This document provides an overview of colorectal trauma and injuries. It discusses relevant anatomy, considerations for colonic and rectal trauma including classification systems, management approaches, and risks factors. It also reviews iatrogenic injuries that can occur from various surgical, endoscopic, and diagnostic procedures. Key points include that nondestructive colon injuries can often be primarily repaired, while destructive injuries require resection. Rectal injuries are classified using the "4Ds" concept of debridement, drainage, washout, and sometimes diversion.

1. Colorectal Trauma: The Things
Residents Should Know
Facebook: Happy Friday Knight
30th March, 2018
General Surgical Residency Program
Thailand

2. • Introduction
• Relevant Anatomy
• General considerations
– Antibiotics
– Wound management
• Colonic trauma
– Classification
– Destructive VS non-destructive injuries
– Essential issues
• Rectal trauma
– “4Ds”
– classification
– Intraperitoneal VS extraperitoneal injuries
• Iatrogenic colorectal injuries

3. Introduction
• Radical changes of colorectal injuries
management result in dramatic reduction of
colon-related mortality from 60% during WWI
to less than 3% in the last decade
• However, abdominal sepsis after this trauma is
about 20%
• For rectal injuries, “4Ds” concept has been
challenged

4. Introduction
• The vast majority of colorectal injuries are due to
penetrating trauma, usually firearms during war
• Colonic injuries:
– 2nd most common GSW after small bowel: transverse colon
– 3rd most common abdominal stab wound after liver and
small bowel: lt colon
• Blunt trauma is uncommon
– Most superficial
– mechanisms:
• Mesenteric tear and ischemic necrosis
• Transient formation of closed loop and blowout perforation

5. Relevant Anatomy

6. Netter’s Atlas of anatomy.

7. Netter’s Atlas of anatomy.

8. Netter’s Atlas of anatomy.

9. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.

10. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.

11. Netter’s Atlas of anatomy.

12. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education,
2015.

13. Collateral Communication Arteries
• Arc of Buhler: celiac a to SMA
• Arc of Riolan: meandering mesenteric artery:
SMA to IMA
• Marginal artery of Drummond: SMA to IMA

14. http://cvandir.blogspot.com/2012/10/arc-of-riolan-meandering-mesenteric.html

15. http://ueu.co/accesssurgery-print-12/

17. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education,
2015.

18. Netter’s Atlas of anatomy.
0, 2, 4, 7, 11, 15
0 = anal verge
2 = dentate line
4 = anorectal ring
7 = lower to midrectum
11 = mid to upper rectum
15 = upper rectum to
rectosigmoid junction

19. Netter’s Atlas of anatomy.

20. General Consideration
• Antibiotics
• Wound management

21. Antibiotics
• Cover E.coli and B.fragilis
• Enterococcus in early abdominal sepsis is
controversial
• Duration: 24-hr prophylaxis is at least as
effective as prolonged prophylaxis for 3 – 5
days

22. Wound Management
• Delayed primary closure for 3 -5 days
postoperatively when fecal spillage

23. COLONIC TRAUMA

24. Diagnosis
• Almost always made intraoperatively
– Paracolic hematoma
• Should be explored in penetrating trauma
• Serial examination and CT scan evaluation
– Free air
– Free fluid
– Thickening colonic wall
– Contrast leak
• Delayed peritonitis in ischemic necrosis from torn
mesentery

26. Management of Colonic Trauma

27. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.

28. Colon Injuries
• Nondestructive
– < 50% circumferential
– No devascularization
– Grade II
• Destructive
– > 50% circumferential
– Devascularization
– At least grade III

29. Nondestructive Colon Injuries
• There is now enough class I evidence
supporting primary repair in all
nondestructive colon injuries irrespective of
risk factors.

30. Destructive Colon Injuries
• Require segmental colonic resection
• Primary anastomosis or diversion?

31. Risk Factors for Abdominal
Complications after Colon Injuries
• Sepsis rate higher than 20%
• Most of risk factors failed scientific scrutiny:
– Left versus Right colon injuries
– Associated abdominal injuries
– Shock
– Blood transfusion
– Fecal contamination
– Time from injury to operation
– Retained missiles
– Skin closure

32. Left versus Right
• Perception: anatomical differences between 2 sides of
the colon?
• It led to primary repair in right colon and colostomy in
left colon
• But no study demonstrates healing differences
• Colocolostomy is found to be more leakage than
ileocolostomy
• Conclusion:
– No differences
– Right hemicolectomy is procedure of choice for rt colon
injuries
– Good blood supply is cornerstone for colon healing

33. Associated Abdominal Injuries
• Although multiple injuries, the method of
colon management does not affect the
incidence of abdominal sepsis
• presence of pancreatic or urine leaks is
associated with increased risk of anastomotic
failure

34. Shock
• Although shock is not a contraindication for
primary anastomosis, duration and severity of
hypotension might be important factors that
need further investigation

35. Blood Transfusion
• Multiple transfusion (≥4U in 24 hrs) is most
important risk factor on abdominal sepsis but
management of colon did not differ in
complication rates in this group of patients
• It might be factor for anastomotic failure

