Rectal Anatomy
15-17 cm - Rectosigmoid junction
11-13 to 15-17 cm - Upper rectum (Intraperitoneal)
8-9 to 11-13 cm - Middle rectum (Peritoneal Reflection)
Up to 8-9 cm - Lower rectum (Extraperitoneal)
2.5-3 to 4-5 cm - ano-rectal junction
2.5-3 cm dentate line
Bounded by Pelvis (Rigid)
Close proximity to Ureters
2/3 Extraperitoneal
Rectal Blood Supply
Superior rectal artery
Sudek's point
Middle rectal artery
Inferior rectal artery
Anatomic Challenges
Inaccessible
Close to ureters
Tenuous Blood Supply
Majority lacks serosa
Mechanism
85% Penetrating
• 80% GSW
• 5% Stab/Impalement
10% Blunt
• Pelvic Fxs
5% Transanal
• Scope Trauma
• Enemas/Thermometers
• "Autoerotic Accidents"
Associated Injuries
Small bowel 56 %
Bladder 31% (6% intraperitoneal, 12% extraperitoneal, 13% combined intra- and extra- peritoneal)
Ureter 6%
Urethra 1%
Vagina 3%
Uterus 1%
Ovary 1%
Colon 16%
Iliac vasculature 3%
Pelvic fractures/ hip joint involvement 23%
Spinal cord 4%
Mean penetrating abdominal trauma index 23.6%
Diagnosis
Digital Rectal Exam
Rigid Proctoscopy
XR/CT
DRE – 55% Sensitive
DRE + Rigid Procto – 78% Sensitive (blood)
~90% sensitive for extraperitoneal injuries
~50% able to visualize injury itself
Presence of fresh blood in rectum after trauma: ~ 100% specific for rectal injury
CT for Penetrating Pelvic Trauma
•Visualizes tract
•Cystogram
•Useful in selecting pts for laproscopic ostomy
Colon Trauma – Current Management
Primary Repair
Damage Control Stapling + Delayed PR
? Benefit from Colostomy c: Mitigating Other Injuries and/or ongoing instability
Rectal Trauma Treatment
Colostomy
+/- Repair
+/- Presacral Drainage
+/- Rectal Washout
Rectal Trauma – Historical Perspective
WW II & Korea:
• Establishment of: Diverting sigmoid colostomy, drainage +/- repair
Vietnam:
• Validation of diversion and presacral drainage, more emphasis on repair, addition of distal rectal washout
Modern Civilian Data
• Anatomic approach
Diverting Colostomy
• Most of rectum lacks serosa
• More difficult technically to repair
• Historically colostomy was recommended with all rectal trauma
Hard to bring up
Difficult to maintain
Diverting Loop Sigmoid Colostomy
Provides Total Fecal Diversion (confirmed clinically and with barium studies)
Favored approach for extraperitoneal or repaired injuries
Minimally invasive, simple takedown
Other Colostomy Options
Stapled Loop Colostomy
• Hypothetically more diverting
• More difficult to perform & takedown
End Ostomy c Mucous Fistula
•Difficult to Make
•Difficult to Maintain
•Difficult to Takedown
End Colostomy c Hartman’s Pouch
•Optimal approach for Large Injuries communicating c Peritoneum
•Requires celiotomy for takedown
Presacral Drainage
It seemed logical to assume that removal of feces from this segment at the time of initial surgery, would prevent continued contamination and effect a reduction in morbidity and mortality
Combat Rectal Trauma
Delayed treatment
High Velocity
High rate of fecal impaction
Post – Vietnam Era
Increased abscess rate noted c irrigation by Baker in Br J Surg 1990; 77:872
Tuggle & Huber question mandatory washout in Am J Surg 1984; 148:806
Distinction between combat & civilian trauma by Burch, Feliciano & Mattox in Ann Surg 1989; 209:600
Presacral Drainage – Randomized, Prospective Civilian Trial
50 gunshot rectal injuries from 10/93 – 7/97
All diverted, none lavaged
Randomized to: Drainage for 3-5 days c 2 JPs vs. No drainage
Equivalent PATI & other parameters
3 non-rectal injury related deaths excluded
2 abscesses in drainage group (8%)
1 Fistula in Nondrained group (4%) - no significant difference
Presacral Drainage
Drains the Rectal Confined Space
Probably beneficial in low, posterior, unrepaired injuries
(should be the opening of a cavity, not the creation of one)
Penrose in close proximity (but not direct contact) with wound/closure
Management by Anatomic Level
Intraperitoneal - primary repair
Extraperitoneal upper two thirds - primary repair or resection and anastamosis; proximal diversion at surgeons discretion (based on complexity of wound and status of patient)
Extraperitoneal lower one third - wound accessible - primary repair w/ proximal diversion
Extraperitoneal lower one third - wound is inaccessible - proximal diversion and presacral drainage
Cape Town Approach
Suspected extraperitoneal rectal injury - transpelvic, gluteal, upper thigh gunshot and stab wounds, hematochezia
--> digital rectal exam, proctosigmoidoscopy -->rectal injury
-->acute abdomen -->laparotomy -->treat associated injuries -->extraperitoneal rectal injury --> no repair, diverting loop stoma via abdominal wall trephine, no DRW/PSD
-->non-peritonitic abdomen/equivocal abdominal tenderness --> diagnostic laparotomy
--> any intra-peritoneal blood and/or breach in peritoneal cavity --> laparotomy
--> normal --> no repair, diverting loop stoma via abdominal wall trephine, no DRW/PSD
Rectal Washout
Benefit demonstrated in Vietnam experience
• 18 pts with colostomy and drainage --> 22% mortality, 61% septic complications
• 10 pts with colostomy and debridement and closure and rectal irrigation --> 0% mortality, 10% septic complications
Mixed benefit (and some harm) demonstrated in civilian experience
• increased abscess rate noted with irrigation by Baker in Br J Surg 1990
• Decreased infection rate noted by SHannon & moores in JOT 1988
Source differences? constipated soldiers, high velocity war rounds, unrepaired vs. repaired wounds