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
121
1
40
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