Small & Large Bowel Injuries

PROF:AKMAL JAMALFCPS:FRCSEd:26 April 2012

Klinika Chirurgii Urazowej Grala

“You You see what you look for” Stephen Sondheim

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Diagnosis of hollow viscus injury

is difficult, challenges even modern diagnostic modalities, and requires a high degree of suspicion

Nonoperative management is still possible but requires compulsive patient monitoring

Outcomes improve if the “evil that lurks within the abdomen” is diagnosed and treated early

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Solid Organs and Hollow StructuresSolid:• Liver• Pancreas• Spleen• Kidneys• Ovaries

Hollow:• Stomach• Small Intestine• Appendix• Large

Intestine/Colon• Gallbladder• Bladder• Uterus• Aorta• Common bile duct• Fallopian tubes

What is the "golden hour"?

The first hour after injury provides a unique opportunity to provide life-saving interventions. Because more than half of trauma deaths occur early due to bleeding or brain injury, rapid transport, appropriate triage, evaluation, resuscitation, and intervention can affect outcomes.

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What is the "golden hour"? The "golden hour" concept needs to be extended

to several hours in the rural setting, but with the same structured approach.

When Trauma Deaths Occur?

<1 hour 1-3 hours 4 to 6 weeks

Temple College EMSP 9“The Trimodal Distribution”“The Trimodal Distribution”

Immediate Deaths(<1 hour)

• Complete airway Obstruction• Brain Stem Laceration• High C-Spine Lesion• Aortic/Heart Rupture

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Early Deaths (1-3 hours)

• Epidural Hematoma• Subdural Hematoma• Hemo/Pneumothorax• Intra-abdominal Bleeding• Pelvic Fractures• Femur Fractures• Multiple Long Bone Fractures

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Late (2-4 weeks)• Sepsis SIRS• Multiple Organ Dysfunction/ Failure

MOD/MOF

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S/S of Abdominal Injury

• Pain, tenderness• Nausea, emesis• Guarding• Fetal positioning• Coffee-ground emesis• Hematuria• Melena• Obvious trauma

Lacerations, bruising, deformity or asymmetry

Tachypnea Distention Rigidity Referred pain Hypovolemic shock

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Overview:Small bowel Injury

• Seat belts, direct blow or penetrating trauma• Minimal bleeding• Peritoneal signs (intoxicated or deeply unconsious

patients – absent)• US, CT nondiagnostic• Diagnosis - DPL and laparotomy • Primary repair or segmental resection and

anastomosis, close mesenteric defects

Much less common in blunt than penetratingNonetheless, 3rd most common blunt abdominal injury

Management:Small BowelSmall Bowel Injury

Blunt Abdominal Trauma

SMALL BOWEL INJURY

• . Mechanism:* Crushing of bowel against the spine* Sudden deceleration sheering of the bowel from its mesentery at a fixed point* Bursting of “pseudo-closed-loop” from sudden increase in intraluminal pressure

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Blunt bowel injury

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Blunt bowel injury

Seatbelt injuries

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The three-point shoulder-lap belt is the most effective restraining system and is associated with the lowest incidence of abdominal injuries.

However, abdominal injuries are still ascribed to shoulder-lap and lap-belt systems.

Seatbelt Sign

pathogensis

o compression of bowel between the belt and the vertebral column.

o an acute short closed-loop obstruction occurs along with perforation secondary to the sudden generation of high intraluminal pressures.

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Peneterating TRauma

• Small bowel trauma-25-30%

Stab wound The liver, followed by the small bowel, is the organ most often damaged by stab wounds Gunshot Wounds handguns, rifles, and shotgun

Stab wound to right lower quadrant with caecal evisceration. No colon injury at laparotomy.

MCQ

• Small bowel injury is the most common injury resulting from ___ abdominal trauma.

• penetrating• blunt

MCQ

• Small bowel injury is the most common injury resulting from ___ abdominal trauma.

• penetrating• blunt

INJURY TO COLON AND RECTUM

Blunt Abdominal Trauma-5% cases Mechanism: rapid deceleration with steering

wheel compression• uncommon• Disruptions of colonic wall or avulsion injury

of mesentery• Present with hemoperitoneum, peritonitis.

INJURY TO COLON AND RECTUM

Peneterating Abdominal Trauma-95% Large number of colonic injuries are due to

peneterating trauma. Rectal injuries –assosiatied with pelvic #

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Operative Management

• Treatment of injury is dictated by location and severity. In general…– Antibiotics is administered before skin incision and for 24

hours if injury is confirmed– Abdominal exploration performed through mid-line

incision sufficient to access entire peritoneal cavity– After initial control of any significant bleeding is achieved,

inspection commences in a systematic fashion

Management:Small Bowel

Operative Management• Injuries to the Small Bowel

– Evaluated intraoperatively by “running the bowel”, from the ligament of Treitz caudad to the ileocecal valve

Injured Structure AAST Grade Characteristics of Injury AIS-90 Score

Small Bowel

IContusion or hematoma without devascularization; partial-thickness laceration

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II Small (<50% of circumference) laceration 3

III Large (≥50% of circumference) laceration 3

IV Transection 4

V Transection with segmental tissue loss; devascularized segment 4

Management:Small BowelScSmall Bowel Injury Scaleale

I Hematoma Contusion without devascularization

Laceration Partial thickness, no perforation

II Laceration <50% circumference

III Laceration >50% circumference without transection

IV Laceration Transection of small bowel

V Laceration Transection with segmental tissue loss

Vascular Devascularized segment

Operative Management,

–Primary repair,– Resection or– Combination thereof is employed at

the discretion of the surgeon

Operative Management, cont’d

– Grade I –reapproximation of the seromuscular layers with interrupted sutures

– Grade II –limited debridement and closure in either one or two layers

– Grade III –repaired primarily if luminal narrowing can be avoided; otherwise, resection and anastamosis

