Surgical Therapy of Bladder Rupture A-Intraperitoneal bladder rupture (vỡ bàng quang trong phúc mạc) Most, if not all, intraperitoneal bladder ruptures require surgical exploration. These injuries do not heal with prolonged catheterization alone. Urine takes the path of least resistance and continues to leak into the abdominal cavity. This results in urinary ascites, abdominal distention, and electrolyte disturbances. Surgically explore all gunshot wounds to the lower abdomen. Because of the nature of associated visceral injuries, immediately take patients with high-velocity missile trauma to the operating room, where the bladder injuries can be repaired concomitantly with other visceral injuries. Stab wounds to the suprapubic area involving the urinary bladder are managed selectively. Surgically repair obvious intraperitoneal injuries, and manage small extraperitoneal injuries expectantly with catheter drainage. B- Extraperitoneal extravasation Bladders with extensive extraperitoneal extravasation often are repaired surgically. Early surgical intervention decreases the length of hospitalization and potential complications, while promoting early recovery. C- Preoperative Details Follow the basic trauma protocol (advanced trauma life support [ATLS]), and stabilize the patient. Administer broad-spectrum antibiotics, and obtain a surgical informed consent, if possible. In the setting of emergency trauma, however, there is often no time for a formal surgical consent from the patient. D- Intraoperative Details (Chi tiết phẫu thuật) 1-Position the patient in a supine fashion. 2-Create a vertical midline abdominal incision. 3-Conduct a thorough inspection of the pelvic viscera, ureters, bowel, and blood vessels. 4-Note the presence of pelvic hematoma and, if present, leave undisturbed. 5-Bivalve the dome of the bladder. 6-Inspect the interior of the bladder. Foreign bodies such as bone or orthopedic hardware are often encountered and should be removed. 7-Identify both ureteral orifices and ensure that they are intact. 8-Once the bladder injury is localized, débride all nonviable tissue. 9-High-velocity missile injuries may cause extensive damage to the bladder tissues. 10-Close the bladder in a watertight fashion using 3 layers with an absorbable suture. Every effort should be made to protect the closure from any sharp edges or bony protusions from associated pelvic fractures. Omental fat is often interposed on the closure as an additional layer. 11-Test the integrity of the closure by inflating the bladder with saline or water. 12-Place a large-bore suprapubic tube through a separate cystotomy site prior to closing the bladder. 13-Place a pelvic drain in the perivesical space (Đặt một ống dẫn lưu ở vùng chậu trong khoảng trống quanh bàng quang) 14-Close the abdomen in layers, and apply staples to the skin. E- Postoperative Details 1-Continue intravenous antibiotics until the patient is discharged. 2-Remove the pelvic drain when the drainage output is minimal, usually within 48-72 hours. 3-Leave in the SPT and indwelling urethral catheters until an x-ray cystogram is performed. 4-Discharge the patient when he or she shows diet toleration and is ambulatory, afebrile, and relatively pain-free. F- Follow-up 1-Instruct the patient to return in 7-10 days for staple removal, and check the wound at that time. 2-Obtain the x-ray cystogram 10-14 days after surgery. 3-If the cystogram finding is normal, remove the urethral catheter. 4-Perform a voiding trial via the SPT. 5-Remove the SPT when the patient passes the voiding trial. 6-Advise the patient to return to normal activity within 4-6 weeks after surgery. Do đó chỉ cần đặt một ống dẫn lưu ở vùng túi cùng Douglas là đủ, vì túi cùng Douglas là vị trí thấp nhất trong ổ bụng của bệnh nhân nơi mà tất cả các chất dịch tự do trong ổ bụng sẽ dồn vào đó, dù chỉ hiện diện với số lượng ít. Tham Khảo: Bladder Trauma: Treatment Raymond Rackley, MD, Professor of Surgery, Cleveland Clinic Lerner College of Medicine at CWRU; Co-Section Head, Section of Voiding Dysfunction and Female Urology, Glickman Urological Institute, Cleveland Clinic Foundation Sandip P Vasavada, MD, Co-Head, Section of Female Urology, Joint Appointment, Urological Institute and Department of Gynecology, Co-Director, Center for Pelvic Neuromodulation, Cleveland Clinic Foundation; Benjamin S Battino, MD, Consulting Staff, Urology Specialists of Wisconsin . Surgical Therapy of Bladder Rupture A-Intraperitoneal bladder rupture (vỡ bàng quang trong phúc mạc) Most, if not all, intraperitoneal bladder ruptures. extravasation Bladders with extensive extraperitoneal extravasation often are repaired surgically. Early surgical intervention decreases the length of hospitalization