Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Labarotomy
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Peritonitis
Stomac and duodenum
Gallbladder
Appendix
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Abdominal Trauma
 


> RUPTURED SPLEEN
> LACERATION OF THE LIVER
> SMALL INTESTINE
> COLON
> RETROPERITONEUM
> RUPTURE OF THE BLADDER
> MANAGEMENT OF RUPTURED
> BLADDER


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.

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.

Figure 6.63
Figure 6.63
Figure 6.64
Figure 6.64
Figure 6.65
Figure 6.65
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.

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.

3 In cases of intraperitoneal rupture, remove the urethral catheter after about two days of intermittent clamping, provided that no problems result.


> RUPTURED SPLEEN
> LACERATION OF THE LIVER
> SMALL INTESTINE
> COLON
> RETROPERITONEUM
> RUPTURE OF THE BLADDER
> MANAGEMENT OF RUPTURED
> BLADDER



Top of Page