Lateral Approach Technique to Minimize Bladder
Injury During Abdominal Hysterectomy in Cases with Previous Cesarean Sections: An Observational Study
Ibrahim Saif Elnasr*
Obstetrics and Gynecology Department, Menoufia University-Menoufia governorate, Egypt
Submission:October 04, 2018 ; Published: October 25, 2018 ;
*Corresponding author: Ibrahim Saif Elnasr, Obstetrics and Gynecology Department, Faculty of Medicine, Menoufia University-Menoufia governorate, Egypt.
How to cite this article: Ibrahim Saif E. Lateral Approach Technique to Minimize Bladder Injury During Abdominal Hysterectomy in Cases with Previous
Cesarean Sections: An Observational Study. J Gynecol Women’s Health. 2018: 12(3): 555837. DOI: 10.19080/JGWH.2018.12.555837
Objective:to evaluate the safety and efficacy of Lateral approach technique to avoid bladder injury during total abdominal hysterectomy in cases with previous Cesarean section.
Methods: This prospective observational study included 150 patients with previous cesarean deliveries who were candidates for total abdominal hysterectomy due to various indications. Enrolled patients were divided in two groups; Group 1 included 75 patients to whome the urinary bladder was dissected from the uterus by classical central approach and Group 2 included 75 patients to whome the bladder was dissected from the uterus by lateral approach technique. The rate of intraoperative bladder injury, operative time and late urological complications were the main outcome measures. Data was collected and tabulated.
Results: there was significant statistical difference between two groups as regarding urinary bladder injury (<0.05) with only one case of bladder injury in group 2 compared to 10 cases in group one. The duration of the procedure was shorter in group 2 (p<0.001).Group one Patients need excessive analgesia (<0.05 ), post-operative fever increased in group one (<0.001). Group one Patients need blood transfusion (<0.05 ) and hospital stay more than group 2 (<0.001).
Conclusion: lateral approach technique for bladder dissection was safer and faster in preventing bladder injury during total abdominal hysterectomy compared to the classical central approach. Larger multicenter trials are warranted to enforce or refute these findings.
Hysterectomy is one of the most common operations performed in the United States. Approximately 600,000 per year, It was reported that uterine fibroid considered the Most common indications for hysterectomy (40.7%) followed by endometriosis (17.7%) and prolapse (14.5%) .
Multiple surgical approaches may be applied to perform Hysterectomy including abdominal approach, vaginal approach, laparoscopic assisted vaginal approach, laparoscopic and robotic assisted approaches . However, analysis of U.S. surgical data shows that abdominal hysterectomy is the most common rout for hysterectomy and performed in 66% of cases, vaginal hysterectomy in 22% of cases, and laparoscopic hysterectomy in 12% of cases .
Many complications may occur during Hysterectomy. Urological injuries considered common complication during hysterectomy especially in patients with history of previous
caesarian section . As reported by Sheth, et al. , Bladder
injury considered the commonest urological complication
during hysterectomy and the increasing number of cesarean deliveries nowadays may contribute to a higher incidence of bladder injuries in subsequent hysterectomies due to dense vesicocervical adhesions and distorted anatomy . For women with histories of cesarean delivery, the odds ratios for bladder injury were 7.50 for laparoscopic-assisted vaginal hysterectomy (LAVH), 1.26 for total abdominal hysterectomy (TAH), and 3.00 for transvaginal hysterectomy .
Adhesions between the bladder and the lower uterine segment after cesarean section commonly limited to vesicocervical space with sparing of parametrial space. W-c Chang, et al.  considered dissecting the bladder from lateral to medial through the broad ligament decrease risk of bladder injury during laparoscopic assisted vaginal hysterectomy (LAVH) . This study was conducted to evaluate the efficacy and safety of Lateral approach technique through the broad ligament to avoid bladder injury during total abdominal hysterectomy in cases with previous Cesarean section.
After the study protocol was reviewed and approved by
the local ethics committee at Menoufia University hospital, this
prospective observational study was performed at the Obstetrics
and Gynecology department at Menoufia university hospital,
Shibin El-kom city, Menoufia governorate, Egypt in the period
between January 2017 till August 2018.
