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MANAGEMENT
OF RUPTURED BLADDER
Technique
| 1 |
Administer
a general anaesthetic. Expose the bladder as in the initial
stages of cystostomy with a midline suprapubic incision
between the umbilicus and the symphysis pubis. Achieve
haemostasis by pressure and ligation. Open the rectus
sheath, starting in the upper part of the wound. Continue
dissection with scissors to expose the gap between the
muscles. In the lower part of the incision, the pyramidalis
muscles will obscure this gap. Carry the incision in
the linea alba down to the pubis, splitting the pyramidalis
muscles. With a finger, break through the prevesical
fascia behind the pubis; then sweep the fascia and peritoneum
upwards from the bladder surface. Take care not to open
the peritoneum if it has not already been torn. Insert
a self-retaining retractor to hold this exposure. Cautiously
aspirate any blood or urine in the retropubic space,
but leave the area unexplored, as uncontrollable bleeding
can result.
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| 2 |
In
a patient with intraperitoneal rupture, the bladder will
be empty. The site of the tear is usually in the fundus
of the bladder. Open the peritoneum, inspect the site
of the rupture, and aspirate the fluid in the peritoneal
cavity. Introduce a Foley catheter into the bladder through
the urethra and then suture the tear with two layers
of seromuscular stitches of 0 absorbable suture. Do not
include the mucosa in the first layer (Figures
6.63, 6.64, 6.65). After inspecting the other viscera, close
the abdomen.
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| 3 |
Extraperitoneal
rupture is usually associated with bladder distension
and extravasation, which become obvious when you expose
the bladder. Open the bladder, and look for the site
of the tear. It may be difficult to find but, if it is
clearly visible, close it from within with 2/0 absorbable
suture and insert a suprapubic catheter. If no tear is
apparent, simply insert a suprapubic catheter. Close
the opening in the bladder to construct a suprapubic
cystostomy. Insert a latex drain into the retropubic
space and close the wound in layers. |
Aftercare
| 1 |
Administer
antibiotics for the first five days and give adequate
fluids to maintain the urinary output. The drain can
be removed when urine or blood drainage has ceased.
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| 2 |
For
extraperitoneal rupture, clamp the catheter for increasing
periods of time, beginning on about the fifth day. The
patient with a suprapubic catheter may start passing
urine during this period; if so, remove the catheter.
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| 3 |
In
cases of intraperitoneal rupture, remove the urethral
catheter after about two days of intermittent clamping,
provided that no problems result. |
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