Laparoscopic Approach to Severe Bladder Adhesions: Simple Steps

INTRODUCTION: Anterior cul-de-sac adhesions are commonly seen during gynecologic surgeries. The main risk factor for bladder adhesions is history of cesarean section. More than one third of the women with at least one cesarean section have bladder adhesions. This risk increases with the number of caesarean sections: 32% after one cesarean section, 42% after two cesarean sections, and 59% after three or more cesarean sections. Other risk factors for anterior cul-de-sac adhesions include: endometriosis, obesity, and postpartum or other pelvic infections Systematic approach to anterior cul-de-sac adhesions is crucial given that the relative risk of urinary tract injury is about 3.5 in cases with history of previous cesarean sections. OBJECTIVE: In this video, we describe simple steps to conquer bladder adhesions and obliterated anterior cul-de-sac. METHODS: The idea is to approach the pathology from the least distorted anatomy; lateral spaces are often less distorted. Lateral to medial approach helps avoid cutting on the adhesions themselves. Once the uterine vessels are clearly isolated and skeletonized, the pedicels are desiccated therefore reducing risk of bleeding. Next step is to identify the endopelvic fascia anterior and medial to the uterine vessels; identify the avascular plane with characteristic pearl white endopelvic fascia. By developing this plane, the bladder can be safely dissected away from the lower uterine segment. Use other tools to safely delineate the borders: backfill bladder and cold cut in cases where the bladder is closely adhered to the area of interest. RESULTS: By following this approach, the surgeon mitigates the risk of bladder injury during laparoscopic hysterectomy. CONCLUSIONS: Even the most severe bladder adhesions can be addressed by following the systematic approach: Circle the dragon; lateral to medial approach to start from normal anatomy, desiccating all pedicles to reduce blood loss, identifying end-pelvic fascia, and avoiding the adhesions themselves (Figures 1 and 2).