Shrewsbury and Telford Hospital NHS Trust, UK.
Ann R Coll Surg Engl. 2022 Nov;104(9):e255-e257. doi: 10.1308/rcsann.2021.0344. Epub 2022 Apr 21.
We report a rare complication involving a healthy 45-year-old male patient who underwent an emergency laparoscopic appendicectomy for acute perforated gangrenous appendicitis. The patient was catheterised pre- procedure and the ports were inserted under vision. Upon completion of the procedure, a 15 Fr Robinson drain was left in the pelvis and was fed through the suprapubic port hole. Postoperatively the patient developed worsening, generalised abdominal pain and high output from the drain. The patient was re-catheterised but the computed tomography (CT) cystogram did not show any injury to the bladder. The drain fluid creatinine was noted to be raised (>4,000), indicating that urine was leaking into the drain. Conventional cystogram confirmed a contrast leak from the dome around the drain. Flexible cystoscopy confirmed that the drain had transversed the vesicourachal diverticula. The drain was pulled back and converted to a suprapubic catheter with the patient subsequently being discharged. Vesicourachal diverticula is a rare and often asymptomatic anomaly. When undertaking laparoscopic surgery, precautions should be taken to prevent port site injury such as catheterising the patient to ensure the bladder is empty and inserting the ports under direct vision. It is safer to visualise muscle rather than peritoneum during port insertion. In this case, the bladder diverticula was noticed extraperitoneally. Though the indirect CT cystogram reported no injury, this was unreliable as the bladder was not distended which led to the subtle injury being missed. Traditional cystogram should be considered in cases with a negative CT cystogram and a strong suspicion of bladder injury.
我们报告了一例罕见的并发症,涉及一位健康的 45 岁男性患者,他因急性穿孔坏疽性阑尾炎而行紧急腹腔镜阑尾切除术。患者在术前进行了置管,并且在直视下插入了端口。手术完成后,在盆腔中留下了一个 15Fr 的 Robinson 引流管,并通过耻骨上端口穿出。术后,患者出现恶化的、全身性腹痛和引流管高流量。患者再次进行了置管,但 CT 膀胱造影并未显示膀胱有任何损伤。引流液中的肌酐升高(>4000),表明尿液漏入引流管。常规膀胱造影证实了引流管从周围穹顶处有造影剂泄漏。软性膀胱镜检查证实引流管穿过了膀胱输尿管憩室。将引流管向后拉并转换为耻骨上导管,随后患者出院。膀胱输尿管憩室是一种罕见且通常无症状的异常。在进行腹腔镜手术时,应采取预防端口部位损伤的措施,如对患者进行导尿以确保膀胱排空,并在直视下插入端口。在插入端口时,观察肌肉而不是腹膜更安全。在这种情况下,膀胱憩室是在腹膜外发现的。尽管间接 CT 膀胱造影报告没有损伤,但这是不可靠的,因为膀胱没有膨胀,导致轻微的损伤被遗漏。在 CT 膀胱造影阴性且强烈怀疑膀胱损伤的情况下,应考虑传统的膀胱造影。