66.11 Large gut injuries

Most injuries of the large gut are caused by penetrating wounds, but blunt injuries can also damage it. These injuries are particularly difficult to treat, because: (1) The peritonitis which follows them is more serious than that which follows injuries to the small gut. Caecal peritonitis is particularly deadly. Even a small suture line can leak, and its consequences are only partly prevented by a drain. (2) Retroperitoneal infection from the ascending and descending colon is at least as dangerous as peritonitis. (3) There may be a large area of bruising around the tear, especially if this is caused by a high veolocity missile. (4) The patient’s gut will not have been prepared for anastomosis. (5) He will probably have a haemoperitoneum which can readily become infected. All these factors make end-to-end anatomosis particularly dangerous. For, all these reasons it is a good principle never to suture and close any but the smallest wounds of the large gut.

If you are not experienced, aim to: (1) Bring the wound outside the patient’s abdomen as a loop colostomy, as described in Section 9.5. Or, (2) resect the injury and bring the ends of his gut out as a double barrelled colostomy. How best you can do this depends on how mobile the particular part of his injured large gut is. Two other factors are also important. (a) How large his injury is. (b) How old it is. Operate early, if possible within three hours. The larger and older the wound, the more important is it to exteriorize it. Later, when he has recovered, you can refer him to have his colostomy closed, or close it yourself. The closure of a colostomy is a major procedure and carries the risk of any large gut anastomosis. Refer him if you can.

If you are experienced, and his right colon is injured, you have the option of doing a right hemicolectomy and an end–to–side anastomosis, as in Fig. 9-7. Leaking ileal contents are less dangerous than those of the large gut, so a skillful ileocaecal anastomosis is acceptable.

It is a good principle in all colonic surgery to dilate the patient’s anus by Lord’s procedure (21.5). This will help faeces to trickle out of it, instead of building up at the suture line, and threatening the anastomosis. His sphincters will recover in a few days, by which tirne the tear should have healed.

INJURIES OF THE LARGE GUT

For the earliest steps see Section 66.3. Be sure to give the patient the perioperative antibiotics described in that section.

If there is an obvious wound in his large gut, cobble it up temporarily, or clamp it, before doing anything else, to prevent faeces spilling. Cover the wound with a pack.

Figure 66.18: MAKING A CAECOSTOMY WITH A DE PEZZER CATHETER. A, shows the final result with a de Pezzer catheter invaginated into the patient’s caecum which is sutured to his abdominal wall. B, the opening in his caecum being closed with a purse string suture. C, the catheter in place and the purse string about to be closed. D, the catheter being drawn through a separate stab wound. The first suture to hold the caecum is loosely in place. E, the final caecostomy. After Maingot with kind permission.

If there is no obvious wound, start with his caecum and check the whole of his colon for tears, perforations, bruises, and blow outs. If a bullet or small missile fragment is responsible, look for tiny perforations which may be obscured by omentum.

If he has a bullet wound of his large gut, avoid suturing it if you can; the surrounding tissues are injured and the wound will break down. If you do decide to suture it, be sure to do a proximal colostomy.

CAUTION! (1) Where possible, avoid bringing a colostomy out through his laparotomy wound, or it will probably become infected. (2) Try to avoid contaminating his laparotomy wound, or any missile wound, with faeces from his colostomy. (3) Beware of retroperitoneal bruises, because they may indicate hidden wounds. If necessary, mobilize his ascending or descending colon and look behind them. (3) Always complete the operation by doing Lord’s procedure.

LORD’S PROCEDURE Do this in all cases. Dilate the patient’s rectal sphincters so much by Lords procedure (21.5) that they are paralysed. They will recover in a few days, by which time the tear should have healed.