1. Bowel injury should be: Primarily repaired
T Hardcastle
Trauma Surgeon
IALCH Durban

2. NEVER A NEVER, NEVER AN ALWAYS
Debate?
Problem
No one rule that fits all situations
You will be wrong some of the time
NEVER A NEVER, NEVER AN ALWAYS
IN TRAUMA!

3. Primary repair – is it safe?
Yes: For most situations
Civilian:
Surg Ann 1991: 203 – 223
Unfallchirurg 1991: 105
J R Coll Surg Edinb 1996: 20 – 24
Ann R Coll Surg Engl 1999: 58 – 61
Injury 2002: 611 – 615
J Trauma 2003:
World J Surg 2006: 488 – 94
Cochrane 2003 CD002247
Military
J Trauma 2009: 1286 – 1291
Dis Colon Rectum 2007: 870 – 877

5. Primary Repair – how to do it!
Small bowel
First stop any bleeding
Get rid of the contamination
Either debride the wound edges or do your resection
Check the numbers
Patient not for damage control
Single layer sero-submucosal absorbable suture and close mesentery
Stapled anastomosis higher leak rates*
*J Trauma 2001; 51: 1054

7. Primary Repair – when to do it!
Large bowel
Stable patient
Minimal transfusions
Good edge bleeding*
Even after resection^
No residual soiling or devitalized tissue
Single layer sero-submucosal preferably interrupted suture. Absorbable material
Consider omental wrap (Levuno Wrap)
*Surg Ann 1991: 203 – 223
^ Ann R Coll Surg Eng 1999:

9. Primary repair not advised?
Colonic injury
Severely shocked patient
Damage control criteria
Left colonic flexure*
Massive transfusion and marginal artery
Other bowel
Complex duodenal injury – maybe!
Most of these can be repaired
Rectal injury – extraperitoneal^
*J Trauma Aug 2005: 59: 359
^World J Surg 2007: 1345

10. So is it really a debate? More about DECISION MAKING
GOOD judgment comes from experience, experience comes from BAD judgment!
Must know ALL options and choose the appropriate one at the appropriate time

11. ?