Conservative laparoscopic treatment of post-caesarean section bladder flap haematoma: two case reports
© Springer-Verlag Berlin / Heidelberg 2006
Received: 10 April 2006
Accepted: 24 May 2006
Published: 19 July 2006
A bladder flap haematoma (BFH) is an unusual complication of caesarean section and results from bleeding at the uterine suture. This haematoma arises between the posterior bladder wall and lower uterine segment. On ultrasonographic examination, it appears as a solid area or a complex mass with clean walls and reinforcement of the distal echoes. No clear and defined protocol exists for clinical management of BFH; in more severe cases, when the blood loss is continuous or if it transforms into an abscess, it needs non-standardized surgical treatment. When surgery is performed, usually the BFH is only drained, reserving hysterectomy for severe uterine necrosis, myometritis or abscess formations. In our experience, we have performed two conservative laparoscopic treatments with drainage of the BFH.
Caesarean section (CS) is the most frequently utilized intraperitoneal obstetric surgical event, and the two most common techniques used around the world are the Misgaw Ladach technique (or Stark CS)  and the traditional method .
The difference between these methods is in the closure of the peritoneum: the first one does not utilize peritoneal closure, and the second one closes the abdomen with suturing of the visceral and parietal peritoneum. The Stark method is believed to determine anatomical changes instead of the classic technique of Pfannenstiel-Kerr, in which the abdomen is closed with suturing of the visceral and parietal peritoneum .
The parietal non-sutured peritoneum, particularly, evokes abdominal wall anatomical modification in the Retzius or vesicouterine space, which normally can be the post-surgical fluid collection site, particularly after a CS.
In a CS, performed without visceral peritoneum suturing, the vesicouterine space communicates with the large peritoneal cavity . If during a CS without use of the visceral and parietal peritoneum suturing technique some pathological fluid collections arise in this space, this decants its content into the large peritoneal cavity, and if the post-operative haemostasis is inadequate, a subfascial haematoma (SFH) can develop and, finally, haemoperitoneum .
Thus, an unusual complication of CS is the bladder flap haematoma (BFH). As a result of bleeding at the incision site, a haematoma forms between the bladder and lower uterine segment (LUS), so that a BFH is generally thought of as a blood collection in a potential space located between the urinary bladder and LUS (vesicouterine space) . These collections can also extend over the bladder and uterus beneath the peritoneal reflection.
First case report
A 38-year-old female, second pregnancy, without risk factors, with a body mass index (BMD) of 24 and a mean blood pressure of 90 mmHg, underwent repeat caesarean delivery.
In agreement with the patient, the post-operative follow-up was performed by serial TAUEs in 102 days to evaluate the BFH dimension and evolution; at the end of this period, the patient showed dysuria, persistent lower abdominal pain and fever (38.7°C).
So, in agreement with the infectivologist, we began antibiotic therapy with ceftriaxone (4 g/daily) plus tobramycin (160 mg/daily) for 10 days, but no important improvement was observed and the patient was submitted to laparoscopic treatment.
We performed the abdominal first access creating a pneumoperitoneum with a Verres needle, inserted into the umbilical zone, an optical first trocar introduction (EndoTIP, Karl Storz Endoscopy, Tuttlingen, Germany) and three additive trocars (two of 5 mm diameter in the classic lateral zone and one of 10 mm diameter in the suprapubic zone).
The pelvic-abdominal inspection showed a 10-cm right tumescence between the posterior bladder wall and anterior lower uterine body, as visualized by TAUE, and we proceeded in the following way.
At the end of laparoscopy we placed a catheter inside the pelvis for drainage; the total operative laparoscopic time was of 47 min, with minor blood loss (<20 ml) and no post-operative complications.
Second case report
A 31-year-old female, nullipara, without risk factors, with a BMD of 21 and a mean blood pressure of 82 mmHg, underwent caesarean delivery for cervical dystocia.
In agreement with the patient, the post-operative follow-up was performed, as in the first patient, by serial TAUEs in 84 days and, at the end of this period, the patient was operated by laparoscopy for persistent lower abdominal pain and fever too (38.6°C).
As in the first patient, we performed the abdominal first access creating a pneumoperitoneum with a Verres needle, inserted into the umbilical zone, an optical first trocar introduction (ENDOPATH, Ethicon Endo-Surgery, Cincinnati, OH, USA) and three additive trocars (two of 5 mm diameter in the classic lateral zone and one of 10 mm diameter in the suprapubic zone).
At the end of laparoscopy we placed a catheter inside the pelvis for drainage; the total operative laparoscopic time was of 39 min, with minor blood loss (<20 ml) and no post-operative complications, as in the last patient.
During a CS, if the haemostasis has not obtained after closure of the uterine incision, a haematoma may rise up between the bladder and the lower uterine segment (LUS); the flap haematoma is adjacent to the incision in the LUS, but covered by a fold of the incised, reflected and re-approximated peritoneum, during surgery.
Ultrasonography (US) can detect this complication easily and accurately and it can be used as non-invasive monitor and guide for therapy. The post-CS BFH is an unusual complication, its frequency is variable and so is its treatment.
Baker et al. reported 13 patients, of 1,458 CS, with a BFH diagnosed by US; 5 of these were treated by antibiotics, 1 had an explorative laparotomy, 1 confirmed haematoma was not drained but followed by US and 1 patient required an hysterectomy for myometritis and uterine wound dehiscence .
Burger et al. previously examined the uterine scar in 48 patients by a post-CS US, without clinical exam; they speculated that a mass interposed between the bladder and LUS, at the site of the incision, could be secondary to tissue reaction or oedema, blood or serous fluid or partial wound separation .
A study by Winsett et al. implied that the subfascial haematoma is an extension of the BFH ; Weiner et al. sustained that there was no US evidence of direct extension between the retrovesical BFH and the prevesical subfascial haematomas .
Woo et al. reported that of 14 patients who had CS with a subsequent fever, 13 women had a BFH showed by magnetic resonance (MR) ; Lev-Toaff assessed 31 patients with a post-CS fever and found 4 haematomas either with MR either by US, and 1 of these required a laparotomy .
Faustin et al. studied 100 post-CS women; in 29% of these echo-free areas were detected anterior to the uterine incision site, which corresponded to the described fluid collections that were more frequently found in patients with excessive blood loss during surgery . Of these, patients with an echo-free area anterior to the uterine incision site that was 3.5 cm large or more had significant post-operative morbidity.
The differentiation between a haematoma and an infected haematoma or abscess can be difficult, but the presence of air inside it gives an evidence for the latter; the haemorrhage usually is confined by overlying peritoneum but it may spread laterally along the broad ligaments into the retroperitoneum.
Nagele et al. reported that closure of the visceral peritoneum may determine the formation of the BFH; in fact, leaving the visceral peritoneum open prevents the formation of subperitoneal “pockets” .
In more than seven cases, with continued blood loss or abscess formation, an explorative laparotomy is performed; in our experience non-closure of the visceral peritoneum during a CS is associated with a lower febrile and infective morbidity, in accordance with reports from a Cochrane review and other authors [14–17].
However, if a BFH forms, in our experience it is possible to treat and resolve this complication successfully by performing laparoscopic treatment in the way we describe.
Laparoscopy is an effective method for management of BFH and it expands the spectrum of surgical gynaecology. Since the scientific literature currently does not provide that much evidence, several other studies or case reports are needed to show the possibilities and the advantages of laparoscopy in BFH treatment.
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