COLON_INJURY-1 - Colon& Rectum Colon& Rectum Injuries...

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Unformatted text preview: Colon & Rectum Colon & Rectum Injuries Prayuth Sirivongs M.D. COLONIC INJURIES COLONIC INJURIES Anatomy • Cecum • Ascending colon • Transverse colon • Descending colon • Sigmoid colon COLONIC INJURIES 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 COLONIC INJURIES COLONIC INJURIES Diagnosis Pre­operation Blood in rectum Acute abdomen series Water soluble contrast enema Triple contrast CT COLONIC INJURIES COLONIC INJURIES Intra operation Intra operation Rule of “ two “ Complete mobilize Blood staining Fecal odor segmental squeeze COLONIC INJURIES COLONIC INJURIES Treatment • Colostomy • Exteriorized repair • primary repair COLONIC INJURIES COLONIC INJURIES colostomy End Colostomy Protective Colostomy COLONIC INJURIES COLONIC INJURIES colostomy End Colostomy Protective Colostomy COLONIC INJURIES COLONIC INJURIES Indication for colostomy ( Stone & Fabian) 1.Shock c BP<80/60 mmHg 2.Intraperitoneal blood loss > 1000 ml 3.Intra­abdominal 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 COLONIC INJURIES 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 COLONIC INJURIES COLONIC INJURIES Exteriorized repair • • • • Avoided resection Reduced contamination Reduced colostomy Limited in some part of colon • Stomal care is more difficult than colostomy COLONIC INJURIES COLONIC INJURIES Primary repair • Sutured repair • Resection with primary anatomosis COLONIC INJURIES COLONIC INJURIES Primary repair • Sutured repair • Resection with primary anatomosis COLONIC INJURIES 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 COLONIC INJURIES COLONIC INJURIES outcome cause of death exanguination sepsis ; intra­ abdominal abscess multi organ failure fistula (primary repair) RECTAL INJURIES RECTAL INJURIES Anatomy Promontary of sacrum to anus • intraperitoneal • extraperitoneal Length ~12­20 cm. RECTAL INJURIES RECTAL INJURIES Anatomy Anal canal Anorectal ring to anal verge Sphincter complex puborectalis muscle external sphincter internal sphincter RECTAL INJURIES RECTAL INJURIES Etiology Penetrating injuries ; gun shot ~80% Stab & impalement <5% Blunt injury ~ 10% Transanal injury ; ~ 6% Anal intercourse Anal rape Iatrogenic ; enema, thermometer RECTAL INJURIES RECTAL INJURIES Diagnosis Suspected in GSW ; Trunk , buttock , perineum upper thigh Stab ; buttock , perineum , lower abdomen Blood in rectum ( rectal exam ) RECTAL INJURIES RECTAL INJURIES Investigation • X­ray pelvis & abdomen ; bullet tract,foreign body, fracture pelvis • Rigid proctosigmoidoscope • Water soluble contrast study RECTAL INJURIES RECTAL INJURIES Treatment 1.Intraperitoneal rectal injuries; as colonic injuriession 2.Extraperitoneal rectal injuries ; Diversion Debridement Distal washout Presacral drainage RECTAL INJURIES RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure RECTAL INJURIES RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure RECTAL INJURIES RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure RECTAL INJURIES RECTAL INJURIES Diversion 1. Loop colostomy 2 .Loop colostomy c stapling distal lumen 3 .End colostomy c mucous fistula 4 .Hartmann’s procedure RECTAL INJURIES RECTAL INJURIES 2. Debridement : removed devitalize tissue repair defect if possible severe injury ; resection 3.Distal washout : decrease septic complication RECTAL INJURIES RECTAL INJURIES 4.Presacral drainage RECTAL INJURIES RECTAL INJURIES Outcome • Cause of death: Sepsis, Multi­organ failure • Anorectal abscess • Rectal fistula PERINEAL INJURIES PERINEAL INJURIES •Perineum •Inferior end of trunk •Anterior (urogenital) Genital organ Urethra •Posterior (anal) Anus PERINEAL INJURIES PERINEAL INJURIES FEMALE MALE PERINEAL INJURIES PERINEAL