Grade
Type of injury
Description of injury
I
Hematoma
Contusion or hematoma without devascularization
Laceration
Partial-thickness laceration
II
Laceration
Laceration <50% of circumference
III
Laceration
Laceration >50% of circumference
IV
Laceration
Full-thickness laceration with extension into the perineum
V
Vascular
Devascularized segment
8.5 Surgical Strategy
Surgical decisions for anorectal injuries depend upon:
Hemodynamic stability: In an unstable patient, damage control surgery is recommended and should be limited to clearing immediate threats to life, i.e., diverting the fecal stream by proximal colostomy, debriding the devitalized tissue, and drainage of the presacral space.
Condition of local tissues: If there is local tissue loss with devitalization, edema, and gross contamination, anastomotic leak is likely. In such cases, proximal diversion is advisable. If the local tissues are healthy, primary closure can be attempted.
Anatomic location: Intraperitoneal (IP) rectal injuries are managed like colonic injuries, and the current evidence is in favor of primary closure without diversion. Extraperitoneal (EP) rectal wounds are difficult to access and therefore difficult to close and hence theoretically can lead to intra-abdominal sepsis, particularly in the presacral area due to contamination from the rectal contents, and thus evolved the concept of routine use of proximal diversion, presacral drainage, and distal rectal washouts (DRW). This was extensively practiced in military settings and later also applied to civilian settings (Brunner and Shatney 1987; McGrath et al. 1998). But today, four points are often debated in management of rectal injuries: (1) routine use of proximal diversion, (2) primary closure without diversion, (3) presacral drainage, and (4) distal rectal washouts (DRW).
There is a theoretical risk of contamination of the prerectal space with distal washouts (Tuggle and Huber 1984). Ivatury et al. 1991 reported safety of primary closure in rectosigmoid wounds and usefulness of diversion and presacral drainage, but did not find evidence to support the use of DRW (Ivatury et al. 1991). McGrath reported that intraperitoneal injuries can be treated by primary closure (McGrath et al. 1998). In those extraperitoneal rectal tears which can be accessed and sutured satisfactorily, presacral drain is probably not required. But for those extraperitoneal tears which are not accessible and difficult to suture, presacral drainage is advisable to prevent presacral abscesses. Gonzalez et al. also dismiss the utility of presacral drain placement in preventing local septic complications (Gonzalez et al. 1998). Laparoscopy has been advocated by Navsaria et al. to rule out intraperitoneal injury in penetrating rectal injury. They have reported successful use of diverting sigmoid colostomy without formal laparotomy for managing the extraperitoneal rectal injury without presacral drainage and DRW (Navsaria et al. 2001; Navsaria et al. 2007). Weinberg et al. (2006) have suggested a pathway based on anatomical location of rectal injury (IP or EP) and have suggested that omission of colostomy in most IP injuries and selected EP injuries and judicious use of presacral drainage to reduce the risk of retrorectal abscess in EP injuries (Weinberg et al. 2006). However, enough evidence was not found to categorically support the practice of colostomy in open pelvic fracture cases with rectal injury to prevent septic complications (Lunsjo and Abu-Zidan 2006). Gonzalez et al. reported that extraperitoneal nondestructive, penetrating rectal injures could be managed successfully without diversion and, however, stated the need for a randomized controlled trial (RCT) (Gonzalez et al. 2006).
Suggested algorithm for management of rectal injury is shown in Fig. 8.1.
Fig. 8.1
Algorithm showing management of rectal injuries, distal rectal washout (DRW)
8.5.1 Technical Points in Surgery
Various controversial issues sometimes make surgical decisions challenging. Burch et al. have discussed the following technical points to improve surgical outcome in these patients (Burch et al. 1989).
Colostomy: The purpose of colostomy is complete diversion of fecal stream from the injury site. Cecostomy, “tube” colostomy, and “window” colostomy or a sunken colostomy are suboptimal and ineffective.
Site of colostomy: The sigmoid colon is preferred unless there is severe destruction of the rectosigmoid, in which case transverse colostomy is carried out.
