1. Colorectal trauma
By
Youssri S. Gaweesh
Prof. of surgery Alexandria Univeristy

2. 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.

3. 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.

4. 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.

5. 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.

7. 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.

8. 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.

9. ?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).

10. ?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.

11. 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)

12. 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

13. Contraindications of primary
closure
1. Patient is or has been in shock ( systolic less
than 80 mm Hg)
2. The 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

14. 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.

15. 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

17. 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.

18. 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.

21. 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

23. 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.

24. 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 injury's
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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.