This patient has developed a parastomal hernia around their colostomy stoma, which is causing discomfort and leakage. Options for repair include closing the stoma and restoring intestinal continuity, resiting the stoma to a better location, or a local repair using techniques like bowel resection, suture plication, and mesh to reinforce the abdominal wall defect. The elastic garment around their waist is an abdominal binder intended to provide symptomatic relief.

1. Small & Large Bowel Injuries
PROF:AKMAL JAMAL
FCPS:FRCSEd:
26 April 2012

2. Klinika Chirurgii Urazowej Grala

3. “You You see what you look for” Stephen
Sondheim

4. 4

5. Diagnosis of hollow viscus injury
is difficult, challenges even modern diagnostic
modalities, and requires a high degree of suspicion
Nonoperative management is still possible but
requires compulsive patient monitoring
Outcomes improve if the “evil that lurks within the
abdomen” is diagnosed and treated early

6. Solid Organs and Hollow Structures
Solid: Hollow:
• Liver • Stomach
• Pancreas • Small Intestine
• Spleen • Appendix
• Kidneys • Large Intestine/Colon
• Ovaries • Gallbladder
• Bladder
• Uterus
• Aorta
• Common bile duct
• Fallopian tubes
6

7. What is the "golden hour"?
The first hour after injury provides a
unique opportunity to provide life-
saving interventions. Because more than
half of trauma deaths occur early due to
bleeding or brain injury, rapid
transport, appropriate
triage, evaluation, resuscitation, and
intervention can affect outcomes.
.

8. What is the "golden hour"?
The "golden hour" concept needs to be extended
to several hours in the rural setting, but
with the same structured approach.

9. When Trauma Deaths Occur?
<1 hour 1-3 hours 4 to 6 weeks
“The Trimodal Distribution”
Temple College EMSP

10. Immediate Deaths(<1 hour)
• Complete airway Obstruction
• Brain Stem Laceration
• High C-Spine Lesion
• Aortic/Heart Rupture

11. Early Deaths (1-3 hours)
• Epidural Hematoma
• Subdural Hematoma
• Hemo/Pneumothorax
• Intra-abdominal Bleeding
• Pelvic Fractures
• Femur Fractures
• Multiple Long Bone Fractures

12. Late (2-4 weeks)
• Sepsis SIRS
• Multiple Organ Dysfunction/ Failure
MOD/MOF

13. S/S of Abdominal Injury
• Pain, tenderness  Lacerations, bruisin
• Nausea, emesis g, deformity or
• Guarding asymmetry
• Fetal positioning  Tachypnea
• Coffee-ground emesis  Distention
• Hematuria  Rigidity
• Melena  Referred pain
• Obvious trauma  Hypovolemic shock
13

14. Overview:Small bowel Injury
• Seat belts, direct blow or penetrating trauma
• Minimal bleeding
• Peritoneal signs (intoxicated or deeply unconsious
patients – absent)
• US, CT nondiagnostic
• Diagnosis - DPL and laparotomy
• Primary repair or segmental resection and
anastomosis, close mesenteric defects
Klinika Chirurgii Urazowej Grala

15. Management:
Small Bowel Injury Small Bowel
Much less common in blunt than
penetrating
Nonetheless, 3rd most common blunt
abdominal injury

16. Blunt Abdominal Trauma
SMALL BOWEL INJURY
• . Mechanism:
* Crushing of bowel against the spine
* Sudden deceleration sheering of the
bowel from its mesentery at a fixed point
* Bursting of “pseudo-closed-loop” from
sudden increase in intraluminal pressure

17. 6/7/2012

18. 18

19. Blunt bowel injury
Klinika Chirurgii Urazowej Grala

20. Blunt bowel injury
Klinika Chirurgii Urazowej Grala

21. Seatbelt injuries
.
The three-point shoulder-lap belt is the most effective
restraining system and is associated with the lowest
incidence of abdominal injuries.
However, abdominal injuries are still ascribed to
shoulder-lap and lap-belt systems.

22. Seatbelt Sign

25. pathogensis
o compression of bowel between the belt and the
vertebral column.
o an acute short closed-loop obstruction occurs along
with perforation secondary to the sudden generation
of high intraluminal pressures.

