Colon and Rectum

 

1. The morbidity and mortality from injuries to the colon have been significantly reduced by an aggressive surgical approach. Sepsis is the most formidable added risk when dealing with colonic injury.

2. Specific care should be directed by the type, location, and extent of injury as well as the condition of the colon, whether or not it is obstructed and distended or is simply filled with fecal content. Also, the anatomic location of the injury is important; whereas injuries to the intraperitoneal right, transverse, and sigmoid colon do not require drainage, injuries to the retroperitoneal descending colon and rectum require that the suture line be protected by retroperitoneal drainage and/or fecal diversion by colostomy.

3. It is important that the time from injury to definitive operation be as short as possible. It is similarly important to avoid, by all means, fecal soilage or contamination. Antimicrobials are not a substitute for surgical technique. However, antibiotics should be used judiciously preoperatively and postoperatively.

4. Diagnosis

a. A sudden smell of fecal odor during an abdominal or laparoscopic procedure, even in the absence of visible extravasation of stool, indicates an entrance into the colon or rectum. Careful inspection leads to the recognition of the injury and a complete repair.

b. Plain film of the abdomen should be employed if there is a perforated colon with leakage of air into the free peritoneal cavity following laparotomy. This examination is of limited value after laparoscopic procedures. Sigmoidoscopy or colonoscopy can be used in the examination of patients suspected of colonic perforation after surgery. Computed tomography (CT) scan of the abdomen and pelvis may be helpful in selected cases. Barium contrast material should not be used because of the high morbidity and mortality associated with leakage of barium and feces into the free peritoneal cavity. Aqueous opaque media such as Gastrografin are preferable when penetration of the colon is suspected.

5. Treatment

a. An incision capable of an easy extension is used because operation on the colon often requires wide mobilization of at least two flexures. Incisional infections are discouraged by protecting the wound with moist pads or 7-in. ring plastic wound protectors (Vidrape, 3M Corporation).

b. First the peritoneal cavity should be carefully explored and close examination of the lesion itself reserved for last. The strategy of the operation is planned, and the procedure is conducted with the avoidance of contamination or bleeding.

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