1. Colon & Rectum Injuries
Prayuth Sirivongs M.D.

2. COLONIC INJURIES Anatomy Cecum Ascending colon Transverse colon
Descending colon
Sigmoid colon

3. COLONIC INJURIES Etiology Penetrating Injury :
Gun Shot ~ 75%
Stab wound ~ 20%
Blunt Injury : Motor vihicle
Trananal Injury :
Iatrogenic ; colonoscopy ,B.E.
Sexual related : foreign body

4. COLONIC INJURIES Diagnosis Pre-operation Blood in rectum
Acute abdomen series
Water soluble contrast enema
Triple contrast CT

5. COLONIC INJURIES Intra operation Rule of “ two “ Complete mobilize
Blood staining
Fecal odor segmental squeeze

6. COLONIC INJURIES Treatment Colostomy Exteriorized repair
primary repair

7. COLONIC INJURIES
colostomy
End Colostomy
Protective Colostomy

8. COLONIC INJURIES
colostomy
End Colostomy
Protective Colostomy

9. COLONIC INJURIES Indication for colostomy ( Stone & Fabian)
1.Shock c BP<80/60 mmHg
2.Intraperitoneal blood loss > 1000 ml
3.Intra-abdominal organ injuries > 2 organs
4.Significant fecal contamination
5.Time to operation >8 hrs
6.Colonic wound require resection
7.Major loss abdominal wall /Mesh

10. COLONIC INJURIES Colonic Injury Severity score (Shanon&Moore)
Grade 1 ; Serosal injury
Grade 2 ; Single wall injury
Grade 3 ; < 25% wall involvement
Grade 4 ; > 25% wall involvement
Grade 5 ; Whole colonic wall involvement
and blood supply injury

11. COLONIC INJURIES Exteriorized repair Avoided resection
Reduced contamination
Reduced colostomy
Limited in some part of colon
Stomal care is more difficult than colostomy

12. COLONIC INJURIES Primary repair Sutured repair
Resection with primary anatomosis

13. COLONIC INJURIES Primary repair Sutured repair
Resection with primary anatomosis

14. COLONIC INJURIES Primary repair Avoid colostomy
Less morbidity than colostomy
Gained more popularity
Having high risk in
patient c underlying medical illness
massive blood transfusion

15. COLONIC INJURIES outcome cause of death exanguination
sepsis ; intra- abdominal abscess
multi organ failure
fistula (primary repair)

16. RECTAL INJURIES Anatomy Promontary of sacrum to anus intraperitoneal
extraperitoneal
Length ~12-20 cm.

17. RECTAL INJURIES Anatomy Anal canal Anorectal ring to anal verge
Sphincter complex
puborectalis muscle
external sphincter
internal sphincter

18. RECTAL INJURIES Etiology Penetrating injuries ; gun shot ~80%
Stab & impalement <5%
Blunt injury ~ 10%
Transanal injury ; ~ 6%
Anal intercourse
Anal rape
Iatrogenic ; enema, thermometer

19. RECTAL INJURIES Diagnosis Suspected in
GSW ; Trunk , buttock , perineum upper thigh
Stab ; buttock , perineum , lower abdomen
Blood in rectum ( rectal exam )

20. RECTAL INJURIES
Investigation
X-ray pelvis & abdomen ; bullet tract,foreign body, fracture pelvis
Rigid proctosigmoidoscope
Water soluble contrast study

21. RECTAL INJURIES Treatment 1.Intraperitoneal rectal injuries; as
colonic injuriession
2.Extraperitoneal rectal injuries ;
Diversion
Debridement
Distal washout
Presacral drainage

22. RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c
stapling distal lumen
3 .End colostomy c
mucous fistula
4 .Hartmann’s procedure

23. RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c
stapling distal lumen
3 .End colostomy c
mucous fistula
4 .Hartmann’s procedure

24. RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c
stapling distal lumen
3 .End colostomy c
mucous fistula
4 .Hartmann’s procedure

25. RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c
stapling distal lumen
3 .End colostomy c
mucous fistula
4 .Hartmann’s procedure

26. RECTAL INJURIES 2. Debridement : removed devitalize tissue
repair defect if possible
severe injury ; resection
3.Distal washout :
decrease septic complication

