Bladder rupture repair

Bladder injury is divided into two pathological types: contusion and rupture. Bladder contusion is only the bladder mucosa and submucosal damage, the integrity of the bladder is not destroyed, so in addition to bleeding, there is no extravasation of urine, more self-healing, no need for surgery. Bladder rupture is a full-thickness rupture of the bladder wall, with extravasation of the urine, requiring more surgical treatment. According to the location of bladder rupture, there are three clinical types: intraperitoneal, extraperitoneal and intraperitoneal rupture. Intraperitoneal rupture is caused by violence in the lower abdomen when the bladder is filled, or penetrating injury in the lower abdomen. Extraperitoneal rupture is more common in pelvic fractures. Bladder perforation can occur in intravesical instruments such as cystoscopy and prostatectomy. Extraperitoneal rupture can also be seen in surgical injuries and birth injuries. Intra-peritoneal and external rupture is caused by penetrating injury of the lower abdomen. When the bladder is ruptured, the bleeding is generally not serious and does not cause shock. However, if a large amount of bleeding occurs due to intra-abdominal organ injury or pelvic fracture, it may often lead to shock. After the injury, due to extravasation of the bladder urine, the wounded often have no history of urinating after injury, and some have urine, but no urine discharge or only a small amount of hematuria. When the bladder penetrates, blood and urine can flow out of the wound. Symptoms occur after hemorrhage and extravasation of the bladder after rupture of the bladder. When the extraperitoneal rupture occurs, blood and urine extravasate into the pelvic cavity, and local irritation such as lower abdominal pain, muscle tension, and tenderness appear. When the intraperitoneal rupture, blood and urine extravasation into the abdominal cavity, there are symptoms of peritoneal inflammation, such as abdominal pain below the abdominal pain, muscle tension, tenderness and rebound tenderness, and may have mobile dullness. Therefore, the hematoma should be removed as much as possible during surgery, the extravasation of urine must be absorbed and drained, the bladder cleft should be repaired, and the bladder stoma should be paralleled to ensure the healing of the bladder wound. If there is a combined injury, it should be handled accordingly. Curing disease: Indication 1. The symptoms of urinary extravasation occurred after the lower abdomen injury, and 400 ml of isotonic saline was injected into the bladder. The amount of extraction was significantly less than or greater than the amount injected, or the contrast was confirmed by cystography. 2. The wound in the lower abdomen after trauma to the urine. Contraindications Bladder injury is accompanied by other life-threatening vital organs. When the injured person is seriously injured and has shock, he should first treat with anti-shock and indwell the catheter to reduce extravasation. First treat other vital organs that are life-threatening and then treat the bladder damage. Preoperative preparation 1. Check the injury in detail to determine if there is a combined injury. 2. If you have shock, you should first take anti-shock treatment. 3. Indwelling catheter to drain urine to reduce extravasation. 4. Apply antibiotics to prevent infection. Surgical procedure 1. Incision pubic bone upper and lower abdomen midline incision 2. Expose the bladder to cut the skin along the direction of the incision, switch to the subcutaneous tissue with an electric knife, and use a gauze towel to protect the skin after electrocoagulation. The anterior sheath of the rectus abdominis was incised, and the rectus abdominis and conus muscles were separated from the midline, and the transverse fascia was transected. Because the bladder is mostly in an empty state, the peritoneum is often revealed first. The peritoneal reflex is pushed up with gauze to reveal the bladder. Remove the hematoma around the bladder. 3. Exploring a closed bladder rupture, if diagnosed as an extraperitoneal type, and certainly no intra-abdominal organ damage, do not need to explore the abdominal cavity. However, if there are any of the following conditions, abdominal exploration should be performed. 1 The wounded had a sense of urine before injury, indicating that the bladder is filled, and the possibility of intraperitoneal rupture is large; 2 there are signs of peritonitis, abdominal puncture to extract urine or bloody liquid; 3 there is free gas in the abdominal cavity; 4 when cystography, there is The contrast agent overflowed into the abdominal cavity; 5 after the abdominal wall was opened, no hematoma and extravasation were found around the extraperitoneal bladder. Open bladder rupture should first detect the presence or absence of intra-abdominal organs, and pay attention to the presence or absence of retroperitoneal hematoma. If so, the peritoneum should be opened for exploration and finally the bladder should be explored. If the intraperitoneal rupture, after the peritoneum is cut, the rupture is easy to find. In the case of extraperitoneal rupture, the rupture is located in the anterior wall and the side wall, which is easier to find. Located in the posterior wall and neck, it is difficult to find, it must be injected into the bladder with methylene blue solution, and the part where the blue liquid flows out is the crack. If necessary, the bladder can be opened and carefully explored in the bladder. The crack is not difficult to find. 4. When the repair of the rupture of the extraperitoneal bladder is repaired, the contused tissue around the rupture should be cut off, and the 2-0 absorbable line should be used for full-thickness or continuous suture, and then the sarcoplasmic layer should be sutured and sag. When the intraperitoneal bladder rupture is repaired, the peritoneum of the rupture should be slightly separated from the bladder, and the bladder rupture should be repaired as above. The peritoneum was sutured continuously with a No. 1 silk thread. Due to the deep position of the bladder neck laceration, it is not easy to be exposed. The bladder can be pressed back to the upper healthy side to facilitate the exposure of the neck, and the slit is sutured with a short round needle. If it can not be revealed and sutured by this method, the crack can be revealed in the bladder and sutured. 5. After the bladder stoma is repaired, it is generally necessary to puncture the anterior wall of the extraperitoneal bladder and insert the F28 sputum catheter. The upper and lower sides of the tube are sutured with a 2-0 absorbable thread to fix the stoma. tube. Then, 200 ml of isotonic saline was injected into the bladder to observe whether there was leakage of the repaired crack; if any, it was necessary to suture the needle until it did not leak. If the bladder is very small, it is not necessary to make a bladder stoma. The urine is indwelled by the urethra. 6. Place the drainage and thoroughly rinse the wound. After the gauze and the instrument are not missing, place one rubber drainage tube in the posterior pubic space. After the intraperitoneal bladder rupture was repaired, a rubber drainage tube was placed outside the peritoneum at the repair site. The abdominal wall incision was sutured layer by layer, and the bladder stoma was fixed with skin suture. complication 1. Infection mainly refers to infection around the bladder, bladder wounds and abdominal incisions. The reasons are as follows: 1 The wounded came to the hospital late, and there were signs of infection in the local area, which increased the chance of postoperative infection; 2 The hematoma around the bladder and the extravasation of urine were not complete. The preventive measures are to fully drain the hematoma around the bladder and extravasation of the urine and strengthen the application of intraoperative and postoperative antibiotics. After the infection occurs, the skin suture should be removed, the wound should be enlarged, the drainage should be fully extended, and the application of antibiotics should be strengthened. 2. The leakage of urine in the wound is mainly caused by the contusion of the bladder at the breach of the bladder, resulting in poor healing or infection of the bladder. In order to maintain the bladder ostomy tube or the urethral indwelling catheter, the wound is fully circulated, the wound is fully drained, the foreign body such as silk thread in the wound is removed in time, and the application of antibiotics is strengthened. The wound can generally heal, and there is not much chance of forming a bladder wall.