1338 | Laparoscopic Repair of Intraperitoneal Blad- der Rupture after Blunt Abdominal Trauma Dianne Mortelmans, Nouredin Messaoudi, Joris Jaekers, Raymond Bestman, Steven Pauli, Marc Van Cleemput Keywords: abdominal injuries; surgery; laparoscopy; methods; rupture; urinary bladder; inju- ries. INTRODUCTION Urinary bladder rupture following blunt abdominal trauma is frequently encountered in multiple trauma patients with pelvic-ring fractures.(1-3) Rupture of the bladder can be extraperitoneal (50%-71%), intraperitoneal (25%-43%) or combined (7%-14%). (4,5) Conventionally, this injury has been managed with explorative laparotomy and repair. We report a case of a 30 years old woman diagnosed with an isolated intraperitoneal bladder rupture which was successfully treated using a minimal invasive laparoscopic approach. CASE REPORT A 30-year-old woman was admitted to the emergency department after being involved in a car accident. On physical examination, she was agitated with Glasgow Coma Scale 15, but no neurological deficit. The patient had normal vital signs with blood pressure of 115/63 mmHg, a pulse rate of 84 beats per min and normal oxygen saturation. She complained of severe pain in the lower abdomen. Palpation revealed muscular defense and rebound tenderness. Multiple abrasions on both pelvic crests were present, however no sign of pelvic instability was noted. Corresponding Author: Nouredin Messaoudi, MD Department of General Surgery, Monica Hospital, Florent Pauwelslei 1, b2100 Deurne, Belgium. Tel: +32 4 9485 3011 Fax: +32 3 320 5600 E-mail: nouredinmessaoudi@gmail. com Received January 2012 Accepted April 2012 Department of General Surgery, Monica Hospital, Deurne, Belgium. CASE REPORT Case Report 1339Vol. 11 | No. 01 | Jan-Feb 2014 |U R O LO G Y J O U R N A L Intraperitoneal Bladder Rupture | Mortelmans et al Laboratory findings showed no abnormalities, except for a blood alcohol level of 2.06 g/dL. Computed tomography demonstrated free fluid in the abdominal cavity. Solid or- gans showed no pathological signs. Anterograde filling of the bladder after intravenously injected contrast confirmed an empty urinary bladder. Hence, a bladder rupture was sus- pected. There was no pelvic fracture (Figure 1). Associated thoracic injuries were a ruptured breast implant and a fracture of the clavicle, both on the left side. As there was no sign of urethral injury, a Foley catheter was inserted draining gross hematuria. The patient was prepared for laparoscopic exploration and repair under general anes- thesia. Upon inserting a Veress needle to establish pneumo- peritoneum of 15 mmHg, the urine collecting bag started to distend. Using a 30-degree scope, meticulous laparoscopic exploration was underwent. A large amount of free blood- stained fluid was found around the liver and the spleen, and in the pouch of Douglas. Systematic inspection of the abdo- men revealed an intact liver, spleen, stomach, intestines and ovaries. In the dome of the bladder, a 2 cm laceration was noted. The bladder rupture was repaired using an interrupted single layer of absorbable Vicryl 3/0 sutures (Figure 2). Postoperatively, the patient made an uneventful recovery. The urinary catheter was removed after eight days, following a retrograde cystography confirming an intact urinary blad- der without leakage (Figure 3). The associated thoracic in- juries were managed accordingly by the relevant specialists. DISCUSSION Often accompanied by visceral organ damage and pelvic bone fractures, we report a case of an isolated intraperito- neal urinary bladder rupture diagnosed after blunt abdominal trauma. In his case series, Wirth et al and colleagues reported only 17% of traumatic bladder ruptures to be associated with no other injury.(2) Furthermore, intraperitoneal laceration is uncommon, ranging from 25% to 43% of all bladder ruptures following external trauma.(5) In the present case, the diuretic effect of alcohol aggravated by sudden increase of intravesi- cal pressure following blunt abdominal trauma resulted in a lacerated bladder. Nonetheless, spontaneous ruptures of the bladder have been described in previous reports.(6-8) Conservative approach by prolonged catheterization is insuf- ficient in the treatment of bladder rupture.(9) Adequate surgi- cal repair is the treatment of choice. Advances in minimal invasive techniques over the last decade changed the initial approach of trauma patients. Laparoscopy has proven to be an efficient diagnostic and therapeutic tool in selected trauma cases. Conventionally, injury to the bladder was repaired by laparotomy allowing simultaneous evaluation of potentially associated visceral organ damage. In hemodynamically un- stable patients this remains the golden standard.(10) Following a systematic approach described by Gorecki and colleagues,(11) laparoscopic exploration for trauma can be safely preformed in hemodynamically stable patients. In our case, diagnosis was confirmed using laparoscopy, both by visualization of the rupture in the dome of the bladder, as well as distension of the urine collecting bag due to pneu- moperitoneum. The laceration of the bladder rupture was repaired using a single layer suture. There seems to be no advantage difference in outcome between a single layer(3,9,12) Figure 1. Computed tomography scan showing fluid collection in the abdominal cavity and an empty bladder. 1340 | Case Report and double layer suturing technique.(10,13-15) The placement of a supra-pubic catheter is not needed.(9) Watertight closure can be confirmed by the injection of normal saline or methyl- ene blue through the urinary catheter.(3,9,15) In conclusion, laparoscopic repair of an isolated intraperito- neal bladder laceration using single layer interrupted suturing technique is a feasible alternative to laparotomy in hemody- namically stable trauma patients with no other intraabdomi- nal injury, resulting in reduced morbidity, faster recovery and better cosmetic results. CONFLICT OF INTEREST None declared. Figure 2. A) Laparoscopic view of the abdomen demonstrating free blood-stained fluid in the pelvic cavity and the intraperito- neal bladder rupture in the dome. B) Repair of urinary bladder with Vicryl 3/0 single interrupted suture layer. Figure 3. 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