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Colonic trauma. SR Brown Colorectal Surgeon Sheffield Teaching Hospitals. Types of trauma. Penetrating trauma Gunshots Energy transfer proportional to velocity Cavitation Injury away from track Contamination sucked in Stab wounds Low level energy transfer Injury confined to track. - PowerPoint PPT Presentation
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Colonic trauma
SR Brown
Colorectal Surgeon
Sheffield Teaching Hospitals
Types of trauma
• Penetrating trauma– Gunshots
• Energy transfer proportional to velocity
• Cavitation– Injury away from track
– Contamination sucked in
– Stab wounds• Low level energy transfer
• Injury confined to track
Blunt trauma
• Mechanisms for damage– Crushing– Shearing– Bursting– Penetrating
Evaluation of abdominal penetrating trauma
• Haemodynamically unstable – Laparotomy
• Haemodynamically stable– Serial clinical exam– Local wound exploration– DPL– FAST– CT– Laparoscopy– Laparotomy
DPL
• Positive if– >10ml frank blood– RCC>100,000/mm3
– WCC>500/mm3
– Amylase>20 IU/L– Presence bacteria/bowel contents
Adjuncts to evaluation
• CXR
• NG tube
• Catheter
• PR
Pros/cons
• Awake/cooperative patient
• Invasive
• Admission
• Retroperitoneum
• High clinical workload
• Complications
CT features of penetrating abdominal injury
• Signs of peritoneal violation– Free air/fluid– Track
• Signs of bowel injury– Thickening/defect– Contrast leak
• Others– Intravenous contrast leak– Diaphragm tear
Evaluation of blunt abdominal trauma
• Haemodynamically unstable– DPL/FAST/CT
• Haemodynamically stable– Serial examination– FAST– CT
Surgery for abdominal trauma
Advantages of primary repair
• Reduced morbidity of colostomy closure
• Reduced disability of colostomy
• Reduced hospital stay
Colonic surgery; primary repair
Primary repair Colostomy Leak
Stone, 1979 69 72 1
Chappuis, 1991 28 28 0
Falcone, 1992 12 12 0
Sasaki, 1995 43 28 0
Gonzalez, 1996 56 53 2
Total 208 193 3
Colonic injury; primary repair in destructive injury
Primary repair Colostomy Leak
Chappuis, 1991 11 28 0
Falcone, 1992 12 12 0
Sasaki, 1995 12 28 0
Gonzalez, 1996 5 53 1
Total 40 121 1
Risk factors for primary repair
• Haemodynamicaly unstable
• Significant underlying disease
• Associated injuries
• Peritonitis
Damage control surgery
• ‘Multiple trauma patients are more likely to die from intra-operative metabolic failure than a failure to complete operative repairs’
Pathophysiology
• Hypothermia
• Acidosis
• Coagulopathy
Principles of surgery
• Control haemorrhage
• Prevent contamination
• Avoid further injury
Principles of colonic surgery
• Repair small enterotomies
• Extensive damage resect and close off ends
• No stomas– Time consuming– Spillage difficult to control
Abdominal compartment syndrome
• Pressure >25cm water
• Oedema– Reperfusion injury– Crystalloid infusion– Capillary leakage– Packing
Pathophysiology
• Cardiovascular– Decrease cardiac output despite high CVP
• Respiratory– Splint diaphragm
• Renal– Oliguria due to renal vein/parenchyma compression
• Cerebral– Increased CVP results in decreased cerebral drainage
Diagnosis
• Oliguria + increasing CVP
• Foley catheter in bladder– Normal 0 cm water– >25cm water suggestive– >30cm water diagnostic
Treatment
• Anticipate– Difficulty closing– Horizontal view, guts above level of wall
• Laparostomy– Bogota bag– VAC dressing