Candidate’s instruction
You are operating on a woman who has been admitted as an emergency in theatre assisted by an SHO.
The patient is a 32 year-old woman who has been admitted with acute abdominal pain for several days. Her ultrasound scan has shown a 7cm diameter cyst on her left ovary and her signs and symptoms make you suspect torsion. Her BMI is 25. She has two children, both delivered by caesarean section.
You open the abdomen through the previous Pfannenstiel lower abdominal incision. As you cut through the rectus sheath you notice some clear fluid filling the operative field and realize that the bladder has accidentally been opened.
You will be marked on your ability to deal with this complication
Questions
- What immediate action would you take?
- How would you proceed to complete the operation?
- What is your post-operative management plan?
- What issues would you discuss with the patient postoperatively?
Answers
- What immediate action would you take?
- Tell the anaesthetist – Need to extend the anaesthesia
- Tell the theatre team – need of additional procedures
- Call the consultant into theatre
- Assess the site and extent of the bladder injury
- Decide with the consultant whether urological assistance is required
- How would you proceed to complete the operation?
- Absorbable suture for bladder repair (Polyglactin 3-0)
- Repair bladder in 2 layers
- Consider ureters – could they be involved?
- If trigon or ureters involve in the injury, get urologist assistance
- Can use methylene blue dye to check the repaired bladder
- Proceed to deal with torted ovary
- Assess the condition of the ovary
- Untwist and if possible do the cystectomy
- If the ovary is non-viable can go for salpingo-oophorectomy
- Insert peritoneal drain (not suction drain)
- Close abdominal peritoneum
- Approximate rectus muscle over repaired bladder
- Ensure Foley catheter in-situ
- What is your post-operative management plan?
- Careful and complete documentation in notes
- Pain relief with paracetamol or NSAIDs
- Antibiotic prophylaxis
- Leave catheter for 7-10 days on free drainage
- CSU for microbiology post-operatively
- Careful fluid balance chart
- Senior gynaecologist to be alerted if urinary catheter not draining
- Complete an incident form, arrange risk management
- Inform GP
- What issues would you discuss with the patient postoperatively?
- Full explanation of operative details including why the injury happened (bladder stuck to rectus sheath due to previous caesarean sections)
- Explain that no long-term problems are expected
- Explain need for catheter and the duration of catheterization
- May have cystogram before catheter removal
- Arrange follow-up with consultant
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