(Video Poster 32) Laparoscopic Cystotomy Closure: Precision, Proficiency and Practicality

Objectives: Iatrogenic cystotomy can occur during pelvic surgery. The aim of this video is to highlight advanced techniques to improve operative efficiency and surgeon comfort with laparoscopic cystotomy closure. By utilizing these added skills, surgeons can be more confident completing minimally-invasive cystotomy repairs.

Methods: We demonstrate surgical techniques using several unique patient cases with iatrogenic cystotomies of varying sizes and locations. First, it is imperative to identify cystotomy location with relation to the ureters, to best guide the repair and any concomitant procedures. We review considerations for laparoscopic port placement as well as choice of suture material to optimize laparoscopic suturing for the surgeon. We visually demonstrate techniques for laparoscopic needle management and tissue manipulation, including needle loading and introduction, adjustment, and tissue handling. We demonstrate the tenants of good cystotomy repair including tension-free and water-tight closure, and present a method for laparoscopic drain placement to assess for integrity of the repair postoperatively. Finally, postoperative care and follow-up are addressed.

Clinical Relevance: Iatrogenic cystotomy occurs in 1-8 percent of pelvic surgeries, with prior abdominal surgery, including cesarean section, and history of endometriosis increasing this risk. Repair of injuries sustained during laparoscopic surgery may be completed either open or in a minimally invasive approach. Laparoscopic cystotomy closure allows surgeons to maintain a minimally invasive approach while using existing equipment, reducing operative and anesthesia time, minimizing postoperative pain, and accelerating patient recovery. By applying the techniques demonstrated in this video, surgeons can gain greater confidence and proficiency in performing laparoscopic cystotomy repair.