INJURIES ETIOLOGY : Iatrogenic anorectal injury Traumatic anorectal injury Foreign bodies in rectum Anal intercourse & assult PERINEAL INJURIES PERINEAL INJURIES IATROGENIC INJURIES •Obstetric injury •Anorectal surgery •Enema •Rectal thermometer •Urologic & Gynecologic surgery PERINEAL INJURIES PERINEAL INJURIES TRAUMATIC INJURIES • • • • • • • Blunt injury Straddle injury Laceration Implement Gunshot wound Blast High pressure PERINEAL INJURIES PERINEAL INJURIES MANAGEMENT •Primary survey •Resuscitation •Secondary survey •Definitive care PERINEAL INJURIES PERINEAL INJURIES SECONDARY SURVEY •History taking •Symptom & sign –Cause of injury –Perineal pain –Mechanism of injury –Lower abdominal pain –Duration of injury –Bleeding –Associated injury –Sepsis PERINEAL INJURIES PERINEAL INJURIES SECONDARY SURVEY Perineum , anus , buttock , thigh Abdomen Digital rectal examination Associated injuries •Vagina examination •Urethra & prostate gland •pelvis PERINEAL INJURIES PERINEAL INJURIES INVESTIGATION •Film abdomen supine ,upright , lateral •Rigid sigmoidoscopy •Contrast study PERINEAL INJURIES PERINEAL INJURIES TREATMENT •Perineal injury with rectal injury Debridement Diversion Drainage Distal washout PERINEAL INJURIES PERINEAL INJURIES TREATMENT •Perineal injury –Small hematoma ; conservative –Expanded hematoma ; evacuated blood –Laceration ; debridement & stop bleeding –Severe laceration ; debridement , stop bleeding and colostomy PERINEAL INJURIES PERINEAL INJURIES TREATMENT Perineal injury Debridement •Adequate debridement •Left wound open •Frequent debridement •Adequate pain control •Control contamination PERINEAL INJURIES PERINEAL INJURIES TREATMENT •Perineal injury with anal sphincter injury –minimal sphincter injury –severe sphincter injury •colostomy •primary repair •non primary repair PERINEAL INJURIES PERINEAL INJURIES TREATMENT •Incontinence –Sphincteroplasty –Muscle transposition –Artificial sphincter ANAL INTERCOURSE ANAL INTERCOURSE •Mostly in Homosexual •Complication –Retained foreign bodies –Colorectal perforation –Anal tear •Digital rectal exam & sigmoidoscopy ANAL INTERCOURSE ANAL INTERCOURSE •Management Uncomplicated injury Uncomplicated injury –Warm sitz bath –Stool softener –Tropical analgesic preparation ANAL INTERCOURSE ANAL INTERCOURSE •Management Surgery –Deep tear –Perforation –Sphincter injury –Persistent bleeding FOREIGN BODIES IN RECTUM FOREIGN BODIES IN RECTUM •Oral ingested •Anal insertion –Bones –Sex toys –Toothpick –Bottles –Seeds –Cans –Flashlights –Fruit –umbrella FOREIGN BODIES IN RECTUM FOREIGN BODIES IN RECTUM •Age ; 20­30 yrs and more than 60 yrs. • Male : female 25: 1 •Classification –Retained F.B. without injury –Non perforative mucosal laceration –Sphincter injury –Rectosigmoid perforation FOREIGN BODIES IN RECTUM FOREIGN BODIES IN RECTUM •History •Symptom & sign –Anal or pelvic pain –Inability to remove F.B. –Bleeding –Peritonitis FOREIGN BODIES IN RECTUM FOREIGN BODIES IN RECTUM •Physical examination –Abdomen –Digital rectal exam •Investigation –Film abdomen AP& Lateral –Contrast study FOREIGN BODIES IN RECTUM FOREIGN BODIES IN RECTUM •Management Bedside extraction Bedside extraction Local anesthesia Local anesthesia Valsava maneuver Sedation Observation FOREIGN BODIES IN RECTUM FOREIGN BODIES IN RECTUM •Management Operation Fragile object , high level Fragile object , high level Regional or general anesthesia Lithotomy position Sphincterotomy Explore to colotomy FOREIGN BODIES IN RECTUM FOREIGN BODIES IN RECTUM Technique for removal •Under visualization –Foley catheter or Blakemore tube –Snaring –Casting plaster –Rigid sigmoidoscopy after removal Thank you for your Thank you for your attention ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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