Management of Rectal Injuries

Rectal injuries above the peritoneal reflection can be treated as colonic injuries and repaired primarily.

Extraperitoneal rectal injuries should be repaired primarily if possible. The rectum can be mobilised to allow repair, and posterior wall injuries repaired through an anterior wound or colotomy. (Do not repair an anterior wound without examining the posterior rectal wall). Some low rectal injuries can be repaired trans-anally.

Colon & Rectum

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

Where the position of the injury precludes repair a proximal, diverting colostomy should be performed. The options here are loop colostomy, loop with distal soma closed, a colostomy and mucus fistula or a Hartmann's procedure. A well-fashioned loop colostomy is usually preferred, is adequate in diverting the faecal stream away from the repair and is easily closed. The central spur should be above the level of the skin to allow complete diversion.

Where there is more extensive damage to a significant portion of the rectal wall, or the injury is complex, a Hartmann's procedure (proximal colostomy and closed, intra-peritoneal distal end) is probably warranted.

Pre-Sacral Drainage
Drainage of the pre-sacral space used to be a routine procedure for all rectal injuries. However, a propective randomised trial of 48 patients by Gonzalez in 1998 showed a lower complication rate without presacral drainage (8% with drainage, 4% without). Similarly McGrath and Fabian in 1998 also found no difference in presacral infection rates comparing patients with and without presacral drainage.

Pre-sacral drainage probably still has a place in high-energy blunt trauma, pelvic fractures and where there is delayed repair of injuries.

Distal Washout
Washout of the distal rectal stump has also been routinely practiced, but there is no supporting evidence for the procedure. Although it may reduce faecal load in the rectum, it may also force faecal material out of a rectal laceration. McGrath & Fabian in 1998 found no difference in pelvic infection rates comparing those patients with and without distal washout. Distal washout may be more applicable to military injuries where soldiers are often constipated and where surgical procedures are performed after some delay.

Combined Genito-urinary Injuries
Combined rectal and genito-urinary injuries have a significantly higher complication rate than isolated rectal injuries. Complications are increased by distal rectal washout, no presacral drainage, repair of a rectal injury, prolonged supra-pubic drainage and failure to adequately separate the GI and GU injuries.

Management - Guidelines