Type of colostomy: Loop colostomy is the simplest to perform and also to close, but it is important to make an adequate spur supported by a rod which will ensure complete diversion of fecal stream (Fig. 8.2). Proximal colostomy with mucous fistula is preferred if a segment of sigmoid colon needs to be resected. End colostomy with closure of distal stump (Hartmann’s procedure) is preferred when there is destruction of the part of the rectum and sigmoid. Abdominoperineal excision with end colostomy may be done when there is destruction of the sphincter as well.
Fig. 8.2
Spur of a loop colostomy
Presacral drain: The drain is placed between Waldeyer’s fascia and the rectum and is brought out through the perineum through a curvilinear incision between the anus and coccyx (Fig. 8.3).
Fig. 8.3
Site of insertion of a presacral drain
Distal rectal washouts: This is usually carried out after creation of the colostomy and closure of the laparotomy wound. Lithotomy position is given. Rectal stump is irrigated transabdominally through the distal stoma, while the assistant stretches the anal canal to facilitate evacuation of contents.
8.5.2 Anorectal Foreign Bodies
A variety of foreign bodies like sticks, bottles, glasses, and cans have been reported. DRE and plain X-ray of the abdomen and pelvis usually clinch the diagnosis. It is important not to embarrass the patient further by repeatedly asking as to how the foreign body went in! Clinical examination to rule out signs of peritonitis (abdominal tenderness, guarding, and rigidity) is a must. In such a case, laparotomy will be required. Removal is challenging and various innovative methods have been reported for the safe extraction of the foreign body. Lithotomy position, good lighting, good sedation to relax the sphincters, suprapubic pressure, and use of appropriate devices for extraction may help in removal of the foreign body. In difficult cases general anesthesia with muscle relaxation may be of help in achieving safe retrieval. If transanal manual extraction fails, endoscopy-guided retrieval may be attempted. Laparoscopy-guided removal has also been described (Coskun et al. 2013). At times laparotomy and colotomy may be needed for removal of the impacted or inaccessible foreign body (Cologne and Ault 2012).
It must be remembered that patient undergoing successful transanal extraction of foreign body needs to be closely watched for signs of full-thickness rectal tear in spite of the apparently safe extraction, and if perforation is suspected, CECT may be performed to rule out the same (Cologne and Ault 2012).
8.5.3 Obstetric Anal Sphincter Injuries (OASIS)
Perineal tears are common during delivery. Third- and fourth-degree perineal tears involve the sphincter and the anal canal, respectively. It is associated with primiparity, induced labor, epidural analgesia, persistent occipito posterior position, prolonged second stage of labor, forceps delivery, and large baby. In India, unattended home delivery could be a factor. Diversion is generally not warranted (Cawich et al. 2007). Identification and primary repair by a trained operator is the best option. End-to-end or overlapping repair of the external anal sphincter is recommended using monofilament or braided delayed absorbable sutures. Postoperative physiotherapy, laxatives, and antibiotics active against both aerobic and anaerobic organisms are advised (Royal college of Physicians of Ireland 2014). If untreated, patients may suffer from fecal incontinence, fecal urgency, dyspareunia, and perineal pain (Fowler 2010). Clinical examination (Fig. 8.4) along with endoanal ultrasound is diagnostic. Surgical repair of the sphincter by overlapping sphincteroplasty is the treatment of choice.
Fig. 8.4
Clinical photograph of an obstetric perineal injury presenting several years later
8.5.4 Iatrogenic Anorectal Injuries
Although preventable in principle, iatrogenic injuries do occur, The key issues which determine management are time of diagnosis (during the procedure or later), size of the perforation, state of preparation of the colon (for colonoscopy), extent of fecal contamination, and state of the injured rectum (diseased or otherwise). If diagnosed during the procedure, primary repair can be done if there is no contamination. Small puncture wounds can be treated conservatively. Larger wounds have to be closed; which can be achieved by endoscopic clipping, laparoscopic suturing, or open surgical repair. Delayed diagnosis will usually need diversion due to sepsis (Lohsiriwat 2010). Iatrogenic injury to inflamed or diseased rectum will usually need diversion. Extraperitoneal rectal injuries during extraperitoneal radical prostatectomy have been reported to be successfully treated conservatively (Khoder et al. 2009). Anal sphincter injuries have been encountered during surgery for anal disorders particularly for high fistula-in-ano. If recognized during surgery, primary repair has been advocated. In others who present later with incontinence, muscle transposition and artificial sphincters are options (Sheikh 2008).
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