66.12 Injuries of the caecum

These are particularly difficult because the contents of a patient’s caecum are fluid, leak easily, and irritate his skin, so you cannot make a surface caecostomy as if it were a colostomy. A proximal defunctioning caecostomy is also impractical. The alternatives are: (1) To insert a caecostomy tube into his caecum to prevent soiling of his skin, as in A, Fig. 66-18. This is useful for small bullet wounds and stab wounds of the caecum, but it will not defunction the rest of his large gut. (2) A right hemicolectomy, with an ileostomy and colostomy, if you are less skilled (as in C, Fig. 66-19), or with an end-to-side anastomosis (as in D in this figure), or with a side–to–side anastomosis (terminal ileum to transverse colon), if you are more skilled. Don’t try to exteriorize the caecum. If a caecostomy is impractical, a right hemicolectomy will be safer.

The method below tells you how to make a caecostomy with a large de Pezzer catheter which is easier to manage than a Paul’s tube. This is held in place with inverting purse string sutures, after which the caecum is anchored to the abdominal wall (Stamm’s procedure).

Figure 66.19: WOUNDS OF THE CAECUM AND ASCENDING COLON. A, shows the insertion of a de Pezzer catheter into a wound in the caecum. B, shows its insertion into a wound of the ascending colon. C, shows a right hemicolectomy, with an ileostomy and colostomy. D, shows a right hemicolectomy done for the same injury as in C, but with an end-to-side anastomosis. E, exteriorizing a wound of the ascending colon. Modified, by the kind permission of Peter London.