36. Fecal Contamination
• is important factor for abdominal sepsis but
colon management does not influent septic
complication rate

37. Time from Injury to Operation
• Delayed operation increases risk of septic
complications
• Duration is not clear
• Degree of contamination might be more
important factor than duration

38. Retained Missiles
• There is no evidence that retained bullets are
associated with increased risk of local sepsis
• Removal of the missiles does not reduce the
risk of infection

39. Skin Closure
• Associated with wound dehiscence

40. Gordon PH, Nivatvongs S. Principles and
practice of surgery for the colon, rectum,
and anus. 3rd ed. New york: Informa
healthcare USA, 2007

41. Colon Leaks
• 2.2 – 6.6% leaks
• Resection and anastomosis is significantly higher
leak than simple repairs
• Colocolostomies are at higher risk to leak more
than ileocolostomies
• Multiple blood transfusions, severe
contamination, and multiple associated injuries
were not identified as independent risk factors
for anastomotic leak.
• If leaks: nonoperatively: adequate drainage and
low-residual diet

42. Technical Tips
• Control bleeding
• Adequate mobilization of injured segment and
careful inspection of retroperitoneal wall
• Paracolic hematoma due to penetrating trauma
should be explored to rule out perforation
• In blunt trauma,no need for routine exploration
of paracolic hematomas, unless there is a strong
suspicion for an underlying perforation
• Gently squeeze for occult injuries

43. Technical Tips
• Ureters should always be identified in case of Rt
or Lt colon injuries
• Beware of splenic flexure
– Weak point
– Don’t pull it too hard to cause splenic capsular tear
• Adequate debridement of all penetrating wounds
• Anastomosis under tension-free and good blood
supply
• One-layer anastomosis is as safe as a two-layer
anastomosis

44. RECTAL TRAUMA

46. Diagnosis
• Peritonitis  lack in extraperitoneal rectal
injuries
• DRE
• Rigid proctosigmoidoscopy
• CT scan with or without rectal contrast

47. Management
• Intraperitoneal rectal injuries
– as colon injuries  primary repair
• Extraperitoneal rectal injuries: 4Ds
– Debridement
– Presacral drainage
– Distal rectal washout
– Diversion: ostomy

48. Diversion
• The Hartmann’s procedure should be reserved
for patients with extensive destruction of the
rectum
• Routine colostomy has been challenged
• Lesion at too low to repair from
transabdominal approach and too high to
suture transanally can be done by diverting
colostomy without suturing of the perforation

49. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.

50. Presacral Drainage
• Routine use of presacral drains cannot be
supported

51. Surgery for Victims of War (ICRC, 1998, 225 p.)

52. Distal Rectal Washout
• No role

53. Technical Tips
• Lithotomy
• Look for bladder and iliac vessel injuries and
repair separately by using omentum
• In complex anorectal injuries with pelvic
fracture: hemostasis with sigmoid colostomy
• Massive rectal bleeding can be controlled by
embolization, if not, pack
• Rarely, APR may be only option to control
bleeding or sphincter cannot be repaired

54. Iatrogenic Colorectal Injuries

55. Gynecologic Procedures
• Dilatation and curettage can lead to
perforation
• Both total abdominal and vaginal
hysterectomy can lead to perforation and
fistulization
• Intrauterine devices erode peritoneal cavity
and subsequently to colon

56. Anorectal Procedures
• Simple procedures like surgery for
hemorrhoids, fissure, fistula can cause
stenosis or incontinence

57. Urologic Procedures
• Percutaneous nephrostomy: colon perforation
• Perineal prostatectomy, suprapubic
prostatectomy, or transurethral resection of
the prostate can be associated with injury of
the adjacent rectum

58. Neurosurgical and Orthopedic
Procedures
• During inserting VP shunt
• During internal fixation of hip fracture when
the nail being too deep and injures the rectum

59. Endoscopically Induced Trauma

60. Rigid Proctosigmoidoscopy
• Most: near peritoneal reflection of
rectosigmoid
• Factors associated with perforation included
– blind introduction beyond the anal margin,
– reinsertion of the obturator to overcome spasm
– injudicious use of long cotton-tipped applicators
– the attempted forceful dilatation of rectal
strictures with the proctosigmoidoscope

61. • Common sense to decrease perforation rate:
– perform the examinations gently
– obtain biopsies judiciously
– insufflate minimally
Rigid Proctosigmoidoscopy

62. Fiberoptic Sigmoidoscopy and
Colonoscopy
• Major complications of colonoscope is
hemorrhage and perforation
• During diagnostic: abrasion of laceration
(unusual)
– During slide-by technique especially when tip is
entrapped: rectosigmoid, midsigmoid, and the angle
created by the junction of the descending colon and
the sigmoid colon
– When tip is introduced to large diverticulum
– Dilatation of the stenosis
– Overstretching the fixed segment by looping scope

63. • Therapeutic: snare polypectomy (most
common)
– From hot biopsies or snare polypectomy with full-
thickness burn and necrosis
– Treating sessile polyp is even greater risk, to
minimize: Taking <2.0-cm pieces of a sessile polyp
and coagulating them in short two-second bursts,
allowing cooling periods
Fiberoptic Sigmoidoscopy and
Colonoscopy

