Figure 1: Schematic of pre-bent instruments and multi-channel single incision trocar.
The patient is placed in supine position. Trendenburg position of 15-20° and inclination towards the surgeon should also be established (Figure 2). The placement of the trocar was performed in the umbilicus.
Figure 2: Intraoperative patient positioning
Pneumoperitoneum was established and the procedure took place transperitoneally. The diverticulum was distended by saline infusion. Incision of the peritoneum covering the bladder follows (Figure 3a). The identification of the diverticulum was relatively easy because of the balloon of the catheter (Figure 3b). Palpation of the balloon was also possible for the detection of the diverticulum.
Figure 3: a)Incision of the peritoneum to gain access to the bladder. b) Identification of the diverticulum. The inflated balloon facilitates the identification.
One pre-bent instrument was used for tissue retraction and exposure of the diverticulum. The dissection was performed by another instrument which was either pre-bent or straight (Figure 4a).
Figure 4: a) The neck of the diverticulum is identified. One instrument is used to expose the diverticulum, the other instrument performs dissection. b) The diverticulum is incised and the catheter becomes visible.
Incision of the diverticulum followed and the balloon of the catheter was visible (figure 4b).
Figure 5: a) The balloon of the catheter is deflated and the catheter is removed into the bladder. The dissection becomes easier with this manoeuvre. Furthermore, it is easier to identify the neck of the diverticulum since view to the outside and inside of the diverticulum is possible. b) The dissection of the diverticulum is continued. The collum of the diverticulum is dissected on its ventral side.
The latter was deflated and removed to the bladder (figure 5a). The above manoeuvre facilitated the dissection of the diverticulum as the latter could be visualised from outside and inside as well as the neck of the diverticulum was also identified. The diverticulum was initially dissected ventrally following circumferentially (Figure 5b). The dissection of the posterior side of the diverticulum (especially the neck of the diverticulum) could be difficult. The dissection process was facilitated by fixing the diverticulum to the ventral abdominal wall (Figure 6a).
Figure 6: a) The dissection of the posterior side of the diverticulum (especially the neck of the diverticulum) can be difficult. The retraction with a suture as described in the text is helpful. B) The diverticulum is completely resected. The figure shows the view into the bladder after resection of the diverticulum. The DJ- catheters is visible inside the bladder.
A long straight needle was passed from outside through the abdominal wall, stitched through the diverticulum and passed again through the abdominal wall. The suture was fixed on the outer side of the abdominal wall with the help of a clamp. When the diverticulum was completely dissected from the bladder wall (Figure 6b), it was placed in an endoscopic retrieval bag. The ureteral stents are visible inside the bladder (Figure 7b). The bag was closed and placed in the abdomen. The bladder lesion was closed by interrupted sutures (2-0 Polysorb on a GU-46 needle or 2–0 Vicryl with UR-6 needle) (Figure 7a).
Figure 7: a) The whole in the bladder is closed with the help of interrupted sutures (2-0 Polysorb on a GU-46 needle or 2–0 Vicryl on UR-6 needle). A straight needle holder and pre-bent forceps are used. b) Peritoneum is closed with running or interrupted sutures.
Suturing of the bladder was performed with a straight needle holder and pre-bent forceps. Saline (200ml) was infused in the bladder in order to identify any leakage. Any leakage could be managed by additional sutures. If the sutured bladder was watertight, the peritoneum was closed with running or interrupted sutures (Figure 7b). A thin drain could be placed close to bladder wall into the extraperitoneal space according to the preference of the surgeon before the last suture was closed. Finally, the endoscopic bag containing the diverticulum was grasped with straight forceps and retracted into the TriPort. The endoscopic bag and the TriPort were removed together. The umbilical incision is appropriately closed.