Bladder Mobilization and Cystotomy

Placing the patient in extreme Trendelenburg position aids in displacement of the bowel loops from the pelvic cavity and facilitates the subsequent steps of the procedure. The bladder is distended with saline through the uretheral catheter. The peritoneum overlying the bladder is incised at the medial border of the left medial umbilical ligament and extended to the right in a linear fashion to the right medial umbilical ligament. The median umbilical ligament is taken down during the procedure using electrosurgi-cal scissors. If needed, the lateral peritoneum incisions are extended down along the medial umbilical ligaments to increase exposure. The loose areolar tissue surrounding the bladder is bluntly dissected to expose the anterior bladder neck and perivesical spaces. A large cystostomy is created by making an anterior bladder wall flap through a curvilinear incision that positions the apex at the dome of the bladder and the base extending to the level approaching the trigone (Fig. 6). This type of cystostomy ensures a large dysfunctional disruption of the bladder musculature for increasing the linear length of bladder wall for bowel anastomosis. It is most useful in cases where the uterus

Completion of the posterior wall of the reconfigured bowel segment from an intravesical approach beginning medially and finishing laterally facilitates the best exposure to ensure a watertight anastamosis.

is present and potentially prevents an adequate cystostomy incision. Furthermore, adequate exposure for enterovesical anastomosis in all of the procedures described previously is preserved by avoiding a closure of the deep posterior bladder wall incision in the pelvis that will be obscured by bowel and the isolated bowel segment to be used for the augmentation.

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