Colonic trauma SR Brown Colorectal Surgeon Sheffield Teaching Hospitals

Types of trauma Penetrating trauma –Gunshots Energy transfer proportional to velocity Cavitation –Injury away from track –Contamination sucked in –Stab wounds Low level energy transfer Injury confined to track

Blunt trauma Mechanisms for damage –Crushing –Shearing –Bursting –Penetrating

Evaluation of abdominal penetrating trauma Haemodynamically unstable –Laparotomy Haemodynamically stable –Serial clinical exam –Local wound exploration –DPL –FAST –CT –Laparoscopy –Laparotomy

DPL Positive if –>10ml frank blood –RCC>100,000/mm 3 –WCC>500/mm 3 –Amylase>20 IU/L –Presence bacteria/bowel contents

Adjuncts to evaluation CXR NG tube Catheter PR

Pros/cons Awake/cooperative patient Invasive Admission Retroperitoneum High clinical workload Complications

CT features of penetrating abdominal injury Signs of peritoneal violation –Free air/fluid –Track Signs of bowel injury –Thickening/defect –Contrast leak Others –Intravenous contrast leak –Diaphragm tear

Evaluation of blunt abdominal trauma Haemodynamically unstable –DPL/FAST/CT Haemodynamically stable –Serial examination –FAST –CT

Surgery for abdominal trauma

Advantages of primary repair Reduced morbidity of colostomy closure Reduced disability of colostomy Reduced hospital stay

Colonic surgery; primary repair Primary repairColostomyLeak Stone, Chappuis, Falcone, Sasaki, Gonzalez, Total

Colonic injury; primary repair in destructive injury Primary repairColostomyLeak Chappuis, Falcone, Sasaki, Gonzalez, Total401211

Risk factors for primary repair Haemodynamicaly unstable Significant underlying disease Associated injuries Peritonitis

Damage control surgery ‘Multiple trauma patients are more likely to die from intra-operative metabolic failure than a failure to complete operative repairs’

Pathophysiology Hypothermia Acidosis Coagulopathy

Principles of surgery Control haemorrhage Prevent contamination Avoid further injury

Principles of colonic surgery Repair small enterotomies Extensive damage resect and close off ends No stomas –Time consuming –Spillage difficult to control

Abdominal compartment syndrome Pressure >25cm water Oedema –Reperfusion injury –Crystalloid infusion –Capillary leakage –Packing

Pathophysiology Cardiovascular –Decrease cardiac output despite high CVP Respiratory –Splint diaphragm Renal –Oliguria due to renal vein/parenchyma compression Cerebral –Increased CVP results in decreased cerebral drainage

Diagnosis Oliguria + increasing CVP Foley catheter in bladder –Normal 0 cm water –>25cm water suggestive –>30cm water diagnostic

Treatment Anticipate –Difficulty closing –Horizontal view, guts above level of wall Laparostomy –Bogota bag –VAC dressing