· SB most frequently injured intra-abdominal organ
· Greater degree of force and high rate of associated intra-abdominal injuries
· Association of transverse # of lumbar vertebrae and blunt intestinal injury
· Presence of Chance # and lapbelt contusion warrants laparotomy.
· CT and FAST are not reliable in blunt intestinal injury and so DPL should be used.
Damage control and assessment
· Bleeding mesentery: Running closure with suture or ligation
· Small bowel injury: application of Allis/babcock or suture ligation or stapling until entire extent of injury assessed.
· Run the entire length of SB. Check both sides. Where there is a suspect area of injury near the mesentery then clear mesentery. Compress bowel to find occult leak.
· >50% of circumference is missing then resect. Avoid stapled anastomosis if the bowel is oedematous
· Mesenteric laceration: control bleeding with suture ligation. If section is devascularized then resect
How is colonic trauma graded
grade 1 contusion or haematoma without devascularization, partial thickness
laceration, no perforation
grade 2 laceration <50% circumference
Most Grade 1 and 2 injuries can be treated by colorrhaphy.
grade 3 laceration >50% without transection
grade 4 transection of the colon
grade 5 transection of the colon with segmental tissue loss, devascularized
For Grade 3,4 and 5 injuries the choice is between colostomy and primary resection with anastomosis particularly for right-sided lesions. The choice depends on general condition of patient and intra-peritoneal environment.
What is the management of colonic injury
exteriorisation not mandated
degree of injury (destructive colonic injuries)
primary repair for most cases
exteriorisation for high risk cases
How is rectal injury diagnosed?
High index of suspicion when there is any pentrating trauma to perineum or buttock.
Blood on DRE is indicative.
Proctoscopy with visualisation of blood or injury itself.
What is the management of rectal injuries
Depends on anatomic location of injury, associated injuries and condition of patient
Intra-peritoneal: the anterior and lateral surfaces of the upper 2/3 of rectum.
Managed as colonic injuries
primary repair, resection alone (Hartmanns) or resection and anastomosis (+/- proximal diversion) depending on complexity of wound, contamination, patient condition and suspicion of injuries to EP rectum.
Extra-peritoneal: The lower 1/3 and posterior surface of the upper 2/3.
Proximal EP: upper 2/3 managed in similar manner to IP rectal injuries following mobilization of proximal EP rectum.
Distal EP: Lower 1/3
If wound is accessible easily then primary repair and diversion
- If the wound is inaccessible then proximal diversion and pre-sacral drainage (curved incision between anus and tip of cocyx to insert a penrose drain in front of Waldeyers fascia)
- Proximal diversion is usually via sigmoid colostomy
- The efficacy if distal rectal washout questioned. Probably has a place in severe military-type wounds.
What are the common complications after colon and rectum surgery?
Mortality: 5% - 20% emergency and 2% elective
Immediate; Early (30 days); Late (>30 days).
Early: General: Cardiac (arrythmia, MI, CCF) or pulmonary (Atelactasis, pneumonia, aspiration, PE), infectious (urinary tract, lungs).
Early: Specific abdominal: Ileus, fascia dehiscence and anastomotic failure
Late: Hernia formation (30%), Stoma complications, anastomatic stricture.
What is the risk of anastomotic failure?
Clinical leaks occur in 1-2% of colonic resections
Subclinical and asymptomatic leaks are more common.
How do anastomatic leaks present?
Insidious: Fever, ileus, tachycardia, faeces draining through wound or drain
Localized or generalized peritonitis
Ileocolic and colo-colic anastomosis: May present as generalized peritonitis, colo-cutaneous fistula or localized abscess.
Pelvic colo-rectal anastomosis: May present as a localized pelvic abscess with or without systemic toxaemia or spreading pelvic cellulitis.
How is it diagnosed?
Clinically: Gentle rectal exam and/or proctoscopy showing anastomotic gap
Water-soluable contrast enema
CT with oral, IV and/or rectal contrast.
What is the treatment for anastomtic failure?
An asymptomatic leak discovered incidentally does not require treatment.
For symptomatic leaks the treatment depends on the symptoms and the presumed extent of leak.
Generalized peritonitis: Re-laparotomy take down the anastomosis and exteroirize the ends of the anastomosis. Repeat anastomosis may be attempted with or without proximal diversion however the risks of repeat failure are greater than the primary anastomosis and would not be the standard or recommended treatment.
Faecal fistula in absence of generalized peritonitis or uncontrolled sepsis: Intravenous hyperalimentation, ensure no distal obstruction, treatment of sepsis and take care of skin may close spontaneously.
Pelvic abscess: depends on degree of toxaemia and presence of proximal diversion and size of defect in anastomosis.
Severe toxaemia in uncovered anastomosis: re-laparotomy, washout and placement of drain with proximal diversion (small or inapparent defect) or resection and exteriorization (Hartmanns) if large defect especially with faecal contamination.
Mild systemic symptoms and covered anastomosis with loculated abscess: CT-guided drainage.
Early suspected but not confirmed pelvic leak: NBM, TPN, Abx.
Factors Influence whether colonic injury should have colostomy:
General physiology: shock or blood loss
Time since injury
Mechanism of Injury:
GSW or Blast Injury:
Colostomy is indicated as the extend of injury not present until few days later
Size of Wound
Local Damage of Vascularity
R or L colon