All procedures performed in the current study involving
human participants were in accordance with the ethical standards
of the Menoufia Fcaulty of Medicine research committee and with
the 1964 Helsinki declaration and its later amendments. The
study was approved by Institutional review board of Obstetrics
and Gynaecology department, Letter Number (326H/2016).
The cases of urologic injuries during total abdominal
hysterectomy were identified from the operating room record
book, in patient room record book and departmental monthly
audit reports. Demographic and clinical data collected included
age, parity, body mass index, Number of cesarean deliveries and
indications for hysterectomy Operative data collected included
Type of anesthesia, Operative time, Ureter and Small intestine
injury, Blood transfusion, Bladder injury and blood loss. Postoperative
data collected included venous thromboembolism,
surgical site infection, reoperation, Request for additional
analgesia, Fever and Hospital stay.
In our study we excluded cases underwent total abdominal
hysterectomy without previous CS scar, vaginal hysterectomy,
laparoscopic assisted vaginal hysterectomy, laparoscopic
hysterectomy and cesarean hysterectomy, 150 women with
previous cesarean deliveries who were candidates for total
abdominal hysterectomy enrolled and was allocated into two
Group 1: include 75 patients while the bladder was dissected
from the uterus by classical central approach
Group 2: include 75 patients while the bladder was dissected
from the uterus by lateral approach technique
The patients were in the dorsal position. Sterilization,
catheterization and toweling were done. After general or regional
anesthesia skin incision was conducted vertically or horizontally
according to the indication for hysterectomy. The incision was
made to cut through skin and muscle of the abdomen. The
general condition of the abdomen was inspected. Both round
ligament and infundiplopelvic ligament was clamped and ligated
in both side. The space between anterior and posterior leaflet of
the broad ligament was opened by surgical scissor then easily
through blunt dissection by finger. The key was that we stayed
as lateral as possible and not moved too medially toward the
uterus to avoid injury to uterine vessels with care to vessels in
the lateral pelvic wall. The posterior leaflet of the broad ligament
was cut toward the origin of uterosacral ligament after carful
dissection to avoid ureteric injury.
Once adequate area of posterior leaflet was dissected and
cut and adequate window was created in the broad ligament,
the anterior leaflet of the broad ligament was elevated by artery
forceps then we swept the index finger of the right hand from
lateral to medial to define the midline adhesions secondary to
previous cesarean deliveries. During creation of lateral window
the uterus was taken upward and to the opposite side then it was
centralized upward posteriorly to give more counter traction.
After clearly identifying bladder wall we pushed down the
bladder away before cutting any adhesion band under direct
vision and finger guidance. We preferred to push bladder entirely
from one side (started with Rt side) so once adequate amount
of dissection was conducted we moved easily to the opposite
side to complete bladder dissection. Both uterine arteries were
clamped and ligated then total hysterectomy was performed as
Foleys catheter was inserted to all patients which removed
after patients were fully mobilized. All patients received
routine intraoperative and post-operative care for abdominal
hysterectomy and discharged from the hospital after catheter
removal and returning of intestinal motility. All the patients
were monitored at the outpatient clinic 1 week after operation to
evaluate the wound for surgical site infection and any urological
complaint. Then after one month to evaluate for possibilities of
late urological complication as genitourinary fistula.
The data collected were tabulated & analyzed by SPSS
(statistical package for the social science software) statistical
package version 22 on personal compatible computer.
Quantitative data was analyzed by applying student t- test
or Mann-Whitney test as required while qualitative data was
analyzed by applying Chi-square test and Fisher’s exact test as
required with a significance level of P value less than 0.05.
During the study period out of 170 hysterectomies were
conducted in our unites, 20 cases vaginal hysterectomy, 75 cases
abdominal hysterectomy in patient with no previous scar and
75 cases abdominal hysterectomy in patients with previous
scar. Table 1 represents patients’ characteristics. There was no significant difference between both group regarding age, parity, body mass index, Number of cesarean deliveries and indication for
*Mann Whitney test, CS=Cesarean section
Table 2 revealed the operative data. There was no significant
difference between both group regarding age Type of anesthesia
Operative time, Ureter and Small intestine injury (p>0.05).