• Small bowel anastomoses usually hand sewn or stapled

– Grade IV and V – resection and anastomosis

Management:Small BowelTreatment Grade I

Management:Small BowelTreatment Grade II

Transverse closure preferred (if possible)

Management:Small BowelTreatment Grade III

No difference in hand-swen vs. stapled (Witzke, J Trauma, 2000)No difference in 1 vs. 2-layer anastomosis (Burch, Ann Surg, 2000)

Management:Small BowelTreatment Grade IV

Damage Control:Can staple both ends, control other intra-abdominal damage, resuscitate in ICU, and return to OR in 24-48 hrs for delayed primary anastomosis

(Carillo, J Trauma, 1993)

Management:Small BowelTreatment Grade V

24 hrs perioperative abx if this is the only injury

NG decompression until ileus resolves:* Multi-injured patients have slower return of bowel fxn* Can decompress stomach if jejunal feeds used )* Moderately to severely injured patients do better with enteral feeds started 24-48 hrs postop

Management:Small BowelPostoperative Care

Management:Colon

Gordon-Taylor G. Br J Surg 1942.Most colonic injuries can be fixed primarily, avoid resection, proximal colostomies possibly for extensive injury or descending colon injury. 50% Mortality.

Ogilvie WH. Surg Gynecol Obstet 1944.Colostomy for colon injuries. 60% Mortality., mandating colostomy for all colonic injuries.Improvement in postoperative care towards the end of WWII led to 5-20% mortality, credited incorrectly to use of colostomy.

Woodhall, Ochsner. Surgery 1951. Re-introduced primary repair.

Management:ColonHistorical Notes – Backwards as Usual

Management:ColonColonic Injury Scale

I Hematoma Contusion without devascularization

Laceration Partial thickness, no perforation

II Laceration <50% circumference

III Laceration >50% circumference without transection

IV Laceration Transection of colon

V Laceration Transection with segmental tissue loss

Vascular Devascularized segment

Injuries distributed evenly throughout the colon

Sometimes even difficult to diagnose intra-operatively

Explore all:Blood staining / hematoma on colonic wallInjured mesentery in proximity to colonic wall (may even need to divide one or two terminal mesenteric vessels for exposure)Mobilize all colon in injured areasFollow trajectories if possibleMilk luminal contents through areas of suspicion

Management:ColonIntraoperative Diagnosis

Management:ColonFactors Determining Optimal Tx

1.Shock (preoperative BP < 80/60)2.Hemorrhage (blood loss > 1L)

3.Multiorgan injury (>2 organ systems)4.Significant peritoneal spillage

5.Delayed operation (>8 hrs post injury)6.Nonviable colon (wall destruction or ischemia)7.Major loss of abdominal wall (close range blast

injury)8.Location of injury (distal vs. proximal to middle

colic)

Management:ColonSuture Repair

Management:ColonResection and Primary Repair

Management:ColonEnd colostomy

Management:ColonExteriorization

Management:Colon

Sample Algorithm

Resection required?NO YES

Suture Repair Proximal to MCA?YES NO

Resection and ileocolostomy

Evaluate Local Conditions:

Resection and Colocolostomy vs.

Hartmann’s

Operative Management, cont’d

– Colonic injuries further categorized as either non-destructive or destructive

• Destructive - wounds that completely transect the colon (grade IV) or involve tissue loss and devascularized segments (grade V)

• Patients with destructive colonic injuries who had:– comorbid medical conditions – required transfusions of more than 6 units of blood– in shock– delayed operation…significantly higher risk for suture line breakdown

when managed with resection and primary anastomosis

Operative Management, cont’d– Non-destructive wounds (grades I-III)

• Seromuscular closure for partial thickness• Primary closure for full thickness

– Destructive wounds (grades IV-V)• Repair with resection and primary anastomosis

– Destructive wounds with risk factors• Resection with end colostomy or resection and primary

anastomosis with proximal diversion– Proximal diversion

» loop colostomy (with open or closed distal stoma)» end colostomy (with a mucous fistula or closure of the rectal

stump)

Operative Management, cont’d

• Injuries to the Rectum– Classified according to anatomic criteria

• Anterior and lateral sidewalls of the upper two thirds of the rectum managed in the same manner as colonic injuries

• Upper two thirds posteriorly and lower one third of the rectum circumferentially - extraperitoneal

– Upper two thirds - exploration and suture repair, fecal diversion with loop or end colostomy as adjunctive measure

– Lower one third - explored and repaired if accessible Fecal diversion recommended

» Wounds difficult to reach - proximal fecal diversion and presacral drainage

“You see what you look for” – Stephen Sondheim

The Value of Serial ObservationThe Value of Serial Observation

Case 1: Troublesome stoma

This 57 year old man was having increasing discomfort from his stoma and associated leakage from a stoma appliance that was difficult to apply.

1. What abnormality is shown?.2. Methods for repair? 3. What is the elastic garment around this patients waist?

ANSWER1. What abnormality is shown?.A parastomal hernia

2. Methods for repair? -consider stoma closure restoring intestinal continuity

-resiting stoma to another area with non attenuated abdominal wall tissues

-local repair. This may include amputation of some bowel length, suture plication of the abdominal wall defect, mesh repair to reinforce the abdominal wall tissues.3. What is the elastic garment around this patients waist?-abdominal binder for symptomatic relief