Healthcare

1. Supra – Pubic
CYSTOSTOMY
Presented by: KPEHE JIG MAIME – INTERN

2. Outline
• Definition
• Indication
• Contra- indications
• Anatomy
• Types
• Pre – Operative Preparation
• Pre – Incision
• Exposure and Procedure
• Closure
• Post – Op Management
• Complications

3. Definition
• Is a form urinary diversion
• A self retaining catheter is placed into the
bladder via the suprapubic region for purpose
of draining urine.

4. Indications
• Urine retention when urethral catherization fails
• Ruptured urethra
• Urethero – Cutaneous Fistula
• Periurethral abscess
• Extravasation of urine
• Chronic retention in neurogenic bladder

5. Contra-
indications
(Absolute)
Bladder
- Not distended
- Not Palpable
- Cannot be localized by Ultrasound
- Patient has a history of bladder cancer

6. Contra-
indications
(Relative)
- Coagulopathy
- Previous lower abdominal or pelvic surgery
- Pelvic Cancer

7. Anatomy

8. Types  Open or Percutaneous
 Temporal or Permanent
 Emergency or Elective

9. Pre – Op
Preparation
• History and examination
• Investigations based on indication;
- U/A, Clotting profile, Abd Us
• Informed Consent
• Pre – Op shaving
• Pre – Op Antibiotics (Ciprofloxacin
Preferably)

10. Pre –
Incision
Anesthesia
• Local
• Spinal
• GA
Position - Supine
• Surgeons, Assistant or nurse scrub and gowned
• The skin is prep (from the nipple line to the mid – thigh)
and draped exposing the supra – pubic region.

11. Incision • The transverse incision along the skin crease
• 2 finger breath above the pubic symphysis
(heals better less likely to herniate)
• Sub umbilical median incision, 3 – 5 cm long,
3 cm from the symphysis

12. Exposure • The incision is traverse the subcutaneous tissue;
fascia
• Achieve hemostasis by ligation and pressure
• Open the rectus sheath, starting in the upper
part of the wound.
• Continue dissection with scissors to expose the
gap between the muscles
• The muscles are separated at the midline with
artery forceps and the retractor repositioned and
retracted laterally

13. Exposure
• The transversalis fascia, preperitoneal fat and peritoneum
are carefully pushed upwards by gauge dissection until the
bladder is exposed
• The bladder is pale, thing wall vessels courses over the
surface and can be aspirated with needle and syringe
• The wall of the bladder is fixed with two stay sutures
(Silk 1-0)
• Using electrocautery or knife, a transverse incision is made
about 2cm distal to the fundus between the stay sutures
• The bladder is then emptied by suction
• The interior explored with the finger to exclude calculi,
diverticuli and tumor

14. Exposure • The suprapubic catheter is placed through the
abdominal wall by stab incision in the upper
skin flap, inserted into the bladder
• The catheter is secured with purse string
(Vicryl 2-0)
• The balloon is then inflated
• The catheter then anchored to the skin with
nylon – 2-0, before wound closure and
continuous drainage established.

15. Closure • The wound is closed in layers with a drain
in the prevesical space
• Rectus is approximated with vicryl 2-0
• Rectus sheath nylon – 1
• Skin with nylon 2-0
• Wound is cleaned and dressed

16. Post – Op
Management
• Antibiotics
• Analgesics
• Monitoring urine output

17. Complications  Hematuria
 Surrounding organ injury
 Catheter blockage
 Dislodgment
 Skin site infection
 UTI
 Stone formation

18. References 1. WHO Surgical Manual at District Hospital
2. Norman S.Williams et al, Bailey & Love
Short Practice of Surgery, 25th Edition
3. Principles & Practices of Surgery in the
Tropics “ Archampong 2010 Edition.