Bowel injury should be: Primarily repaired T Hardcastle Trauma Surgeon IALCH Durban

NEVER A NEVER, NEVER AN ALWAYS Debate? Problem No one rule that fits all situations You will be wrong some of the time NEVER A NEVER, NEVER AN ALWAYS IN TRAUMA!

Primary repair – is it safe? Yes: For most situations Civilian: Surg Ann 1991: 203 – 223 Unfallchirurg 1991: 105 J R Coll Surg Edinb 1996: 20 – 24 Ann R Coll Surg Engl 1999: 58 – 61 Injury 2002: 611 – 615 J Trauma 2003: 399 - 406 World J Surg 2006: 488 – 94 Cochrane 2003 CD002247 Military J Trauma 2009: 1286 – 1291 Dis Colon Rectum 2007: 870 – 877

Primary Repair – how to do it! Small bowel First stop any bleeding Get rid of the contamination Either debride the wound edges or do your resection Check the numbers Patient not for damage control Single layer sero-submucosal absorbable suture and close mesentery Stapled anastomosis higher leak rates* *J Trauma 2001; 51: 1054

Primary Repair – when to do it! Large bowel Stable patient Minimal transfusions Good edge bleeding* Even after resection^ No residual soiling or devitalized tissue Single layer sero-submucosal preferably interrupted suture. Absorbable material Consider omental wrap (Levuno Wrap) *Surg Ann 1991: 203 – 223 ^ Ann R Coll Surg Eng 1999: 58 - 61

Primary repair not advised? Colonic injury Severely shocked patient Damage control criteria Left colonic flexure* Massive transfusion and marginal artery Other bowel Complex duodenal injury – maybe! Most of these can be repaired Rectal injury – extraperitoneal^ *J Trauma Aug 2005: 59: 359 ^World J Surg 2007: 1345

So is it really a debate? More about DECISION MAKING GOOD judgment comes from experience, experience comes from BAD judgment! Must know ALL options and choose the appropriate one at the appropriate time

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