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.
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.
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.