Selection and Mobilization of the Bowel Segment

Various segments of the gastrointestinal system may be used for the procedure depending on the clinical requirements of the patient. A length of 20 cm of bowel is usually desirable to attain an adequate augmented bladder capacity. An appropriate segment of bowel is identified based on the following criteria: (i) the bowel segment will reach the area of the bladder neck without tension and (ii) a well-defined arterial arcade should be present in the isolated bowel mesentery.

In laparoscopic ileocystoplasty, the initial step is identification of the ileocecal junction. With the use of laparascopic small bowel clamps, a 20-cm segment of ileum at least 15 cm proximal to the ileocecal junction is identified (Fig. 2). The mesentery adjacent to the proximal and distal ends of the selected bowel loop is scored with laparoscopic electrosurgical scissors for subsequent extracorporeal identification.

In laparoscopic sigmoidocystoplasty, a loop of sigmoid colon is selected using similar techniques. Many patients with neurogenic bladder dysfunction also have defecating dysfunction resulting in a redundant sigmoid colon. In patients planning to perform intermittent catheterization via the urethra, the sigmoid colon may be the preferred segment of bowel for harvesting if continent stoma formation is not required. Extracorporeal manipulation of the sigmoid is best achieved via extension of the left lower abdominal port defect (Fig. 3).

The right colon and terminal ileum are selected in patients who require continent abdominal stoma formation in addition to bladder augmentation. The cecum and ascending colon are used for the bladder augmentation, and 10 cm of terminal ileum is used to create the catheterizable conduit and stoma at the umbilicus. The peritoneum lateral to the cecum and ascending colon and the peritoneum of the terminal aspect of the Z line are incised. The entire right colon and terminal ileum are mobilized for extra-coporeal manipulation via the extended incision of the umbilical port. Ensuring a low position of the patient's thighs via low-lithotomy enables proper manipulation of the laparoscopic instruments through the lower abdominal ports for mobilization of the right colonic flexure.

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