Rectal injury

Aetiology

• Blunt trauma (often a/w pelvic fracture)
• Gunshot or stab wound
• Impalement
• Foreign body
• Blast

Anatomic classification

• Intraperitoneal or extraperitoneal
• High extraperitoneal if above peritoneal reflection

Diagnosis

• DRE is essential if considering, but insensitive
  • Blood
  • Palpable bony fragments
  • Wall defects
  • Position of prostate

Management

• Intraperitoneal
  • Treat similar to colon wounds - primary repair for all but the sickest patients
• Proximal extraperitoneal
• Distal extraperitoneal
  • Difficult to manage due to difficult exposure, limited space, nearby structures, anatomic distortion.
  • Only 20% are amenable to primary repair
  • If inaccessible, some say lap-assisted diverting loop sigmoid colostomy is ok in haemodynamically stable patients without peritonitis. Cameron's says they prefer exploratory laparotomy and diversion in that situation, to allow assessment of mesorectum and potential repair of proximal extraperitoneal injuries.
  • Best to do loop colostomy if doing a colostomy. (why?)
  • Presacral drain in setting low posterior anorectal injury. Inserted via curvilinear incision between coccyx and anus, followed by blunt dissection through Waldeyer's fascia to enter presacral space. Closed suction or 1-inch Penrose and gradually withdraw between post-op days 5 and 7. But presacral drainage is overall controversial, and may actually make things worse in lower-grade injuries, some say.
  • Rectal washout was done in the military previously but probably doesn't help.
• Anorectal injury
  • DRE essential - palpate for mucosal defects, bony fragments, gross blood. Assess resting and squeeze sphincter tone.
  • Simple lacerations to anal mucosa - repair primarily
  • Complex lesions involving distal perineum and rectum may require diverting loop colostomy
    • Plan debridements as much as daily for the first 3 days
    • If extensive debridement is required, overlapping sphincteroplasty is the repair of choice, since simple apposition of muscle has a failure rate of 40%.
    • Transposition of gluteus or gracilis with creation of a neosphincter is sometimes required.
  • Rectal foreign body
    • Consider assault
    • Clinically ill or peritonitis: laparotomy in lithotomy
    • If well: Lubricate and try and get it with sigmoidoscopy, but may need to proceed with laparoscopy/laparotomy
    • After extraction, review the mucosa with rigid sig
• Complications
  • Intra-abdominal abscess - if <2cm, treat with antibiotics. May need perc drainage. Re-exploration indicated if peritonitis, not amenable to drainage, unwell.
  • Colonic fistula - usually resolves with time and adequate drainage. Leave the drain catheter in place and flush twice daily with normal saline to prevent occlusion. Re-image once drainage drops, and slowly remove it over a few days.
  • Pelvic sepsis - ranges from small isolated abscess to extensive retroperitoneal infection. Will need drainage/debridement.
  • Wound infections very common, so don't close skin at same time as fascia.

Operation

• Lithotomy position
• Lone star retractor?