towels and retractors are placed. The rectus muscle is incised or split by blunt
dissection and retracted. The prevesical fat and peritoneum are retracted upward with
(2) The top of the bladder is dissected free, using thumb forceps and
Metzenbaum scissors. The wall of the bladder is grasped on either side of the midline
with Allis forceps. Two traction sutures of number 0 chromic gut may be placed through
the bladder wall and held with straight Halsted hemostats. The muscle of the bladder is
spread by blunt dissection with the tip of a clamp or scissors until the mucosa is seen.
Two Allis clamps are placed, and the bladder is incised with a sharp blade. At this point
the distended bladder may be emptied via the urethral catheter, which is unclamped
under the drapes by the circulating member of the team, or a suction tube may be
introduced through the stab wound to remove the fluid as the bladder mucosa is incised.
(3) The bladder opening is extended with scissors. Bladder retractors are
placed, and the bladder is explored for diverticula, calculi, or tumor. Removal of the
pathological area or other corrective procedure is carried out and wound closure begun.
A Malecot catheter may be used to drain the bladder suprapubically and a Foley
retention catheter to drain through the urethra. The prevesical space may be drained
with Penrose tubing.
(4) The bladder is sutured in two layers. A continuous suture of catgut is
used on the mucosa and interrupted stitches of chromic catgut on the muscle layer.
The abdominal muscle fascia and subcutaneous tissue are closed with catgut. Tension
sutures of nylon or silver wire may be needed for some patients. A suture is placed
around the cystostomy tube and affixed to the skin. The skin may be closed with silk or
stainless steel wire.
(5) The wound is dressed with bulky dressings. The wound and cystostomy
tube are held in place by adhesive tape strips.
3-23. TROCAR CYSTOSTOMY
a. General. This operation consists of opening the bladder, drainage by blind
puncture using needles or trocar, and insertion of a catheter.
b. Operative Procedure. The skin at the site of the puncture is nicked with the
scalpel, and the trocar is inserted into the bladder (see figure 3-8). The trocar obturator
is withdrawn, and a catheter is passed into the bladder over the catheter guide. The
cannula is withdrawn, and the catheter is sutured to the wound edges. The wound is