Open supratrigonal cystectomy with ileal conduit for benign disease

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Before the knife: marking, consent, position The stoma nurse marks the site the day before with the patient sitting, standing and lying: over the right rectus, below the belt line, away from the umbilicus, scars and skin folds, where the patient can see it. On the table the patient is supine with a slight break at the umbilicus, arms out, a urethral catheter in on the sterile field, calf compression on and antibiotics given at induction. Bowel preparation is not routine. The house officer stands on the patient's left, opposite the surgeon, and will hold the retractors, cut the sutures and follow the swab count.
2. Incision and the layers of the abdominal wall A lower midline incision from the pubic symphysis to just above the umbilicus, curving around it to the left. Skin with a number 22 blade, then subcutaneous fat down to the linea alba with diathermy; the Langenbeck retractors go in here. The linea alba is opened in the midline with the blade and extended with scissors, the rectus muscles are swept apart with a swab, and the transversalis fascia and parietal peritoneum are picked up between two Kocher forceps and opened with scissors, checking that no bowel is caught. From skin to cavity: skin, Camper's and Scarpa's fascia, linea alba between the anterior rectus sheaths, the rectus bellies, transversalis fascia, extraperitoneal fat, parietal peritoneum.
   where it bites: the peritoneum is opened at the top of the wound where the bladder cannot be; low in the wound a distended bladder or a loop of bowel sits directly under it.
3. Retraction and packing When the peritoneum opens the small bowel is straight underneath it, in the way of everything, so the first job is to move it. Moist packs sweep the loops and the sigmoid up into the upper abdomen and a Deaver retractor holds them there, handed to the house officer with the instruction not to lift but to lean. A Balfour self-retaining retractor is then placed with its two lateral blades on the wound edges and the bladder blade over the pubis; on a larger patient the Bookwalter ring goes on the post instead. A Morris retractor holds the bladder dome downward while the peritoneum over it is inspected. The table is tipped head-down (Trendelenburg) so gravity keeps the bowel out of the pelvis.
4. Finding the ureters, and the rule about their blood supply The peritoneum is incised lateral to the sigmoid on the left and over the caecum on the right, and each ureter is found where it crosses the common iliac bifurcation at the pelvic brim: a pale cord under the posterior peritoneum, medial to the gonadal vessels, which stays stuck to the peritoneum when the peritoneum is lifted. Touched with a forceps and given a moment it vermiculates, a slow peristaltic wave; a vessel pulsates and does not. Its blood supply runs in the adventitia and enters from the medial side above the pelvic brim and from the lateral side below it, so the dissection stays on the far side from the supply at each level and the sheath is never stripped. The sling goes on in one sequence: a Lahey or Mixter right-angle forceps is passed beneath the ureter with its curve pointing down, hugging the ureter so nothing behind it is caught, until the tip is seen on the far side; the jaws are opened, the scrub nurse lays the tip of a vessel loop into them, the jaws close on it, and the forceps is drawn back the way it came so the loop follows around the ureter. Both ends are held in a clip. The ureter is then mobilised in its sheath down to the bladder and divided between two Ligaclips or ties of 2-0 Vicryl a centimetre from the bladder, the bladder end ligated.
   where it bites: above the brim the supply comes from medially, below it from laterally, and it runs in the adventitia; dissect on the wrong side or strip the sheath and the anastomosis strictures.
5. Dropping the bladder The urachus and the medial umbilical ligaments are divided high between clips with the diathermy, and the bladder is dropped off the anterior abdominal wall into the retropubic space of Retzius with a swab on a stick. Laterally the superior vesical pedicle is taken between Kelly clamps and tied with 2-0 Vicryl, or sealed with a LigaSure, working from the divided ureter toward the base. The inferior pedicle and the posterior attachments below the level of the trigone are left alone: this is a supratrigonal operation and the pelvic floor is not entered.
6. The supratrigonal transection The bladder is opened on the dome with the Harmonic shears and the cystotomy is extended so the interior can be seen: both ureteric orifices, the interureteric ridge between them and the bladder neck below. The line of transection is marked about a centimetre and a half above the interureteric ridge, outside the trigone, and the body of the bladder is taken off with the Harmonic, which seals as it cuts. Rather than delivering the whole body as one piece it is split down the midline, sagittally, and comes out in two halves, each lifted with a Lane tissue forceps and sent for histology. The urethral catheter is left in place: the trigonal remnant is closed over it in two layers, a running 3-0 Vicryl on the mucosa and a second 2-0 Vicryl on the muscle, and the balloon sits inside the closed remnant and stays there, draining it, as a second drain beside the tube drain in the pelvis.
   where it bites: the ureteric orifices mark the trigone; cutting below the interureteric ridge takes the trigone the operation is designed to keep.