There was significant difference between both group regarding
Blood transfusion (<0.05). there was significant difference
between both group as regarding Bladder injury with marked
improvement in group 2 one case of bladder injury in contrast
to 10 cases in group 2 (<0.05 ). There was highly significant
difference between both group as regarding blood loss (<0.001).
Table 3 shows postoperative data. There was no significant
difference between both group VTE=Venous thromboembolism,
SSI=Surgical site infection and reoperation (>0.05). There was
significant difference between both group regarding Request for additional analgesia (<0.05). There was highly significant difference between both group as regarding Fever and Hospital stay
*Fischer’s exact test, †Student t-test, VTE=Venous thromboembolism, SSI=Surgical site infection.
Hysterectomy remains the most common gynecologic
procedure in the United States and all over the world; although
Minimally invasive approaches to hysterectomy have welldocumented
advantages, yet abdominal hysterectomy remains
the most common mode of access, accounting for more than 60%
of all hysterectomies performed in the United States .
Multiple cesarean deliveries are associated with an
increased risk of pelvic adhesive disease and difficulty with
bladder dissection during subsequent gynecologic surgery
especially hysterectomy. The bladder dome adhered to the lower
uterine segment requires meticulous dissection to avoid injury.
Cystostomy occurs in greater than 20% of women with more
than 3 prior cesarean deliveries .
Urinary bladder injury considered important surgical
hazardse specially during hysterectomy and cesarean section.
With regard to bladder injury, the dome of the bladder is
commonly involved in injury during total hysterectomy. Nearly
two thirds of all bladder injuries occur during gynecological
surgery and most of these complications occur during surgeries
via abdominal route compared to vaginal route .
Urinary bladder injuries due to obstetric and gynecologic
surgery are normally divided into two categories: acute
complications such as bladder laceration that can be identified
immediately during the operation, and chronic complications
such as vesico-vaginal fistula which can occur later on. To
avoid these injuries the gynecologist must have an accurate
understanding of pelvic anatomy, use a meticulous and
methodical surgical technique, and maintain a constant high
degree of vigilance .
Most adhesions between the bladder and the loweruterine
segment after cesarean delivery are located in the vesico-cervical
space, which is in the middle of the operation field flanked by
bilateral parametrial space inside the broad ligaments. The idea
of trying to go from lateral to medial toward the bladder is that
in almost cases of previous section the fibrous scar tissue related
to uterus only and lateral space not affected so we the bladder
was separated and fibrous tissue was cut under vision and finger
In our study symptomatic uterine fibroid was the most
common indication for hysterectomy and other indications listed
in Table 1. All patient passed flatus and had oral fluid intake
at next day of surgery. We noticed that blood loss and blood
transfusion was less in group 2 this may be due to reaching a
good plane for bladder dissection which was less vascular
without injury to any pelvic venous plexus.
There was significant difference between both group as
regarding Bladder injury with marked improvement in group 2
where one case of bladder injury in contrast to 10 cases in group
2 (<0.05 ) this is may be due to proper identification of bladder
anatomy. This in consistence with the study conducted by WC
Chang et al.  where 50 patients with vesicocervical adhesion
after previous cesarean deliveries who underwent laparoscopic
assisted vaginal hysterectomy After incorporation of the lateral
intervention method into the LAVH procedures, no bladder
injury occurred among any of the 50 patients.
Our results not consistence with the study conducted by
Tarek R et al.  where 570 patients had abdominal hysterectomy
The frequency of bladder injury was higher being 2.3%. This
high incidence may be due to bladder dissection in classic
approach. All cases with bladder injury during total abdominal
hysterectomy were diagnosed intraoperatively and immediately
repaired by urological consultant in two layers with 2/0 vicryl
with Foleys catheter drainage for 10 days. Only one case (group
1) presented after one month from surgery complaining of
urine leak, investigated and diagnosed as having vesicovaginal
fistula which repaired after three months from the surgery. In
this study we had some technical difficulties in the first few case
but in rapid fashion the surgical team became familiar with the
technique and short operative time for abdominal hysterectomy
We founded that lateral approach technique of bladder
dissection was very useful in preventing bladder injury in our
cases and also was very easy to be performed. Larger multi
center trials are warranted to enforce or refute these findings.
We recommend proper training of this approach by all staff
and application of this approach to other cases as cesarean
hysterectomy in cases of placenta accreta.