Bladder injury during laparoscopic appendectomy: Detection, management, and learning point for surgical trainees

Background: Laparoscopic appendectomy is one of the most common emergency surgeries. There is a paucity in the literature regarding the incidence and management of iatrogenic bladder injuries. We reviewed a series of iatrogenic bladder injuries during laparoscopic appendectomy to determine incidence, preventable risk factors and management.Methods: We performed a retrospective review of laparoscopic appendectomy at two large regional teaching hospitals over a five-year period from February 2014 to February 2019. The outcomes measured included intraoperative data, such as type of port used and surgeon experience, incidence of iatrogenic bladder injury, mechanism and time of bladder injury recognition, management and clinical outcome.Results: A total of 1147 patients underwent laparoscopic appendectomy. Two iatrogenic bladder injuries secondary to port placement were identified (0.17%). Both procedures were performed after-hours by surgical trainees. There was no previous history of abdominal surgery. Neither patient had an indwelling catheter (IDC) during the procedure. There were no other visceral or major vascular injuries. Both bladder injuries were identified in the early post-operative period. One case was managed conservatively, whilst the other required laparoscopic repair of the bladder perforation. Conclusion: Bladder injury should be suspected in patients with abdominal pain, elevated creatinine and anuria following laparoscopic surgery. Although iatrogenic bladder injury during laparoscopic appendectomy is rare, it has the potential for considerable patient morbidity. Therefore, adequate laparoscopic supervision and specific counselling on port access injuries for surgical trainees, adequate bladder decompression with an IDC, and early detection and management guided by the location of injury are essential.