7. Choosing and isolating the ileal segment The terminal ileum is delivered and a segment of about fifteen centimetres is chosen twenty centimetres proximal to the ileocaecal junction, on a mesentery that reaches the marked stoma site without tension when the segment is lifted to the skin. The mesentery is held up against the theatre light so the arcades show through, and the segment is taken where a good arcade runs to it. Three windows are then poked through the mesentery at the proximal end of the segment and three at the distal end, between the arcades, with a fine haemostat; the Harmonic divides the mesentery between the windows and the bowel at each end, and only the segment is freed on its own mesentery. The rest of the ileum is not disturbed. A Babcock holds the conduit without crushing it.
   where it bites: a mesentery that is short at the moment the segment is chosen is a dusky stoma at the end of the operation.
8. Restoring the bowel Bowel continuity is restored above the conduit with a stapled side-to-side (functional end-to-end) ileo-ileal anastomosis: the two ends are laid antimesenteric border to antimesenteric border, held with Babcocks, a GIA 75 fired along their length and the common enterotomy closed with a TA 60 or a running 3-0 PDS. The mesenteric window is closed with interrupted 3-0 Vicryl so that nothing can herniate through it, keeping the conduit and its mesentery caudal to the anastomosis. The conduit is irrigated with saline through a catheter until it runs clear.
9. The Wallace anastomosis over stents The left ureter is passed under the sigmoid mesentery to the right side through a window made with a finger, without kinking, and both ureters are brought to the open proximal end of the conduit. Each is spatulated for fifteen to twenty millimetres along its lateral wall with Potts scissors, keeping the adventitia. Their medial edges are then sewn together with a running 5-0 PDS so that the two ureters become a single plate, the Wallace technique. Before the plate goes in, a 6 French single-J stent, forty centimetres long, is passed up each ureter to the renal pelvis and fed out through the conduit, and the stents are fixed to the conduit with a fine fast-absorbing suture. The plate is then sewn into the open end of the conduit, mucosa to mucosa, in four quadrants with interrupted 4-0 PDS, so the bowel closes around the joined ureters. The Bricker alternative joins each ureter separately, end-to-side, to the conduit wall. With the plate in, the conduit is filled with 50 millilitres of saline through the distal end and the join watched; a leak is closed with an interrupted suture and the fill repeated.
   where it bites: a tensioned or twisted anastomosis is a planned stricture; the ureters should lie without a bend when the packs come out.
10. The stoma The Balfour comes out so the wall lies flat, and at the marked site a disc of skin two to two and a half centimetres across is lifted with a Kocher and excised, the subcutaneous fat is spread rather than cut, a cruciate incision is made in the anterior rectus sheath, the rectus is split along its fibres with two fingers, and the posterior sheath and peritoneum are opened until two fingers pass. The distal end of the conduit is brought through the wall, its staple line trimmed, and the bud is matured everted as a spout with 3-0 Vicryl or Monocryl sutures taking skin edge, then seromuscular bowel, then the cut end of the bowel, so the mucosa turns out on itself. A clear appliance goes on in theatre so the bud can be watched.
    where it bites: a bud that is dusky before the drapes come down is revised now, not on the ward.
11. Closure The pelvis is washed and a tube drain is placed near the anastomoses, brought out through a separate stab. The swab, needle and instrument count is confirmed aloud with the scrub nurse. The linea alba is closed as a mass closure with a looped 1 PDS on a blunt needle, continuous, taking centimetre bites a centimetre apart so that the suture length is at least four times the wound length, approximating rather than strangling the tissue. Interrupted 1 PDS or nylon, the same bites tied one by one, is used instead where the sheath is poor or the abdomen is distended. Fat is not closed; a dead space is drained, not stitched. Skin is closed with staples, an Adson toothed forceps everting the two edges so the stapler sits square on them and a staple goes in every eight millimetres, or with a subcuticular 3-0 Monocryl, and the clear appliance is fitted to the finished stoma before the drapes come down.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance