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Colonic trauma

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  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

  3. Blunt trauma • Mechanisms for damage • Crushing • Shearing • Bursting • Penetrating

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

  5. DPL • Positive if • >10ml frank blood • RCC>100,000/mm3 • WCC>500/mm3 • Amylase>20 IU/L • Presence bacteria/bowel contents

  6. Adjuncts to evaluation • CXR • NG tube • Catheter • PR

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

  8. 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

  9. Evaluation of blunt abdominal trauma • Haemodynamically unstable • DPL/FAST/CT • Haemodynamically stable • Serial examination • FAST • CT

  10. Surgery for abdominal trauma

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

  12. Colonic surgery; primary repair

  13. Colonic injury; primary repair in destructive injury

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

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

  16. Pathophysiology • Hypothermia • Acidosis • Coagulopathy

  17. Principles of surgery • Control haemorrhage • Prevent contamination • Avoid further injury

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

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

  20. 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

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

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

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