Colonic trauma
SR Brown
Colorectal Surgeon
Sheffield Teaching Hospitals
Types of trauma
• Penetrating trauma– Gunshots
• Energy transfer proportional to velocity
• Cavitation– Injury away from track
– Contamination sucked in
– Stab wounds• Low level energy transfer
• Injury confined to track
Blunt trauma
• Mechanisms for damage– Crushing– Shearing– Bursting– Penetrating
Evaluation of abdominal penetrating trauma
• Haemodynamically unstable – Laparotomy
• Haemodynamically stable– Serial clinical exam– Local wound exploration– DPL– FAST– CT– Laparoscopy– Laparotomy
DPL
• Positive if– >10ml frank blood– RCC>100,000/mm3
– WCC>500/mm3
– Amylase>20 IU/L– Presence bacteria/bowel contents
Adjuncts to evaluation
• CXR
• NG tube
• Catheter
• PR
Pros/cons
• Awake/cooperative patient
• Invasive
• Admission
• Retroperitoneum
• High clinical workload
• Complications
CT features of penetrating abdominal injury
• Signs of peritoneal violation– Free air/fluid– Track
• Signs of bowel injury– Thickening/defect– Contrast leak
• Others– Intravenous contrast leak– Diaphragm tear
Evaluation of blunt abdominal trauma
• Haemodynamically unstable– DPL/FAST/CT
• Haemodynamically stable– Serial examination– FAST– CT
Surgery for abdominal trauma
Advantages of primary repair
• Reduced morbidity of colostomy closure
• Reduced disability of colostomy
• Reduced hospital stay
Colonic surgery; primary repair
Primary repair Colostomy Leak
Stone, 1979 69 72 1
Chappuis, 1991 28 28 0
Falcone, 1992 12 12 0
Sasaki, 1995 43 28 0
Gonzalez, 1996 56 53 2
Total 208 193 3
Colonic injury; primary repair in destructive injury
Primary repair Colostomy Leak
Chappuis, 1991 11 28 0
Falcone, 1992 12 12 0
Sasaki, 1995 12 28 0
Gonzalez, 1996 5 53 1
Total 40 121 1
Risk factors for primary repair
• Haemodynamicaly unstable
• Significant underlying disease
• Associated injuries
• Peritonitis
Damage control surgery
• ‘Multiple trauma patients are more likely to die from intra-operative metabolic failure than a failure to complete operative repairs’
Pathophysiology
• Hypothermia
• Acidosis
• Coagulopathy
Principles of surgery
• Control haemorrhage
• Prevent contamination
• Avoid further injury
Principles of colonic surgery
• Repair small enterotomies
• Extensive damage resect and close off ends
• No stomas– Time consuming– Spillage difficult to control
Abdominal compartment syndrome
• Pressure >25cm water
• Oedema– Reperfusion injury– Crystalloid infusion– Capillary leakage– Packing
Pathophysiology
• Cardiovascular– Decrease cardiac output despite high CVP
• Respiratory– Splint diaphragm
• Renal– Oliguria due to renal vein/parenchyma compression
• Cerebral– Increased CVP results in decreased cerebral drainage
Diagnosis
• Oliguria + increasing CVP
• Foley catheter in bladder– Normal 0 cm water– >25cm water suggestive– >30cm water diagnostic
Treatment
• Anticipate– Difficulty closing– Horizontal view, guts above level of wall
• Laparostomy– Bogota bag– VAC dressing