Velmahos has suggested that endoscopic evaluation of the rectum should be the first step if rectal injury is considered. If the diagnosis of an extraperitoneal rectal injury is made using proctoscopy, a fecal diversion can be employed as a rapid and safe manner of controlling contamination and potential pelvic soft tissue infection. The extraperitoneal rectal injury does not need to be explored and repaired and diversion is enough [15, 16]. Injuries to the upper two-thirds of the rectum are intraperitoneal and should be treated like intra-abdominal colonic injury with primary repair if feasible. If the injury is low and can be adequately visualized without extensive dissection, some authors recommend primary repair [17].

Presacral drainage has now largely fallen out of favor, and is mostly of historical interest only [18]. In this technique, an incision is made in the presacral space between the anus and coccyx. Blunt dissection would allow for placement of “open” drains, such as a Penrose. Presacral drainage for the management of rectal injuries traditionally has been combined with distal rectal washout and diversion. Presacral drainage may have a role in patients with a suspected rectal injury that can neither be identified or definitively repaired [17, 19]. An extraperitoneal abscess after diversion, however, may be amenable to image-guided drainage. Distal rectal washout is no longer commonly practiced – but there is no real data that suggests that this is a harmful practice [20].

Colostomy closure can usually be safely accomplished 2–6 months after the initial operation. In many cases, where the patient has an end colostomy, the patient needs to be counseled about the risks and benefits of the operation, as this may represent a major procedure. Ideally, the skin incision should be healed from the first operation before takedown is scheduled, and patients should be recovered from other traumatic injuries. Some authors have advocated for early colostomy closure – at the index admission – after radiographic documentation of distal healing [21].

Preoperative planning may include a CT scan of the abdomen and pelvis, as this will afford a survey of the abdominal wall, and associated herniae. The practitioner may order a barium enema to document a healed rectal stump and also allow the surgeon to gauge the length. Other authors have found barium enema to be unnecessary prior to colostomy closure [22].

While the reversal of a loop colostomy can be done through a local operation, an end colostomy reversal is more involved. The operation is performed in the lithotomy position in stirrups, with or without preoperative stenting of the ureter. The anastomoses performed should be tension-free and with a good blood supply. This may require full mobilization of the descending colon. The anastomosis should be performed with an “end-to-end” or circular stapler with confirmation of an adequate cuff of tissue or “donut” after firing. The anastomosis should be tested in the operating room with proctoscopy and air insufflation for leak. Any suspicion of leak, or question about the integrity of the anastomosis, should be a reason to divert the bowel contents with a loop ileostomy. The morbidity associated with low pelvic anastomotic leak far outweighs the nuisance associated with a temporary loop ileostomy that can be reversed.

Contemporary authors have supported the role of antibiotic stewardship. Short courses of antibiotic covering colonic flora are favored. In colonic trauma, antibiotics can be stopped 24 h after the initial operation [23]. Fabian et al. have found similar rates of major abdominal infection in patients treated for 24 h versus 5 days with antibiotics [24].