1. Colorectal traumaBy Youssri S. GaweeshProf. of surgery Alexandria Univeristy
2. Etiology Penetrating trauma This is the most common type of traumaseen, and is usually due to high velocity missiles. rectal impalement injuries result when a patient fallson a penetrating object or using foreign bodies forsexual satisfaction. iatrogenic injuries due to uterine perforation duringcurettage of the uterus, use of endoscopies whetherdiagnostic or during polypectomies or other rectalinstrumentations. during surgical operations for urologic or gynecologicoperations. 3. Etiology Blunt trauma This is rare due to the protected situationof the anus and rectum and it is usuallyassociated with fracture pelvis. Thecommonest cause is motor vehicleaccidents followed by falls and crushinjuries. 4. Pathology The pathology depends on the following The inflicting agent The severity of the trauma (contusion versuslaceration versus devitalization). If laceratedlesion is more than 2cm after debridement this isa contraindication to primary suturing the defect. The site of injury or the presence of multiplesites of injury. If multiple sites of injury arepresent, no primary suture is allowed. 5. Pathology Whether the injury is retro or intra peritoneal. The presence or absence of loaded large boweland the degree of spillage of contents. If spillageis for a distance of more than 5 cm from thelarge bowel site of injury, no primary suture isallowed. The associated injuries and or the presence ofshock, this prohibits primary sutures. The time lapsed before management. If morethan 8 hours no primary sutures are allowed. 6. How to suspect large bowelinjuries? Intra-abdominal injuries are diagnosed asany abdominal trauma by the presence ofmanifestations of peritoneal irritation, freeintraperitoneal fluid or air, and/or byassuring the presence of penetration intothe peritoneal cavity. 7. How to suspect large bowel injuries? Rectal, anal canal and perineal trauma arediagnosed by proper inspection and per rectalexamination of the patient. The presence of bleeding per rectum is a veryimportant sign. The presence of different types of uretheralinjuries as well as different types of fracturepelvis should stimulate the surgeon to properlyexamine and even sigmoidoscope the rectumand the pelvic colon. 8. ?And how to investigate Recently CT abdomen and to a lesserextent the ultrasound examination isreplacing the time honored methods ofdiagnosis of abdominal trauma which arethe plain standing abdomen and thediagnostic peritoneal lavage (DPL). 9. ?And how to investigate Sigmoidoscope (the preferred method ofinvestigation) the rectum and the pelviccolon. If an enema is to be used, water solublecontrast (gastrographin) is a must andbarium should never be used. Again a CT abdomen and pelvis withdouble or at least I.V. contrast isindispensable for proper diagnosis. 10. 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) 11. Remarks on primary closure No difference exists between right and leftcolon No difference exists between mesentericand ante-mesenteric injuries Close in one or two layers using 3/0 vicrylon rounded needle using interruptedsutures Test your closure tightness and lumenpatency 12. 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 13. Treatment In practice this is only valid in situationswhere the colon and or the rectum areinjured in a patient whose large bowel isprepared as in operative or endoscopiciatrogenic injuries. 14. Options of management Resection of the injured area withdirect anastomosis of the small bowel tothe transverse colon. This is only valid inright sided lesions where direct closure iscontraindicated. Other rare option for cecal injuries is Do end ileostomy with long Hartmann closurefo thedistal bowel 15. Options of management Double barrel colostomy at the site of injury(instead of exteriorization of the repaired injuredcolon) is done in transverse colon or the sigmoidcolon if the injury is in a mobile area with longmesentery. It is really meaningless to exteriorize a repairedloop because you cannot replace it before twoweeks and also because obstruction andleakage occurs in more than 50% of the casesafter replacement of the loop. 16. Options of management If the injured segment is exteriorized as a doublebarrel colostomy, a second stage of colostomyclosure is a must, with all the possiblecomplications of leakage, sepsis and peristomalhernia which are far less common in thissituation. General rules of colostomy surgery are obeyed,and large trephines are created to accommodatethe two limbs of the large bowel in differentareas of the abdominal wall. 17. Options of management Resection with end colostomy and mucosalfistula or Hartmann pouch. This is done if the injury is at a site wheremobility of the distal limb is limited while mobilityof the proximal limb is free. One condition is a must. This is to ensureevacuation and emptiness of the distal limb ofthe large bowel. This is especially applicable inthe following situations: An injury near the splenic flexure of the colon An injury at the distal region of the sigmoid colon 18. Options of management Suture closure with proximal diversion. This meansprimary closure of the laceration even if some conditionsprohibit that closure with protection of the primary repairwith proximal fecal diversion either by ileostomy orcolostomy with the following conditions: The diversion should be complete with no chance of anyfecal 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 inproximal intraperitoneal rectal injuries. 19. Principles of management ofrectal injuries The injury in the rectum is detected by athrough endoscopic examination preferablydone by a rigid sigmoidoscope in the left lateralor lithotomy position to determine the injuryslocation whether in the intraperitoneal segmentor in the extraperitoneal one. The extraperitoneal space for the rectum isdivided into retroperitoneal high up in theabdomen and sub peritoneal low in thepresacral space. Also using the scope removalof the retained feces with irrigation is done. 20. Principles of management ofrectal injuries Direct per rectal repair is done in lowinjuries (sub peritoneal spaces) withpossible drainage of the presacral spacethrough an incision situated midwaybetween the coccyx and the anus. Thisis specially indicated in posterior injuries. 21. Principles of management ofrectal injuries Direct repair through abdominalexploration is done in injuries of theintraperitoneal segment or in theretroperitoneal segment, with possibleuse of suction drainage of the presacralspace if the injury is posteriorly located,and drainage of the Duoglas pouch if it isanteriorly located as is usually the case. 22. Principles of management ofrectal injuries A proximal complete fecal diversion is amust in all situations Ensure removal of all retained feces byirrigation through either the distal limb ofthe colostomy or better still through therectum. 23. Perineal and anal canal injuries In perineal and anal canal injuries, no attemptshould be done for primary sphincteric or tissuerepair, only debridement and hemostasis aredone. It is however, mandatory to divert the fecalstream totally from the wound in the perineum ifthe lesion is even moderately extensive andspecially if involving the sphincteric complex ofthe anal canal. After healing of the wound and before anycolostomy closure, sphincteric repairs can bedone under cover of the diversion usually withsatisfactory results. 24. Wound closure Abdominal cavity should be irrigated withcopious amounts of warm saline The fascia is closed with monofilamentinterrupted sutures Irrigation of the wound with saline and betadine The skin is better left open and dressed twicedaily Secondary sutures are done after 4 to 5 days.