27. RECTAL INJURIES
4.Presacral drainage

28. RECTAL INJURIES Outcome Cause of death: Sepsis, Multi-organ failure
Anorectal abscess
Rectal fistula

29. PERINEAL INJURIES Perineum Inferior end of trunk Anterior (urogenital)
Genital organ
Urethra
Posterior (anal)
Anus

30. PERINEAL INJURIES
MALE
FEMALE

31. PERINEAL INJURIES ETIOLOGY : Iatrogenic anorectal injury
Traumatic anorectal injury
Foreign bodies in rectum
Anal intercourse & assult

32. PERINEAL INJURIES IATROGENIC INJURIES Obstetric injury
Anorectal surgery
Enema
Rectal thermometer
Urologic & Gynecologic surgery

33. PERINEAL INJURIES TRAUMATIC INJURIES Blunt injury Straddle injury
Laceration
Implement
Gunshot wound
Blast
High pressure

34. PERINEAL INJURIES Primary survey Resuscitation Secondary survey
MANAGEMENT
Primary survey
Resuscitation
Secondary survey
Definitive care

35. PERINEAL INJURIES SECONDARY SURVEY History taking Symptom & sign
Cause of injury
Mechanism of injury
Duration of injury
Associated injury
Symptom & sign
Perineal pain
Lower abdominal pain
Bleeding
Sepsis

36. PERINEAL INJURIES SECONDARY SURVEY examination
Perineum , anus , buttock , thigh
Abdomen
Digital rectal examination
Associated injuries
Vagina
Urethra & prostate gland
pelvis
SECONDARY SURVEY
examination

37. PERINEAL INJURIES INVESTIGATION Film abdomen supine ,upright , lateral
Rigid sigmoidoscopy
Contrast study

38. PERINEAL INJURIES TREATMENT Perineal injury with rectal injury
Debridement
Diversion
Drainage
Distal washout

39. PERINEAL INJURIES TREATMENT Perineal injury
Small hematoma ; conservative
Expanded hematoma ; evacuated blood
Laceration ; debridement & stop bleeding
Severe laceration ; debridement , stop bleeding and colostomy

40. PERINEAL INJURIES TREATMENT Debridement Perineal injury
Adequate debridement
Left wound open
Frequent debridement
Adequate pain control
Control contamination

41. PERINEAL INJURIES TREATMENT minimal sphincter injury
Perineal injury with anal sphincter injury
minimal sphincter injury
severe sphincter injury
colostomy
primary repair
non primary repair

42. PERINEAL INJURIES TREATMENT Incontinence Sphincteroplasty
Muscle transposition
Artificial sphincter

43. ANAL INTERCOURSE Mostly in Homosexual Complication
Retained foreign bodies
Colorectal perforation
Anal tear
Digital rectal exam & sigmoidoscopy

44. ANAL INTERCOURSE Management Uncomplicated injury Warm sitz bath
Stool softener
Tropical analgesic preparation

45. ANAL INTERCOURSE Management Surgery Deep tear Perforation
Sphincter injury
Persistent bleeding

46. FOREIGN BODIES IN RECTUM
Oral ingested
Bones
Toothpick
Seeds
Anal insertion
Sex toys
Bottles
Cans
Flashlights
Fruit
umbrella

47. FOREIGN BODIES IN RECTUM
Age ; yrs and more than 60 yrs.
Male : female 25: 1
Classification
Retained F.B. without injury
Non perforative mucosal laceration
Sphincter injury
Rectosigmoid perforation

48. FOREIGN BODIES IN RECTUM
History
Symptom & sign
Anal or pelvic pain
Inability to remove F.B.
Bleeding
Peritonitis

49. FOREIGN BODIES IN RECTUM
Physical examination
Abdomen
Digital rectal exam
Investigation
Film abdomen AP& Lateral
Contrast study

50. FOREIGN BODIES IN RECTUM
Management
Bedside extraction
Local anesthesia
Valsava maneuver
Sedation
Observation

51. FOREIGN BODIES IN RECTUM
Management
Operation
Fragile object , high level
Regional or general anesthesia
Lithotomy position
Sphincterotomy
Explore to colotomy

52. FOREIGN BODIES IN RECTUM
Technique for removal
Under visualization
Foley catheter or Blakemore tube
Snaring
Casting plaster
Rigid sigmoidoscopy after removal

53. Thank you for your attention