly, this advantage is independent of the nature of the bladder injury.

Contrast CT scan with retrograde cystography is the most sensitive and specific test to diagnose intraperitoneal bladder injuries.[4] Smaller tears can be accurately diagnosed since they are unlikely to be masked by a distended bladder, thus reducing the need for a post-drainage film.[5]

In our view, laparoscopy should be the technique of choice in children with intraperitoneal bladder injuries provided hemodynamic stability is proven, high-grade solid organ injury is excluded, and backup for a quick conversion to laparotomy is available. This is because laparoscopy allows a thorough diagnosis of bladder as well as associated injuries, safe and effective closure of the bladder, complete clearance of the peritoneal urine and early return to feeds. It has been successfully offered in adults since 1994.[5678910] As suggested by previous authors, it also allows good magnification and clearance of bladder clots.[5]

Despite the traditional teaching of recommending a two layered bladder repair,[67] a single layer repair of the bladder appears equally safe and effective.[8910] This has been reported in the adult series as well as animal studies.[5] Further, interrupted stitches seem to be effective so long as water tight closure is confirmed[10] as was seen in one of our cases. This flexibility is of great help and importance when working in small abdomens and relatively difficult angles as can happen in little children with injuries of the intraperitoneal bladder wall, which are difficult to access (posterior) or difficult to suture (anterior).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.