Enterovesical Anastomosis

Although different approaches can be used for intracorporeal suturing of the bowel segment to the bladder as shown in Figure 6, we prefer to begin by running the preplaced suture on the "posterior" wall of the reconfigured bowel patch to the apical aspect of the bladder flap in a medial to lateral direction on each side.

Completion of the posterior wall of the reconfigured bowel segment from an intravesical approach beginning medially (point A) and finishing laterally (points B and C, respectively) facilitates the best exposure to ensure a watertight anastamosis.

If one attempts to complete the anterior wall of the reconfigured bowel patch to the bladder first as shown in Figure 6, it may be difficult to visualize the suturing of the posterior wall anastomosis to the bladder owing to the constraints of pelvic anatomy. To complete a circumferential, continuous, full-thickness, single-layer anastomosis of the bowel to the bladder, we finish by running the preplaced sutures of the anterior wall of the reconfigured bowel patch and additional sutures as required. Free hand laparoscopic suturing and intracorporeal knot tying techniques are used exclusively for the entire procedure. Exposure of the operative field for intracorporeal suturing can be improved by temporarily fixing the anterior bladder flap to the abdominal wall. This not only opens the operative suturing field for easier identification of the bladder and bowel mucosal edges, but also stabilizes the tissues for rapid suture placement. At the completion of the anastomosis, the bladder is distended to confirm a watertight anastomosis.

A suction drain is inserted into the pelvic cavity through one of the lower lateral 5-mm port sites. Postoperative bladder drainage is maintained with a 22 French urethral catheter. Because a smaller urethral catheter may be preferred for postoperative drainage in males, a suprapubic tube may be placed through the bladder wall and externalized via the remaining lower port site.

The umbilical and remaining 10-mm ports are closed in layers. In patients who require a catheterizable stoma, the previously refashioned ileal segment is located and the attached red rubber catheter is grasped with an endoscopic clamp via the umbilical port site. After the pneumoperitoneum is decompressed, the terminal end of the ileal segment is delivered to the umbilicus and secured to the anterior rectus fascia and skin at the level of the umbilicus (Fig. 7). A Y-V flap maturation of the stoma to the skin of the umbilicus is performed using 4-0 chromic sutures. In obese patients, use of the umbilicus at the site of stoma formation decreases the amount of ileum needed to mature the stoma to the skin. A 16-Fr catheter is placed through the stoma and into the bladder to optimize bladder drainage and healing of the newly created catheterizable segment in the early postoperative period.

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