66.14 Injuries from the hepatic flexure to the rectum

There are three possibilities: (1) If the wound involves part of the circumference of the gut, you can make a loop colostomy without dividing the gut, as in E, Fig. 66-21. Loop colostomies are easier in the transverse or sigmoid colon. But if you mobilise the colon properly you can use them anywhere at or beyond the hepatic flexure. The loop must lie easily on the abdominal wall without tension. If it is tight, it will gradually retract and cause great problems with abdominal wall abscesses. (2) If you have to resect a short (5 cm) length of gut you can bring the cut ends out through same incision (F). (3) If you have to resect a longer length of gut (more than about 5 cm), you cannot bring the two cut ends out of the same incision. So you will have to bring them out through separate incisions as faecal and mucous colostomies (G). If the lower end of the gut is too short to bring out to the surface, you will have to use Hartmann’s procedure (H). To make a colostomy, goto Section 9.5.