26. 6/7/2012

27. Peneterating TRauma
• Small bowel trauma-25-30%
Stab wound
The liver, followed by the small bowel, is the
organ most often damaged by stab wounds
Gunshot Wounds
handguns, rifles, and shotgun

28. Stab wound to right lower quadrant with caecal
evisceration. No colon injury at laparotomy.

29. MCQ
• Small bowel injury is the most common injury
resulting from ___ abdominal trauma.
• penetrating
• blunt

30. MCQ
• Small bowel injury is the most common injury
resulting from ___ abdominal trauma.
• penetrating
• blunt

31. INJURY TO COLON AND RECTUM
Blunt Abdominal Trauma-5% cases
Mechanism: rapid deceleration with steering
wheel compression
• uncommon
• Disruptions of colonic wall or avulsion injury
of mesentery
• Present with hemoperitoneum, peritonitis.

32. INJURY TO COLON AND RECTUM
Peneterating Abdominal Trauma-95%
Large number of colonic injuries are due to
peneterating trauma.
Rectal injuries –assosiatied with pelvic #

33. Klinika Chirurgii Urazowej Grala

34. Operative Management
• Treatment of injury is dictated by location and
severity. In general…
– Antibiotics is administered before skin incision and for 24
hours if injury is confirmed
– Abdominal exploration performed through mid-line
incision sufficient to access entire peritoneal cavity
– After initial control of any significant bleeding is
achieved, inspection commences in a systematic fashion

35. Management:
Small Bowel

36. Operative Management
• Injuries to the Small Bowel
– Evaluated intraoperatively by “running the bowel”, from the
ligament of Treitz caudad to the ileocecal valve
Injured Structure AAST Grade Characteristics of Injury AIS-90 Score
Contusion or hematoma without
I devascularization; partial-thickness 2
laceration
Small (<50% of circumference)
II 3
laceration
Small Bowel Large (≥50% of circumference)
III 3
laceration
IV Transection 4
Transection with segmental tissue loss;
V 4
devascularized segment

37. Management:
Sc Small Bowel Injury Scaleale Small Bowel
I Hematoma Contusion without devascularization
Laceration Partial thickness, no perforation
II Laceration <50% circumference
III Laceration >50% circumference without transection
IV Laceration Transection of small bowel
V Laceration Transection with segmental tissue loss
Vascular Devascularized segment

38. Operative Management,
–Primary repair,
– Resection or
– Combination thereof is employed at
the discretion of the surgeon

39. Operative Management, cont’d
– Grade I –reapproximation of the seromuscular
layers with interrupted sutures
– Grade II –limited debridement and closure in
either one or two layers
– Grade III –repaired primarily if luminal narrowing
can be avoided; otherwise, resection and
anastamosis
• Small bowel anastomoses usually hand sewn or stapled
– Grade IV and V – resection and anastomosis

40. Management:
Treatment Grade I Small Bowel

41. Management:
Treatment Grade II Small Bowel
Transverse closure preferred
(if possible)

42. Management:
Treatment Grade III Small Bowel
No difference in hand-swen vs. stapled (Witzke, J Trauma, 2000)
No difference in 1 vs. 2-layer anastomosis (Burch, Ann Surg, 2000)

43. Management:
Treatment Grade IV Small Bowel
Damage Control:
Can staple both
ends, control other intra-
abdominal
damage, resuscitate in
ICU, and return to OR in
24-48 hrs for delayed
primary anastomosis
(Carillo, J Trauma, 1993)

44. Management:
Treatment Grade V Small Bowel

45. Management:
Postoperative Care Small Bowel
24 hrs perioperative abx if this is the only injury
NG decompression until ileus resolves:
* Multi-injured patients have slower return of bowel fxn
* Can decompress stomach if jejunal feeds used )
* Moderately to severely injured patients do better with enteral feeds
started 24-48 hrs postop

46. Management:
Colon

47. Management:
Historical Notes – Backwards as Usual Colon
Gordon-Taylor G. Br J Surg 1942.
Most colonic injuries can be fixed primarily, avoid resection, proximal
colostomies possibly for extensive injury or descending colon injury. 50%
Mortality.
Ogilvie WH. Surg Gynecol Obstet 1944.
Colostomy for colon injuries. 60% Mortality.
, mandating colostomy for all colonic injuries.
Improvement in postoperative care towards the end of WWII led to 5-20%
mortality, credited incorrectly to use of colostomy.
Woodhall, Ochsner. Surgery 1951. Re-introduced primary repair.

