Primary Surgery Vol.2 – Trauma: INJURIES OF THE RECTUM

INJURIES OF THE RECTUM

EXAMINATION If a patient might possibly have a rectal injury, study the wound track carefully. Put him into the lithotomy position and examine him with your finger and with a sigmoidoscope. if necessary, examine his rectum under anaesthesia. Is his anal sphincter torn? Does the injury involve the urethra or vagina? (68.3). Carefully examine the patient’s abdomen for signs of peritonitis (6.2). if necessary, take an erect film and look for gas under his diaphragm (66-4).

PERIOPERATIVE ANTIBIOTICS in all but the most trivial rectal injuries, antibiotic protection is critical, particularly protection against anaerobes (2.7). The patient will need intravenous metronidazole 7.5 mg/kg 8 hourly, for 3 or 4 days before switching to the oral route. Combine this with chloramphenicol, gentamicin, or co-trimoxazole.

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Figure 66.23: DRAINING EXTRAPERITONEAL WOUNDS OF THE RECTUM. A, the rectum closed and a colostomy made. B, the external incision. C, the internal incision beside the rectum. D, the direction of drainage. E, a colostomy has been done and drains are in place. After various authors.

INTRAPERITONEAL INJURIES OF THE RECTUM

Make a lower midline incision. Control haemorrhage. This can be severe, and you may very occasionally even have to tie the patient’s iliac arteries on both sides. If so, watch his ureters. Wash out his peritoneal cavity to get it absolutely clean (6.2). Squeeze out any faeces in his rectum into the normal bowel above the lesion, or wash them downwards. Excise the edges of the perforation.

If the patient’s rectal wound is small, suture it, and insert a large rectal tube.

If his rectal wound is large, do a defunctioning colostomy (9.5). Make this as close to the injury as possible. The most convenient place is likely to be his sigmoid or transverse colon. The more worried you are about closure, the more important it is for the colostomy to be fully defunctioning. Insert a drain down to the site of the repair. If his injury is really severe, you may have to resect a length of rectum or rectosigmoid, do a terminal colostomy, and close the blind end of his rectum as for Hartman’s procedure (10.10).

Do Lord’s procedure (21.5).

EXTRAPERITONEAL INJURIES OF THE RECTUM

Do a laparotomy (66.3). Excise the wound track from the patient’s perineum. Clean out his perirectal space from above. Incise his pelvic peritoneum on each side of his abdominal rectum. If necessary, use blunt dissection with your fingers to peel his prostate and seminal vesicles off the front of his rectum. Remove all foreign bodies, pieces of clothing, etc. Make sure his wound is clean.

If possible try to stitch up: (1) his rectum using inverted sutures, (2) his anal sphincter.

Make a double defunctioning colostomy, preferably with his sigmoid colon. Wash out all faeces below the colostomy.

Incise the skin obliquely beside his coccyx. Using a pair of artery forceps, open up a track from his rectovesical pouch to your skin incision. Bring down a large corrugated rubber drain.

POSTOPERATIVE CARE (both kinds of injury) Wait several weeks before referring him for the closure of his colostomy (9.6).

DIFFICULTIES WITH RECTAL INJURIES

If a patient shows SIGNS OF PERITONITIS, do an immediate laparotomy. Put him into the Trendelenberg position, and examine his abdominal cavity through a low midline or paramedian incision. Examine his pelvic viscera.

If his BLADDER HAS RUPTURED INTRAPERITONEALLY, repair it (68.2).

If his URETHRA MIGHT HAVE BEEN INJURED, explore the wound to make sure. If it is normal leave it. If it has been injured, drain his bladder through a suprapubic catheter, and treat him as in Section 68.3.

If he presents late with a FISTULA draining in his buttock, do a proximal defunctioning colostomy in his left iliac fossa. Wait a month or two until his fistula has healed, then close the colostomy.

If digital examination of his rectum shows an injury which FEELS LIKE A TEAR, but he has no signs of peritonitis, assume that he has an extraperitoneal penetrating injury. Drain his pararectal tissues, and do a sigmoid colostomy. Don’t try to suture his rectum.

If his ANAL SPHINCTER iS PARTLY TORN, but his anorectal ring feels intact, toilet and drain his wound.

If his ANAL SPHINCTER IS COMPLETELY TORN across (rare), don’t try primary repair, unless the wound is clean cut. Better, do a colostomy, toilet his peritoneal wound, and refer him for a definitive repair later.