Colonic trauma

SR Brown

Colorectal Surgeon

Sheffield Teaching Hospitals

Types of trauma

• Penetrating trauma– Gunshots

• Energy transfer proportional to velocity

• Cavitation– Injury away from track

– Contamination sucked in

– Stab wounds• Low level energy transfer

• Injury confined to track

Blunt trauma

• Mechanisms for damage– Crushing– Shearing– Bursting– Penetrating

Evaluation of abdominal penetrating trauma

• Haemodynamically unstable – Laparotomy

• Haemodynamically stable– Serial clinical exam– Local wound exploration– DPL– FAST– CT– Laparoscopy– Laparotomy

DPL

• Positive if– >10ml frank blood– RCC>100,000/mm3

– WCC>500/mm3

– Amylase>20 IU/L– Presence bacteria/bowel contents

Adjuncts to evaluation

• CXR

• NG tube

• Catheter

• PR

Pros/cons

• Awake/cooperative patient

• Invasive

• Admission

• Retroperitoneum

• High clinical workload

• Complications

CT features of penetrating abdominal injury

• Signs of peritoneal violation– Free air/fluid– Track

• Signs of bowel injury– Thickening/defect– Contrast leak

• Others– Intravenous contrast leak– Diaphragm tear

Evaluation of blunt abdominal trauma

• Haemodynamically unstable– DPL/FAST/CT

• Haemodynamically stable– Serial examination– FAST– CT

Surgery for abdominal trauma

Advantages of primary repair

• Reduced morbidity of colostomy closure

• Reduced disability of colostomy

• Reduced hospital stay

Colonic surgery; primary repair

Primary repair Colostomy Leak

Stone, 1979 69 72 1

Chappuis, 1991 28 28 0

Falcone, 1992 12 12 0

Sasaki, 1995 43 28 0

Gonzalez, 1996 56 53 2

Total 208 193 3

Colonic injury; primary repair in destructive injury

Primary repair Colostomy Leak

Chappuis, 1991 11 28 0

Falcone, 1992 12 12 0

Sasaki, 1995 12 28 0

Gonzalez, 1996 5 53 1

Total 40 121 1

Risk factors for primary repair

• Haemodynamicaly unstable

• Significant underlying disease

• Associated injuries

• Peritonitis

Damage control surgery

• ‘Multiple trauma patients are more likely to die from intra-operative metabolic failure than a failure to complete operative repairs’

Pathophysiology

• Hypothermia

• Acidosis

• Coagulopathy

Principles of surgery

• Control haemorrhage

• Prevent contamination

• Avoid further injury

Principles of colonic surgery

• Repair small enterotomies

• Extensive damage resect and close off ends

• No stomas– Time consuming– Spillage difficult to control

Abdominal compartment syndrome

• Pressure >25cm water

• Oedema– Reperfusion injury– Crystalloid infusion– Capillary leakage– Packing

Pathophysiology

• Cardiovascular– Decrease cardiac output despite high CVP

• Respiratory– Splint diaphragm

• Renal– Oliguria due to renal vein/parenchyma compression

• Cerebral– Increased CVP results in decreased cerebral drainage

Diagnosis

• Oliguria + increasing CVP

• Foley catheter in bladder– Normal 0 cm water– >25cm water suggestive– >30cm water diagnostic

Treatment

• Anticipate– Difficulty closing– Horizontal view, guts above level of wall

• Laparostomy– Bogota bag– VAC dressing