Mucosal skinning of the bladder for endometriosis

In this video, we show a technique to excise a non-infiltrating endometriotic nodule of the bladder wall. After MRI study and cystoscopy, the decision to do a mucosal skinning is undertaken. Filling of the bladder, use of adequate energy and traction are the main features to perform mucosal skinning. The bladder serosa is then sutured.

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Mucosal skinning of the bladder for endometriosis

Authors

A Wattiez, J Nassif, B Gabriel, S Barata, J Marescaux

Abstract

In this video, we show a technique to excise a non-infiltrating endometriotic nodule of the bladder wall. After MRI study and cystoscopy, the decision to do a mucosal skinning is undertaken. Filling of the bladder, use of adequate energy and traction are the main features to perform mucosal skinning. The bladder serosa is then sutured.

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tips and tricks

Keywords

Mucosal skinning of the bladder for endometriosis

Media type

Surgical video

Duration

05'00''

Publication

2010-02

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E-publication

WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2832.htm

Mucosal skinning of the bladder for endometriosis

1. Identification of the nodule and bladder filling 00'18''

After MRI imaging and cystoscopy, the endometriotic nodule was found not to be infiltrating. Mucosal skinning is a possible method of nodule excision; it has also been described for bowel endometriosis. Our patient had a previous surgery for endometriosis and there was no active nodule on the MRI, so the nodule can be fibrotic. Also, when the bladder is opened, and if there is a need of JJ stunting, the latter procedure is difficult to perform. We fill the bladder with diluted methylene blue dye in order to facilitate the mucosal skinning procedure.

2. Mucosal skinning of the bladder 01'35''

We use a bipolar grasper that we can see on the left part of the screen, a monopolar hook and a regular Manhes grasper. Maintaining the traction using the graspers, the monopolar hook is used to perform the mucosal skinning while the bipolar grasper is used for traction and hemostasis when needed. We pass tangentially to the mucosa and try not to perforate it. Filling the bladder will have two targets, identifying the mucosa, and providing some traction.

3. Extracorporeal running suture of the bladder serosa 03'08''

We introduce a 3.0 Monocryl thread through the left lateral 5mm port, by removing the port passing the end of the thread in the trocar, passing with the needle holder again in the trocar and grasping the thread about 2cm away from the needle. The needle holder tip is inserted through the abdominal wall and the trocar is pushed after it. We perform a running two way suturing by taking only the serosal layer of the bladder wall in order to cover the mucosa. As we can see, we always use turning ergonomic movements in order to save time in laparoscopic suturing. Before removing the needle from the left 5mm trocar, we distort it in order to flatten it. At the end, we tie the knot with a knot pusher and cut the threads. Though some data report that excision of bladder nodules is associated with better results, we think that mucosal skinning is still a good option, especially when there is no mucosal infiltration and that a JJ stent may be discussed at further operative times.