If the patient has a short, clean–cut stab wound, suture it, drain it, and watch him closely. A good procedure for a single small wound is to close it, and to do a loop colostomy, incorporating the suture line in the part which is exteriorized. Don’t open the colostomy. If the suture line heals, replace his gut in his peritoneal cavity. If it leaks, no harm is done.
If the wound involves only part of the circumference of his gut, make a loop colostomy (E in Fig. 66-21).
If it involves the whole circumference of his gut, make a double colostomy (F). If the resected segment is short, bring the two ends out through the same incision as a double colostomy (F). If the resected segment is long, bring them out through separate incisions as faecal and mucous colostomies (G). These can if necessary be far apart, because the cut ends of the gut can easily be joined up subsequently. If the distal end is too short to bring out to abdominal wall, close it in two layers and drop it back into the pelvis (H). This is Hartman’s procedure as described for sigmoid volvulus (10.10).
LOOP COLOSTOMY varies slightly according to the site. For details, see Section 9.5.
If the wound is in the patient’s descending colon, divide the peritoneum of his lateral paracolic gutter, and mobilize bluntly behind his colon, which will come away up to the surface. This will also allow you to inspect its retroperitoneal surface.
If the wound is of moderate size, close it in layers transverse to the axis of his gut, and make a loop colostomy in his transverse colon proximally. Make a separate incision for the colostomy a reasonable distance away from his iliac spines.
If he has several wounds, bring out the most proximal one as a colostomy. Excise the more distal ones back to healthy, bleeding tissue. Either bring the distal end out as a mucous fistula, or do Hartman’s procedure.
CAUTION! (1) If his peritoneum has been contaminated with faeces, put a drain through a stab wound in his flank. (2) Do Lord’s procedure (21.5).
TO CLOSE THE COLOSTOMY wait several weeks until he is well and cheerful. If his gut needs reanastomosis, refer him; if it merely needs closing, you may be able to do this as in Section 9.5.
