Colorectal injuries

Colorectal injuries
DR CARUNYA MANNAN

Colorectal Anatomy
 Ascending, transverse, descending, sigmoid,
rectum
 Blood supply - SMA, IMA vs. inf.
mesenteric/int. iliacs/pudendal art.
Bacterial content
 Increases as more distal to stomach
 60% dry weight stool = bacteria
 Intraperitoneal and retro/extraperitoneal
components

Colorectal Trauma – Etiology
COLON
Penetrating
 >85%
 Stab wounds> shotgun > iatrogenic
Blunt
 MVA, ped struck, falls
 Multiple injuries
 Delayed presentation
RECTUM
 Penetrating - Majority
Impalement / straddle injuries
Iatrogenic
Foreign body
 Blunt
Pelvic fractures - Disruption of pubic symphysis/
Spicules
 Scrape injuries
Drag over pavement s/p motorcycle accident
Trauma to perineum
High index suspicion

Colorectal Trauma
 Trauma algorithms
 ABCs
 History
 Physical
 Abdomen
 Flank
 Perineum
 DRE – blood

How to suspect large bowel injuries?
 Presence of manifestations of peritoneal irritation, free intraperitoneal fluid or
air, and/or by assuring the presence of penetration into the peritoneal cavity
Rectal, anal canal and perineal trauma - diagnosed by proper inspection and per
rectal examination of the patient
 Presence of bleeding per rectum is a very important sign
 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

Colorectal Trauma – Imaging
 CT SCAN
 Blunt Abdominal and Penetrating Flank
 Triple contrast
 DPL
 Abdominal trauma
 Will not evaluate retroperitoneum
 Bacteria / vegetable matter suggestive
 FAST
 Abdominal trauma
 Repeatable
 Non invasive
 Will not evaluate retroperitoneum
 Rigid Proctosigmoidoscopy
 Exploratory Laparotomy

Grading
Colon
Grade I – Contusion or hematoma; partial-
thickness laceration
Grade II – Full-thickness laceration <50 percent
of circumference
Grade III – Full-thickness laceration ≥50 percent
of circumference
Grade IV – Transection
Grade V – Transection with tissue loss;
devascularized segment
Rectum and rectosigmoid colon
Grade I – Contusion or hematoma; partial-
thickness laceration
Grade II – Full-thickness laceration <50 percent
of circumference
Grade III – Full-thickness laceration ≥50
percent of circumference
Grade IV – Full-thickness laceration with
perineal extension
Grade V – Devascularized segment
The American Association for the Surgery of Trauma (AAST) Organ Injury Scales
Weinberg JA, Fabian TC. Chapter 8: Injuries to the stomach, small bowel, colon, and rectum. In: ACS Surgery: Principles and Practice
Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990; 30:1427.

Primary closure
 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

Primary closure
 No difference exists between right and left colon
 No difference exists between mesenteric and ante-mesenteric injuries
 Closure in one or two layers using 3/0 vicryl on rounded needle using interrupted sutures
 No difference noted between single/double layer repairs

Contraindications of primary closure
1. Patient - in shock ( systolic less than 80 mm Hg)
2. Interval between injuries and closure is more than 8 hours
3. More than one organ injured
4. Injuries at two different locations of the large bowel
5. Massive colonic destruction
6. Massive contamination
7. Presence of prosthetic material or the necessity of its insertion
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
 Valid in right sided lesions where direct
closure is contraindicated
Other rare option for caecal injuries
 End ileostomy with long Hartmann closure for
the distal bowel

Double barrel colostomy - transverse colon or the
sigmoid colon if the injury is in a mobile area with
long mesentery
 Exteriorization of the repaired injured colon– Not
recommended - 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

Resection with end colostomy and mucosal fistula or
Hartmann pouch
 Done if the injury is at a site where mobility of the distal
limb is limited while mobility of the proximal limb is free.
 Ensure evacuation and emptiness of the distal limb of the
large bowel
An injury near the splenic flexure of the colon/ at the
distal region of the sigmoid colon

Suture closure with proximal diversion
 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:
 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
 Suitable in descending colon injuries
 Suitable in distal sigmoid lesions and also in proximal intraperitoneal rectal
injuries

Rectal injuries
 Detected by endoscopic examination
preferably - rigid sigmoidoscope in the
left lateral or lithotomy position to
determine the injury (intraperitoneal
/extraperitoneal)
 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

Rectal injuries
 Direct per rectal repair is done in low injuries (sub peritoneal spaces)
 Drainage of the presacral space through an incision situated midway between
the coccyx and the anus
 Specially indicated in posterior injuries

Rectal injuries
 Direct repair through abdominal exploration - injuries of the intraperitoneal
segment or in the retroperitoneal segment
 Drainage of the presacral space if the injury is posteriorly located
 Drainage of the Duoglas pouch if it is anteriorly located

Rectal injuries
 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 / rectum

Perineal and anal canal injuries
 Perineal and anal canal injuries - no attempt should be done for primary sphincteric or
tissue repair, only debridement and hemostasis
 Mandatory to divert the fecal stream totally from the wound in the perineum if the lesion is
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

Stapled versus Sutured Gastrointestinal Anastomoses in
the Trauma Patient
Brundage, Susan I. MD, MPH; Jurkovich, Gregory J. MD; Grossman, David C. MD, MPH; Tong, Wai Chung MBChB;
Mack, Chris D. MS; Maier, Ronald V. MD
Journal of Trauma-Injury Infection & Critical Care:
September 1999 - Volume 47 - Issue 3 - pp 500-508
Anastomotic leaks seem to be associated with stapled bowel repairs compared with sutured anastomoses in the
traumatically injured patient

Colostomy
- the mechanism of injury is a gunshot wound, endo-
lumenal or iatrogenic;
- shock at hospital admission;
- severe fecal contamination;
- CIS grade IV or V with ATI > 30
Primary repair
- the mechanism of injury is a blunt or stabbed abdominal
wound;
- the patient is hemodynamically stable, with no shock
at admission;
- mild or moderate fecal contamination;
- CIS grade I, II or III with ATI < 25;
- CIS grade IV, V with ATI < 30 (Resection and
anastomosis

 Gunshots - 75%
 Primary repair - 56%
 Routine use of diverting colostomy for all left colon injuries - should no longer be justified in current surgical practice.
A liberal use of primary repair, without colostomy, should be encouraged in patients with non destructive injuries of
the colon.

Conclusion
Colon Trauma
 Primary repair, resection + primary anastomosis
 Exceptions destructive injuries w/risk factors
 Shock, delay to management, associated organ injury, transfusion
requirement, co-morbid disease
Rectal Trauma
 Intraperitoneal
 Like colonic injuries
 Extraperitoneal
 Diversion and presacral drainage

Colorectal injuries

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