Colon & Rectum Injuries Prayuth Sirivongs M.D.

COLONIC INJURIES Anatomy Cecum Ascending colon Transverse colon Descending colon Sigmoid colon

COLONIC INJURIES Etiology Penetrating Injury : Gun Shot ~ 75% Stab wound ~ 20% Blunt Injury : Motor vihicle Trananal Injury : Iatrogenic ; colonoscopy ,B.E. Sexual related : foreign body

COLONIC INJURIES Diagnosis Pre-operation Blood in rectum Acute abdomen series Water soluble contrast enema Triple contrast CT

COLONIC INJURIES Intra operation Rule of “ two “ Complete mobilize Blood staining Fecal odor segmental squeeze

COLONIC INJURIES Treatment Colostomy Exteriorized repair primary repair

COLONIC INJURIES colostomy End Colostomy Protective Colostomy

COLONIC INJURIES colostomy End Colostomy Protective Colostomy

COLONIC INJURIES Indication for colostomy ( Stone & Fabian) 1.Shock c BP<80/60 mmHg 2.Intraperitoneal blood loss > 1000 ml 3.Intra-abdominal organ injuries > 2 organs 4.Significant fecal contamination 5.Time to operation >8 hrs 6.Colonic wound require resection 7.Major loss abdominal wall /Mesh

COLONIC INJURIES Colonic Injury Severity score (Shanon&Moore) Grade 1 ; Serosal injury Grade 2 ; Single wall injury Grade 3 ; < 25% wall involvement Grade 4 ; > 25% wall involvement Grade 5 ; Whole colonic wall involvement and blood supply injury

COLONIC INJURIES Exteriorized repair Avoided resection Reduced contamination Reduced colostomy Limited in some part of colon Stomal care is more difficult than colostomy

COLONIC INJURIES Primary repair Sutured repair Resection with primary anatomosis

COLONIC INJURIES Primary repair Sutured repair Resection with primary anatomosis

COLONIC INJURIES Primary repair Avoid colostomy Less morbidity than colostomy Gained more popularity Having high risk in patient c underlying medical illness massive blood transfusion

COLONIC INJURIES outcome cause of death exanguination sepsis ; intra- abdominal abscess multi organ failure fistula (primary repair)

RECTAL INJURIES Anatomy Promontary of sacrum to anus intraperitoneal extraperitoneal Length ~12-20 cm.

RECTAL INJURIES Anatomy Anal canal Anorectal ring to anal verge Sphincter complex puborectalis muscle external sphincter internal sphincter

RECTAL INJURIES Etiology Penetrating injuries ; gun shot ~80% Stab & impalement <5% Blunt injury ~ 10% Transanal injury ; ~ 6% Anal intercourse Anal rape Iatrogenic ; enema, thermometer

RECTAL INJURIES Diagnosis Suspected in GSW ; Trunk , buttock , perineum upper thigh Stab ; buttock , perineum , lower abdomen Blood in rectum ( rectal exam )

RECTAL INJURIES Investigation X-ray pelvis & abdomen ; bullet tract,foreign body, fracture pelvis Rigid proctosigmoidoscope Water soluble contrast study

RECTAL INJURIES Treatment 1.Intraperitoneal rectal injuries; as colonic injuriession 2.Extraperitoneal rectal injuries ; Diversion Debridement Distal washout Presacral drainage

RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure

RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure

RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure

RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure

RECTAL INJURIES 2. Debridement : removed devitalize tissue repair defect if possible severe injury ; resection 3.Distal washout : decrease septic complication

RECTAL INJURIES 4.Presacral drainage

RECTAL INJURIES Outcome Cause of death: Sepsis, Multi-organ failure Anorectal abscess Rectal fistula

PERINEAL INJURIES Perineum Inferior end of trunk Anterior (urogenital) Genital organ Urethra Posterior (anal) Anus

PERINEAL INJURIES MALE FEMALE

PERINEAL INJURIES ETIOLOGY : Iatrogenic anorectal injury Traumatic anorectal injury Foreign bodies in rectum Anal intercourse & assult

PERINEAL INJURIES IATROGENIC INJURIES Obstetric injury Anorectal surgery Enema Rectal thermometer Urologic & Gynecologic surgery

PERINEAL INJURIES TRAUMATIC INJURIES Blunt injury Straddle injury Laceration Implement Gunshot wound Blast High pressure

PERINEAL INJURIES Primary survey Resuscitation Secondary survey MANAGEMENT Primary survey Resuscitation Secondary survey Definitive care

PERINEAL INJURIES SECONDARY SURVEY History taking Symptom & sign Cause of injury Mechanism of injury Duration of injury Associated injury Symptom & sign Perineal pain Lower abdominal pain Bleeding Sepsis

PERINEAL INJURIES SECONDARY SURVEY examination Perineum , anus , buttock , thigh Abdomen Digital rectal examination Associated injuries Vagina Urethra & prostate gland pelvis SECONDARY SURVEY examination

PERINEAL INJURIES INVESTIGATION Film abdomen supine ,upright , lateral Rigid sigmoidoscopy Contrast study

PERINEAL INJURIES TREATMENT Perineal injury with rectal injury Debridement Diversion Drainage Distal washout

PERINEAL INJURIES TREATMENT Perineal injury Small hematoma ; conservative Expanded hematoma ; evacuated blood Laceration ; debridement & stop bleeding Severe laceration ; debridement , stop bleeding and colostomy

PERINEAL INJURIES TREATMENT Debridement Perineal injury Adequate debridement Left wound open Frequent debridement Adequate pain control Control contamination

PERINEAL INJURIES TREATMENT minimal sphincter injury Perineal injury with anal sphincter injury minimal sphincter injury severe sphincter injury colostomy primary repair non primary repair

PERINEAL INJURIES TREATMENT Incontinence Sphincteroplasty Muscle transposition Artificial sphincter

ANAL INTERCOURSE Mostly in Homosexual Complication Retained foreign bodies Colorectal perforation Anal tear Digital rectal exam & sigmoidoscopy

ANAL INTERCOURSE Management Uncomplicated injury Warm sitz bath Stool softener Tropical analgesic preparation

ANAL INTERCOURSE Management Surgery Deep tear Perforation Sphincter injury Persistent bleeding

FOREIGN BODIES IN RECTUM Oral ingested Bones Toothpick Seeds Anal insertion Sex toys Bottles Cans Flashlights Fruit umbrella

FOREIGN BODIES IN RECTUM Age ; 20-30 yrs and more than 60 yrs. Male : female 25: 1 Classification Retained F.B. without injury Non perforative mucosal laceration Sphincter injury Rectosigmoid perforation

FOREIGN BODIES IN RECTUM History Symptom & sign Anal or pelvic pain Inability to remove F.B. Bleeding Peritonitis

FOREIGN BODIES IN RECTUM Physical examination Abdomen Digital rectal exam Investigation Film abdomen AP& Lateral Contrast study

FOREIGN BODIES IN RECTUM Management Bedside extraction Local anesthesia Valsava maneuver Sedation Observation

FOREIGN BODIES IN RECTUM Management Operation Fragile object , high level Regional or general anesthesia Lithotomy position Sphincterotomy Explore to colotomy

FOREIGN BODIES IN RECTUM Technique for removal Under visualization Foley catheter or Blakemore tube Snaring Casting plaster Rigid sigmoidoscopy after removal

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