48. Management:
Colonic Injury Scale Colon
I Hematoma Contusion without devascularization
Laceration Partial thickness, no perforation
II Laceration <50% circumference
III Laceration >50% circumference without transection
IV Laceration Transection of colon
V Laceration Transection with segmental tissue loss
Vascular Devascularized segment

49. Management:
Intraoperative Diagnosis Colon
Injuries distributed evenly throughout the colon
Sometimes even difficult to diagnose intra-operatively
Explore all:
Blood staining / hematoma on colonic wall
Injured mesentery in proximity to colonic wall (may even need to divide one
or two terminal mesenteric vessels for exposure)
Mobilize all colon in injured areas
Follow trajectories if possible
Milk luminal contents through areas of suspicion

50. Management:
Factors Determining Optimal Tx Colon
1.Shock (preoperative BP < 80/60)
2.Hemorrhage (blood loss > 1L)
3.Multiorgan injury (>2 organ systems)
4.Significant peritoneal spillage
5.Delayed operation (>8 hrs post injury)
6.Nonviable colon (wall destruction or ischemia)
7.Major loss of abdominal wall (close range blast
injury)
8.Location of injury (distal vs. proximal to middle
colic)

51. Management:
Suture Repair Colon

52. Management:
Resection and Primary Repair Colon

53. Management:
End colostomy Colon

54. Management:
Exteriorization Colon

55. Management:
Sample Algorithm
Colon
Resection required?
NO YES
Suture Repair Proximal to MCA?
YES
NO
Resection and Evaluate Local
ileocolostomy Conditions:
Resection and
Colocolostomy vs.
Hartmann’s

57. Operative Management, cont’d
– Colonic injuries further categorized as either non-
destructive or destructive
• Destructive - wounds that completely transect the colon (grade IV)
or involve tissue loss and devascularized segments (grade V)
• Patients with destructive colonic injuries who had:
– comorbid medical conditions
– required transfusions of more than 6 units of blood
– in shock
– delayed operation…significantly higher risk for suture line breakdown
when managed with resection and primary anastomosis

58. Operative Management, cont’d
– Non-destructive wounds (grades I-III)
• Seromuscular closure for partial thickness
• Primary closure for full thickness
– Destructive wounds (grades IV-V)
• Repair with resection and primary anastomosis
– Destructive wounds with risk factors
• Resection with end colostomy or resection and primary
anastomosis with proximal diversion
– Proximal diversion
» loop colostomy (with open or closed distal stoma)
» end colostomy (with a mucous fistula or closure of the rectal
stump)

59. Operative Management, cont’d
• Injuries to the Rectum
– Classified according to anatomic criteria
• Anterior and lateral sidewalls of the upper two thirds of the
rectum managed in the same manner as colonic injuries
• Upper two thirds posteriorly and lower one third of the rectum
circumferentially - extraperitoneal
– Upper two thirds - exploration and suture repair, fecal diversion with
loop or end colostomy as adjunctive measure
– Lower one third - explored and repaired if accessible Fecal diversion
recommended
» Wounds difficult to reach - proximal fecal diversion and
presacral drainage

60. “You see what you look for” – Stephen Sondheim

61. The Value of Serial Observation
The Value of Serial Observation

62. Case 1: Troublesome stoma
This 57 year old man was having increasing
discomfort from his stoma and associated leakage
from a stoma appliance that was difficult to apply.
1.What abnormality is shown?.
2. Methods for repair?
3. What is the elastic garment around this
patients waist?

64. ANSWER
1. What abnormality is shown?.
A parastomal hernia
2. Methods for repair?
-consider stoma closure restoring intestinal continuity
-resiting stoma to another area with non attenuated abdominal
wall tissues
-local repair. This may include amputation of some bowel
length, suture plication of the abdominal wall defect, mesh
repair to reinforce the abdominal wall tissues.
3. What is the elastic garment around this patients waist?
-abdominal binder for symptomatic relief