Trauma of the Colon, Rectum, and Anus

Eric K. Johnson

Scott R. Steele

Perioperative Considerations

Diagnosis/Mechanism of Injury

Colon and rectal injuries may occur in the setting of blunt, penetrating, and blast trauma. In military and disaster scenarios, it is not uncommon to see combined mechanisms of injury.
Most colorectal injuries are diagnosed in the operating room (OR) during laparotomy performed for broader indications.

Penetrating Trauma

Any penetrating injury to the abdomen or the pelvis can potentially result in colon or rectal injury.
If there is an anterior violation of the abdominal wall fascia (found on local exploration), the patient likely requires abdominal exploration in the OR. Laparotomy versus laparoscopy can be utilized based on local equipment and expertise. Flank injuries are a bit trickier and often require imaging (potentially triple-contrast computed tomography [CT] scan) to evaluate.
Hemodynamically unstable patients with abdominal trauma should undergo brief resuscitative efforts followed by operative exploration (unless there is an obvious source of hemorrhage outside the peritoneal cavity that can be controlled). A focused assessment with sonography in trauma (FAST) examination is helpful in this setting to look for free intraperitoneal fluid, and diagnostic peritoneal lavage can also be used.

Remember that a projectile/object may cross body cavities. What starts as an entrance wound in the thorax may end in the abdomen. Extremities apply as well. Look for entrance and exit wounds. There should be an even number of wounds. If there is not, plain film imaging may locate a projectile or fragment that is still in the body. The path of injury will alert one to the possibilities of colorectal trauma.

Blunt Trauma

Patients with blunt abdominal trauma can have variable presentations. A hemodynamically stable patient should undergo axial (CT) imaging to evaluate abdominal pain, or suspicious patterns of injury. Free fluid in the absence of solid organ injury and/or free air are suspicious findings that should be evaluated further, typically with laparoscopy or laparotomy.
One could imagine a scenario where diagnostic peritoneal lavage (DPL) could help direct management, but a patient with a negative lavage should still be observed as an inpatient in the setting of the previous CT findings.
Hemodynamically unstable patients with blunt abdominal trauma can be evaluated with FAST or DPL to aid in decision-making. Positive findings should prompt immediate operative exploration after brief resuscitative efforts.
Peritoneal signs on physical examination in the setting of blunt trauma should prompt additional investigation.
In the stable patient, CT scan is the best choice. Solid organ injury with hemoperitoneum may cause peritonitis and does not necessarily require laparotomy.
Suspicious findings, as noted earlier, should prompt operative exploration.

Pelvic Trauma/Potential Rectal Injury

In the setting of blunt or penetrating pelvic trauma, a rectal examination should be performed. Any evidence of rectal bleeding or a suspicious pattern of injury should be further evaluated with proctosigmoidoscopy. This can be performed using a rigid or flexible scope depending on local resources. This can easily be done in the OR if the patient is there for other indications.

Sterile Instruments/Equipment

Standard exploratory laparotomy tray, long instruments may be helpful.
Large self-retaining retractor, Bookwalter, or similar type
Staplers
Gastrointestinal anastomosis (GIA) (linear) staplers—open or endoscopic variety, the endoscopic staplers can be used in open cases, and sometimes give the advantage of ease-of-stapler placement in tight spaces.
End-to-end anastomosis staplers—a range of sizes may be helpful, but attempt to use the largest size that is safely possible.
Thoracoabdominal (TA) staplers—again a range of sizes in length and staple height may be helpful. There are options that include curved/cutting TA staplers that can be helpful in tight spaces—especially the pelvis.
Sutures/ties
3-0 Vicryl helpful for closing enterotomies or suture ligating distal mesenteric vascular injuries
0 and 2-0 Vicryl ties (long)—useful for ligating mesenteric vasculature
Heavy monofilament slowly absorbable suture like polydioxanone, sizes ranging from 1 to 2-0 depending on the needs or surgeon preference for fascial closure
Laparotomy pads have numerous packs of the larger variety that are useful for packing associated solid organ injuries, absorbing blood, and/or enteric material.
Warmed irrigation fluid—helpful for clearing the peritoneal cavity of contaminants and blood, and to improve visualization
Suction devices—a Poole suction and Yankauer suction are both useful.
Umbilical tapes—useful as a quick method for measuring the length of remaining small bowel or for expedient ligature of large intestinal injuries in the damage control setting

Ostomy supplies
Temporary abdominal closure device—negative-pressure dressings, patches, Bogota bag, and so on

Patient Positioning and Preparation

If there is a suspected colorectal injury, it is best if the patient is placed in low lithotomy position. This allows access to the rectum via the anus for proctoscopy or anastomosis. It also allows the operating
surgeon to stand between the legs if needed—this can be helpful during splenic flexure mobilization. In the setting of other potential injuries, the use of lithotomy could be considered controversial. Since it is not completely necessary to deal with all colorectal injuries, the use of other positions should be dictated by surgeon judgment and precedence of potential life-threatening injury.
The abdomen should be prepped widely, we prefer ChloraPrep, but a standard chlorhexidine, betadine, or alcohol prep could be used based on surgeon preference. A perineal, or anal prep, should be left to the discretion of the operating surgeon, as there is no real evidence that this makes any difference in outcomes.
In patients who show hemodynamic instability, or the potential for hemodynamic compromise on anesthetic induction, consider a full prep while the patient is awake so that the operating surgeon is ready to enter the abdomen immediately upon induction.

CONDUCT OF TRAUMA LAPAROTOMY

Technique

There are four essential components to a trauma laparotomy.
- Control of massive hemorrhage through use of packing
- Identification of injuries
- Control of contamination
- Reconstruction—if indicated and possible
Although the detailed description of the conduct of a trauma laparotomy and control/repair of all possible injuries are well beyond the scope of this chapter, we will focus on colorectal injuries.
Once life-threatening hemorrhage has been ruled out or controlled/packed, it is important to control contamination and focus on discovery of intestinal injuries. The entire small bowel and colon should be examined under clear visualization to determine the presence of injury. This may require a large laparotomy incision (though there may be some role for laparoscopy in special circumstances), and one should not be hesitant to enlarge an incision to improve exposure. Adequate visualization may require mobilization of the colon off of the retroperitoneum or mobilization of the colonic flexures.

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