64. • Explosion
– During electrocautery
– During argon plasma coagulation
– Mannitol bowel preparation
– Thegases should be evacuated from the colon and
rectum by suctioning the lumen before any kind of
electrical or laser coagulation
– If explodes, monitor signs and symptoms and
obtain film abdomen for free air
Fiberoptic Sigmoidoscopy and
Colonoscopy

65. • Silent perforation
– Air in retroperitoneum
– Ileus is the most common symptom
– It can be treated nonoperatively, primary repair, or
primary anastomosis
Fiberoptic Sigmoidoscopy and
Colonoscopy

66. Rectal Thermometer
• In newborn
• During measuring temperature
• 50% of perforation occur at <3cm from anal
verge

67. Therapeutic Enema
• Unison?
• Installation of wrong liquid
• Insertion of enema tip
• Majority is anterior wall
• Extraperitoneal perforation can cause abscess,
fistula, or severe hemorrhage.

68. Barium Enema
• Both intra and extraperitoneal perforation
• By both direct penetration of enema tip and
overinflation
• Others include formation of barium granulomas
within the rectal wall, necrotizing proctitis, and
barium embolism
• Most perforations are ruptures through ulcers,
neoplasms, diverticula, hernias, inflammatory
bowel disease, or other areas of disease and from
biopsied

69. Barium Enema
• Combination of barium and feces are fatal complication 
severe inflammatory response
• Management:
– Antibiotics and resuscitation
– Remove barium: resection and diversion may be necessary
– Prevention:
(i) keeping the ‘‘head of pressure’’ of the barium <1 m,
(ii) not overinflating the balloon,
(iii) keeping the balloon tip minimally inserted
(iv) deferring the barium enema in patients who have recently
undergone a biopsy or polypectomy of the colon or rectum

70. Obstetric Trauma
• CPD with vaginal delivery can cause anorectal
trauma including anal sphincter system
– Episiotomy decreases incidence of third degree
laceration involved anal sphincter
• Rectovaginal fistula may be caused from
pressure necrosis: forceps delivery, midline
episiotomies

71. Irradiation-Induced Proctitis
• Acute and chronic phase
– Acute: edema, inflammation, erythema, and friability
of the rectal mucosa
– Chronic: granulation tissue, fibrosis, and telangiectasia
• Indications for colostomy were
– excessive bleeding
– radiation necrosis of the rectum
– fistulization to the vagina, bladder, or bowel
– obstruction caused by stenosis from radiation

72. • Other treatment
– Adequate hydration and antidiarrheals
– Oral and enama sucralfate
– Sulfasalazine
– Argon plasma coagulation
– Topical formalin
Irradiation-Induced Proctitis

73. Ingested Foreign Body
• Rare
• Perforation, abscess formation, obstruction,
hemorrhage

74. Foreign Bodies and Sexual Trauma
• Any object in anorectum used to be for sexual
stimulation: vibrators, plastic phalluses,
cucumbers, baby powder cans, balls, bottles,
flashlights, screwdrivers, thermometers.
• Embarrassment and pain
• Plain radiograph is essential to identify size
and number, but radiolucent objects may not
be visualized

76. Sexual and Child Abuse
• Boys more than girls

77. Unusual Perforation
• Impact feces (stercoral perforation)
• Spontaneous perforation with pre-existing
disease: neoplasm, diverticular disease, IBD

78. Repair of Anal Sphincter Injury
• Primary repair is acceptable unless extensive
injury that colostomy is required
• Delay repair is preferable if critical
• Polyglycolic (dexon) acid or polyglactin (vicryl)
sutures should be used instead of permanent
sutures to prevent chronic suture sinuses

79. Removal of Foreign Bodies
• Appropriate relaxation and sedation to relax
anal sphincter
• Goal is to remove object per anus with intact
sphincter, but sometimes performing an
internal anal sphincterotomy or opening
external sphincter muscles to allow extraction
of large foreign bodies may be necessary and
must be repaired later
• Lubrication and lithotomy position are helpful

80. Removal of Foreign Bodies
• Obstetric forceps, foley catheter, padded
pliers, plaster of paris with a string or clamp
inside, SB tube, and proctoscope can be used
to remove objects
• After removal, proctosigmoidoscope should
be performed to check bleeding or perforation

81. Padded pliers

82. Plaster of paris

83. Removal of Foreign Bodies
• Regional anesthesia may be performed if local
removal fails
• Explore laparotomy is the last choice
– For upper rectum and rectosigmoid
– Surgeon will try milking and removing through anus
– If fails, colotomy will be required
– If perforation, it can be large contusion
,contamination, and too deep to exteriorize so
resection or even diversion are recommended

84. References
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill
Education, 2015.
Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon,
rectum, and anus. 3rd ed. New york: Informa healthcare USA, 2007.
Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.
Netter’s Atlas of anatomy.
Penetrating Abdominal Trauma, Prophylactic Antibiotic Use in. J Trauma.
73(5):S321-S325, November 2012