a 39-year - old woman 161 cm tall weighing 51 kg was diagnosed with uterine myoma and an abdominal wall mass and scheduled for laparoscopic myomectomy .
she was premedicated with 2 mg of midazolam and a 0.5 mg atropine intramuscular injection 30 minutes before arrival to the operation room .
she was monitored intraoperatively by electrocardiography , non - invasive blood pressure , pulse oximetry , end - tidal capnography , sevoflurane concentration , and bispectral index ( bis ; a-2000 , aspect medical system , norwood , massachusetts , usa ) .
carbon dioxide was injected into the peritoneal cavity via a veress needle until peritoneal pressure reach 12 mmhg .
two hours after the operation was initiated , the anesthesiologist notified the surgeon of gaseous distention of the urinary bag which is filled with 150 ml of urine ( fig .
1 ) . the surgeon tried to detect a perforation site by sight but failed to detect a bladder perforation .
subsequently , the bladder was distended with 250 ml of saline under cystoscopy after which a 0.7 cm hole in the dome of the bladder was discovered .
the vital signs of the patient were stable and the urine volume after bladder repair was 100 ml .
the foley catheter was removed after there was no more urine leakage as determined by cystoscopy on postoperative day 15 . a 45-year - old woman 159 cm tall and weighing 59 kg
preoperative blood tests , chest radiography , electrocardiogram , vital signs , and physical examination were normal .
premedication , anesthesia induction , maintenance , and monitoring were the same as case 1 .
after the patient was placed in the lithotomy position , carbon dioxide was injected into the peritoneal cavity via a veress needle until peritoneal pressure reach 12 mmhg .
marked gaseous distention of the urinary bag which was filled with 350 ml was noticed 30 minutes after the operation started .
laparoscopy revealed a 1.5 cm hole in the dome of the bladder including the mucosa layer .
total hysterectomy and bladder repair was performed . the urine volume after bladder repair was 150 ml .
the foley catheter was removed after there was no more urine leakage as determined by cystoscopy on postoperative day 13 .
a 39-year - old woman 161 cm tall weighing 51 kg was diagnosed with uterine myoma and an abdominal wall mass and scheduled for laparoscopic myomectomy .
she was premedicated with 2 mg of midazolam and a 0.5 mg atropine intramuscular injection 30 minutes before arrival to the operation room .
she was monitored intraoperatively by electrocardiography , non - invasive blood pressure , pulse oximetry , end - tidal capnography , sevoflurane concentration , and bispectral index ( bis ; a-2000 , aspect medical system , norwood , massachusetts , usa ) .
carbon dioxide was injected into the peritoneal cavity via a veress needle until peritoneal pressure reach 12 mmhg .
two hours after the operation was initiated , the anesthesiologist notified the surgeon of gaseous distention of the urinary bag which is filled with 150 ml of urine ( fig .
1 ) . the surgeon tried to detect a perforation site by sight but failed to detect a bladder perforation .
subsequently , the bladder was distended with 250 ml of saline under cystoscopy after which a 0.7 cm hole in the dome of the bladder was discovered .
the vital signs of the patient were stable and the urine volume after bladder repair was 100 ml .
the foley catheter was removed after there was no more urine leakage as determined by cystoscopy on postoperative day 15 .
a 45-year - old woman 159 cm tall and weighing 59 kg was diagnosed with endometrioma and scheduled for laparoscopic - assisted vaginal hysterectomy .
preoperative blood tests , chest radiography , electrocardiogram , vital signs , and physical examination were normal .
premedication , anesthesia induction , maintenance , and monitoring were the same as case 1 .
after the patient was placed in the lithotomy position , carbon dioxide was injected into the peritoneal cavity via a veress needle until peritoneal pressure reach 12 mmhg .
. marked gaseous distention of the urinary bag which was filled with 350 ml was noticed 30 minutes after the operation started .
laparoscopy revealed a 1.5 cm hole in the dome of the bladder including the mucosa layer .
total hysterectomy and bladder repair was performed . the urine volume after bladder repair was 150 ml .
the foley catheter was removed after there was no more urine leakage as determined by cystoscopy on postoperative day 13 .
since it was first reported , it has been noted to occur during procedures involving a verres needle , trocars ( primary or secondary ) , and electrocautry regardless of improvements in surgical techniques and safety instructions .
predisposing risk factors for complications during laparoscopic procedures include operation history of the patient , pelvic adhesion , endometriosis , obesity , urachal anomaly , and unskilled surgeons .
bladder perforation during laparoscopic surgery may be detected by intraperitoneal bleeding , clear liquid in the operation field , hematuria , and gaseous distention of the urinary bag . among these , hematuria and gaseous distention of the urinary bag
if hematuria is found intraoperatively or postoperatively , cystoscopy or cystoradiography can be used to confirm bladder perforation .
hematuria may not occur in all bladder perforation cases and there are difficulties in diagnosing intraoperatively .
sia - kho and kelly   reported that they detected a gaseous distention of the urinary bag at the conclusion of laparoscopic adhesiolysis but ignored this , and that the patient complained of abdominal tenderness , nausea , and vomiting 4 hours after operation .
they emphasized that gaseous distention of urinary bag is an initial sign of bladder perforation , and anesthesiologists should monitor the urinary bag .
subsequent cases have verified that observing the urinary bag is a reliable way to monitor bladder perforation [ 6 - 9 ] .
gaseous distention of the urinary bag due to bladder perforation indicates communication between bladder and intraperitoneal space .
because the volume of urinary bag commonly used in korea is 2,000 ml , gaseous distention could reveal within 2,000 ml of total amount including urine and gas .
when a urinary bag with air outlet is used , gaseous distention can occur because the diameter of the inlet for urine and gas is larger than that of the outlet for air . however , gaseous distention would not appear in an inelastic urinary bag , so carbon dioxide gas could be measured at the air outlet by mass spectroscope or infrared spectrometer when bladder perforation is suspected .
detected 10% carbon dioxide at a urinary bag . in our cases , it is thought that bladder perforation occured through laparoscopic dissection of severe adhesion of uterus with bladder despite no previous abdominal surgery . in case 1
, the urinary bag seemed to become distended gradually because the size of the bladder injury was small . in case 2 ,
the urinary bag was distended instantly because the size of the bladder injury was large .
therefore , the size of injury is likely to affect the time of gaseous distention presentation .
further studies about cause - and - effect relationship between peritoneal pressure , the size of injury , and gaseous distention of the urinary bag are needed .
early detection during laparoscopic surgery allows immediate bladder repair via laparoscopy or laparotomy and decreases postoperative morbidity . a small undetected tear may heal if bladder decompression is maintained , but may cause oliguria , peritonitis , and fistula formation .
insertion of a foley catheter is associated with a risk of infection ; on the other hand , this decreases the risk of bladder injury because it permits continuous decompression of bladder .
it also allows early detection of bladder injury which is not found in the operation field , so insertion of indwelling foley catheter is recommended . in conclusion ,
continuous monitoring of gaseous distention of the urinary bag should aid in the early detection of bladder perforation in patients with predisposing factors of bladder injury .
 bladder perforation during laparoscopy is a recognized , uncommon complication . 
 we present two cases of bladder perforation during laparoscopic gynecologic operations that were detected by gaseous distention of the urinary bag . 
 bladder perforation occurred through laparoscopic division of adhesion . 
 one bladder perforation was repaired laparoscopically , and the other case was repaired by laparotomy during the same general anesthesia . in this report , we present evidence that monitoring a gas - distended urinary bag during a laparoscopic procedure can help detect intraoperative bladder perforation . 
Case Reports
Case 1
Case 2
Discussion