1. Colonic trauma SR Brown Colorectal Surgeon Sheffield Teaching Hospitals

2. 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

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

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

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

9. Adjuncts to evaluation CXR NG tube Catheter PR

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

13. 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

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

18. Surgery for abdominal trauma

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

20. Colonic surgery; primary repair Primary repairColostomyLeak Stone, 197969721 Chappuis, 199128 0 Falcone, 199212 0 Sasaki, 199543280 Gonzalez, 199656532 Total2081933

21. Colonic injury; primary repair in destructive injury Primary repairColostomyLeak Chappuis, 199111280 Falcone, 199212 0 Sasaki, 199512280 Gonzalez, 19965531 Total401211

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

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

24. Pathophysiology Hypothermia Acidosis Coagulopathy

25. Principles of surgery Control haemorrhage Prevent contamination Avoid further injury

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

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

30. 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

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

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