Colorectal trauma By Youssri S. GaweeshProf. of surgery Alexandria Univeristy
Etiology• Penetrating trauma• This is the most common type of trauma seen, and is usually due to – high velocity missiles. – rectal impalement injuries result when a patient falls on a penetrating object or using foreign bodies for sexual satisfaction. – iatrogenic injuries due to uterine perforation during curettage of the uterus, use of endoscopies whether diagnostic or during polypectomies or other rectal instrumentations. – during surgical operations for urologic or gynecologic operations.
Etiology• Blunt trauma• This is rare due to the protected situation of the anus and rectum and it is usually associated with fracture pelvis. The commonest cause is motor vehicle accidents followed by falls and crush injuries.
Pathology• The pathology depends on the following• The inflicting agent• The severity of the trauma (contusion versus laceration versus devitalization). If lacerated lesion is more than 2cm after debridement this is a contraindication to primary suturing the defect.• The site of injury or the presence of multiple sites of injury. If multiple sites of injury are present, no primary suture is allowed.
Pathology• Whether the injury is retro or intra peritoneal.• The presence or absence of loaded large bowel and the degree of spillage of contents. If spillage is for a distance of more than 5 cm from the large bowel site of injury, no primary suture is allowed.• The associated injuries and or the presence of shock, this prohibits primary sutures.• The time lapsed before management. If more than 8 hours no primary sutures are allowed.
How to suspect large bowel injuries?• Intra-abdominal injuries are diagnosed as any abdominal trauma by the presence of manifestations of peritoneal irritation, free intraperitoneal fluid or air, and/or by assuring the presence of penetration into the peritoneal cavity.
How to suspect large bowel injuries?• Rectal, anal canal and perineal trauma are diagnosed by proper inspection and per rectal examination of the patient.• The presence of bleeding per rectum is a very important sign.• The presence of different types of uretheral injuries as well as different types of fracture pelvis should stimulate the surgeon to properly examine and even sigmoidoscope the rectum and the pelvic colon.
?And how to investigate• Recently CT abdomen and to a lesser extent the ultrasound examination is replacing the time honored methods of diagnosis of abdominal trauma which are the plain standing abdomen and the diagnostic peritoneal lavage (DPL).
?And how to investigate• Sigmoidoscope (the preferred method of investigation) the rectum and the pelvic colon.• If an enema is to be used, water soluble contrast (gastrographin) is a must and barium should never be used.• Again a CT abdomen and pelvis with double or at least I.V. contrast is indispensable for proper diagnosis.
Treatment• Direct laceration closure.• This necessitates the presence of the following conditions – Small tear less than 2 cm after debridement of the large bowel wound. – Minor spillage reaching to a distance less than 5 cm all around the lacerating wound – Interference in a time less than 8 hours from wound inflection – Unloaded colon – No other large bowel injuries – No other organ injuries – No hemodynamic shock or a status of imperfect tissue perfusion (e.g. septic shock)
Remarks on primary closure• No difference exists between right and left colon• No difference exists between mesenteric and ante-mesenteric injuries• Close in one or two layers using 3/0 vicryl on rounded needle using interrupted sutures• Test your closure tightness and lumen patency
Contraindications of primary closure1. Patient is or has been in shock ( systolic less than 80 mm Hg)2. The interval between injuries and closure is more than 8 hours3. More than one organ injured4. Injuries at two different locations of the large bowel5. Massive colonic destruction6. Massive contamination7. Presence of prosthetic material or the necessity of its insertion
Treatment• In practice this is only valid in situations where the colon and or the rectum are injured in a patient whose large bowel is prepared as in operative or endoscopic iatrogenic injuries.
Options of management• Resection of the injured area with direct anastomosis of the small bowel to the transverse colon. This is only valid in right sided lesions where direct closure is contraindicated.• Other rare option for cecal injuries is – Do end ileostomy with long Hartmann closure fo thedistal bowel
Options of management• Double barrel colostomy at the site of injury (instead of exteriorization of the repaired injured colon) is done in transverse colon or the sigmoid colon if the injury is in a mobile area with long mesentery.• It is really meaningless to exteriorize a repaired loop because you cannot replace it before two weeks and also because obstruction and leakage occurs in more than 50% of the cases after replacement of the loop.
Options of management• If the injured segment is exteriorized as a double barrel colostomy, a second stage of colostomy closure is a must, with all the possible complications of leakage, sepsis and peristomal hernia which are far less common in this situation.• General rules of colostomy surgery are obeyed, and large trephines are created to accommodate the two limbs of the large bowel in different areas of the abdominal wall.
Options of management• Resection with end colostomy and mucosal fistula or Hartmann pouch.• This is done if the injury is at a site where mobility of the distal limb is limited while mobility of the proximal limb is free.• One condition is a must. This is to ensure evacuation and emptiness of the distal limb of the large bowel. This is especially applicable in the following situations: – An injury near the splenic flexure of the colon – An injury at the distal region of the sigmoid colon
Options of management• Suture closure with proximal diversion. This means primary closure of the laceration even if some conditions prohibit that closure with protection of the primary repair with proximal fecal diversion either by ileostomy or colostomy with the following conditions:• The diversion should be complete with no chance of any fecal matter passage to the distal limb• Assure the removal of all fecal residue in the distal limb• This is suitable in descending colon injuries• This is also suitable in distal sigmoid lesions and also in proximal intraperitoneal rectal injuries.
Principles of management of rectal injuries• The injury in the rectum is detected by a through endoscopic examination preferably done by a rigid sigmoidoscope in the left lateral or lithotomy position to determine the injurys location whether in the intraperitoneal segment or in the extraperitoneal one.• The extraperitoneal space for the rectum is divided into retroperitoneal high up in the abdomen and sub peritoneal low in the presacral space. Also using the scope removal of the retained feces with irrigation is done.
Principles of management of rectal injuries• Direct per rectal repair is done in low injuries (sub peritoneal spaces) with possible drainage of the presacral space through an incision situated midway between the coccyx and the anus. This is specially indicated in posterior injuries.
Principles of management of rectal injuries• Direct repair through abdominal exploration is done in injuries of the intraperitoneal segment or in the retroperitoneal segment, with possible use of suction drainage of the presacral space if the injury is posteriorly located, and drainage of the Duoglas pouch if it is anteriorly located as is usually the case.
Principles of management of rectal injuries• A proximal complete fecal diversion is a must in all situations• Ensure removal of all retained feces by irrigation through either the distal limb of the colostomy or better still through the rectum.
Perineal and anal canal injuries• In perineal and anal canal injuries, no attempt should be done for primary sphincteric or tissue repair, only debridement and hemostasis are done.• It is however, mandatory to divert the fecal stream totally from the wound in the perineum if the lesion is even moderately extensive and specially if involving the sphincteric complex of the anal canal.• After healing of the wound and before any colostomy closure, sphincteric repairs can be done under cover of the diversion usually with satisfactory results.
Wound closure• Abdominal cavity should be irrigated with copious amounts of warm saline• The fascia is closed with monofilament interrupted sutures• Irrigation of the wound with saline and betadine• The skin is better left open and dressed twice daily• Secondary sutures are done after 4 to 5 days.