Bladder Safety during Natural Orifice Transluminal Endoscopic Surgery Hysterectomy in the Patients with Extensive Vesicouterine Adhesion

Abstract

Adhesion at the vesicouterine fold presents a great challenge when performing hysterectomy through transvaginal natural orifice transluminal endoscopy surgery (NOTES) in women with a history of cesarean section. An attempt to lyse adhesions often prolongs the procedure and may inadvertently result in cystostomy. The purpose of this report is to demonstrate a safe technique for the lysis of vesicouterine adhesions during NOTES hysterectomy. We present the cases of two patients with a history of cesarean section. Severe adhesions at the vesicouterine peritoneum were encountered in both cases, and one patient had an extensive adhesion involving lower half of the uterus. Although the lateral approach is sufficient in most cases, it does not allow a surgeon to approach the peritoneal cavity if there is extensive adhesion. In cases such as these, direct dissection of the adhesion on the uterus is required.

Keywords: Bladder injury; cesarean section; hysterectomy; natural orifice transluminal endoscopy surgery.

Figure 1

A view of lysis vesicouterine adhesion (adhesion secondary to a previous cesarean section). We tried to identify the junction between peritoneum and uterus (a). After cutting the uterine artery and dissecting the peritoneum at the lateral part (b). The peritoneal cavity was entered (c). C-section: Cesarean section, Lt. UA: Left uterine artery

Figure 2

Lysis of the vesicouterine adhesion. The adhesion involved more than the lower one-half of the uterus. We were unable to enter the peritoneal cavity using a lateral approach (a). Direct dissection of the vesicouterine adhesion (b). The peritoneal cavity was entered (c)