Management of Colonic Injuries

Almost all civilian colon injuries can be repaired primarily.

Colon & Rectum

Introduction
Diagnosis
Management - History
Management - Colon
Management - Rectum
Management - Guidelines
References

Small penetrating wounds can be closed with simple suture. More significant bowel injury should be treated with resection and anastomosis. Repair is with a single-layer, continuous, extra-mucosal, monofilament suture.

Over the past 2 decades there have been several prospective randomised controlled trials comparing primary repair with colostomy formation. All have shown either no difference, or improved outcomes with primary repair (usually in terms of hospital stay and complication rates). The leak rate for primary repair is around 1%.

Analysing subsets, there is no evidence to support routine use of colostomy for colonic injuries, whether left or right colon, blunt or penetrating, simple suture or resection. Primary repair is also cheaper, especially when factoring into account the complications of colostomy closure.

Patients at risk of anastomotic breakdown are those in whom diagnosis has been delayed significantly (24 hours), and those who are hypovolaemic and have reduced gut perfusion in the perioperative period. Where there is a long delay in diagnosis or treatment, repair and proximal colostomy MAY be the preferred option, though each case should be managed on its own merits.

Damage Control
Patients who are in haemorrhagic shock, and are (or soon will be) hypothermic, coagulopathy and acidotic should have a damage control procedure. Once control of haemorrhage is achieved, management of gastrointestinal injury is limited to the control of sepsis. Small wounds may be sutured primarily, but larger areas of damaged colon should be excised and the ends tied or stapled closed. Repair and restoration of intestinal continuity is reserved for a subsequent operation.

Abdominal compartment syndrome is a frequent sequelae of shock and hypoperfusion. The presence of a colostomy in these patients can be disastrous. In the worst case, the abdomen may swell and the colostomy retract into the peritoneal cavity. Even without this, the wound management of an open abdomen with a nearby colostomy can be extremely challenging. If colostomies must be placed they should be brought out far more laterally than their usual position, away from the wound edges.

Management - Rectal Injury