| disease | Colorectal Injury |
| alias | Injury of Colon, Injury of Rectum |
Colorectal injuries are often caused by industrial and agricultural accidents, traffic accidents, domestic mishaps, and fights, with closed abdominal injuries being the most common. The incidence rate ranks fifth among abdominal visceral injuries, following injuries to the small intestine, spleen, liver, and kidneys. The danger of colorectal injuries lies in the leakage of intestinal contents into the abdominal cavity, leading to severe bacterial peritonitis. Prolonged exposure or a large amount of intestinal contents can result in toxic shock.
bubble_chart Etiology
1. Blunt trauma The abdomen is struck by heavy objects, such as industrial accidents, car crashes, falls, tumbles, fights, punches, and other blunt force impacts. The large intestine, located between the posterior and anterior abdominal walls, is subjected to the impact force, resulting in intestinal wall injury, perforation, or rupture.
2. Stab wounds Commonly seen in bayonet injuries during wartime, and in civilian life, they often occur due to fights, homicides, robberies, and other public security incidents.
3. Firearm injuries In wartime, injuries from shrapnel or bullets often involve combined injuries to the small intestine or other abdominal and systemic organs.
4. Iatrogenic injury Colon perforation caused by sigmoidoscopy or fiber colonoscopy is not uncommon nowadays. Among the 468 cases of abdominal injuries reviewed by the author, 3 were caused by fiber colonoscopy-induced colon injury.
bubble_chart Clinical Manifestations
1. contusion (hematoma)
2. laceration
⑴ Non-perforating (not full-thickness or serosal membrane tear);
⑵ Perforating (full-thickness but not completely transected);
⑶ Massive destruction (avulsion, complex, rupture, tissue loss, significant fecal contamination).
3. Clinical manifestations
⑴ Abdominal pain and vomiting: In cases of colon or rectal perforation or massive destruction, fecal matter leaks into the abdominal cavity, leading to immediate abdominal pain and vomiting. The pain initially localizes to the perforation site and then spreads throughout the abdomen, resulting in diffuse peritonitis with generalized abdominal pain.
⑵ Signs of peritoneal irritation: Abdominal tenderness, muscle rigidity, and rebound tenderness. The pain is most pronounced at the site of perforation or rupture.
⑶ Diminished or absent bowel sounds.⑷ Digital rectal examination: In cases of low rectal injury, the injured area may feel hollow upon palpation, with blood on the examining glove. Only a minority of colon injuries show blood on the glove. {|109|}
1. History of trauma: There is a history of trauma to the abdomen or nearby areas, or a history of colonoscopy, followed by abdominal pain or other discomfort symptoms after the injury.
2. Clinical manifestations
⑴ Abdominal pain and vomiting: In cases of colon or rectal perforation or extensive damage, fecal matter from the intestinal cavity spills into the abdominal cavity, leading to abdominal pain and vomiting. The pain initially localizes to the perforation site and then spreads throughout the abdomen, resulting in diffuse peritonitis with generalized abdominal pain.
⑵ Signs of peritoneal irritation: Tenderness, muscle rigidity, and rebound tenderness in the abdomen. The pain is most pronounced at the site of perforation or rupture.
⑶ Decreased or even absent bowel sounds.
⑷ Digital rectal examination: In cases of low rectal injury, a hollow sensation may be felt at the injury site, and blood may be present on the examining finger. In colon injuries, blood is present in only a minority of cases.
3. Blood tests: Increased white blood cell count and neutrophilia.
4. X-ray imaging: For closed injuries, if the patient's condition allows for an upright X-ray, free gas under the diaphragm can often be detected.
5. Ultrasound, CT, MRI: If the above examinations fail to provide a clear diagnosis, one or two of these imaging modalities may be selectively used to aid in diagnosis.
bubble_chart Treatment Measures
(1) Initial stage [first stage] suture repair of perforation or intestinal resection and anastomosis
With advancements in antibiotics, surgical techniques, perioperative management, and total parenteral nutrition, there has been a shift toward initial stage [first stage] surgery for colon and rectal trauma both domestically and internationally in recent years. The advantages of initial stage [first stage] suture repair include shorter hospitalization and recovery times, completion of treatment in a single procedure, and avoidance of the psychological, physiological, and surgical burdens associated with colostomy and subsequent reversal.
2. Surgical methods
⑴ Perforation suture repair: Suitable for perforations in mobile segments such as the transverse or descending colon. For perforations in fixed segments (e.g., ascending or descending colon), the affected colon must be fully mobilized, including division of the hepatocolic or splenocolic ligaments if necessary, and incision of the lateral peritoneal membrane to inspect the anterior and posterior walls of the perforation. The perforation is first closed with a full-thickness suture, followed by a seromuscular layer suture.
⑵ Segmental colon resection and end-to-end anastomosis: Suitable for multiple perforations in close proximity, complete transection, or extensive tissue destruction. After debridement and trimming of the ends, an end-to-end anastomosis is performed, with the first layer as a continuous full-thickness suture and the second layer as interrupted seromuscular sutures.
⑶ Right hemicolectomy with ileum-transverse colon anastomosis: Suitable for severe destruction of the ascending colon or cecum. The right lateral peritoneal membrane is incised, and the cecum and ascending colon are mobilized, followed by division of the hepatocolic ligament. The right colon and terminal ileum are resected, and an end-to-end anastomosis between the ileum and transverse colon is performed, with the first layer as a continuous full-thickness suture and the second layer as interrupted Lembert sutures using silk.
3. Prevention and management of complications: The most common complication after surgical treatment of colon and rectal injuries is anastomotic leakage.
⑴ Causes: The colon has poor blood supply, thin walls, and contains abundant bacteria and fecal material. Postoperative colonic distension, high anastomotic tension, or inadequate suturing can lead to anastomotic leakage.
⑶ Treatment: Reoperation. The abdominal cavity is lavaged with copious isotonic saline, the anastomotic site is addressed, and the initial stage [first stage] suture (anastomosis) is converted to an intermediate stage [second stage] procedure. Double-lumen drainage is placed intra-abdominally for postoperative continuous negative-pressure suction.
(2) Staged surgery
During World War I, due to limited surgical techniques, lack of effective anti-infective agents, and suboptimal perioperative management, initial stage [first stage] suture (anastomosis) for large intestine injuries had a mortality rate of 55–60%. In World War II, this was changed to intermediate stage [second stage] surgery, reducing mortality to 35%. During the Korean War, staged surgery further reduced mortality to 15%. As a result, staged surgery remains widely recommended by many surgeons today.
1. Indications
① Time from injury to surgery exceeds 6 hours; ② Severe intra-abdominal fecal contamination; ③ Multiple associated injuries or multi-organ abdominal trauma; ④ Poor overall patient condition, unable to tolerate prolonged surgery; ⑤ Older age; ⑥ Left-sided colon injury; ⑦ Wartime mass casualties who cannot remain under observation at the treatment facility for over a week postoperatively.
2. Surgical methods
⑴ Exteriorization of the colon: Suitable for multiple rupture injuries in the mobile parts of the colon such as the transverse colon and sigmoid colon. After exploration, make another incision to exteriorize the injured bowel loop, then create a small hole below the vascular arcade of the mesentery. Use a glass tube with catgut as a support tube to fix the injured bowel loop outside the abdominal wall to prevent retraction into the abdominal cavity.
⑵ Injury Loop Suture with Proximal Exteriorization: Suitable for injuries to fixed loops such as the ascending colon, descending colon, and rectum. During the procedure, the lateral peritoneum adjacent to the injury must be incised, the injured loop mobilized, the wound debrided, and exploration performed for multiple perforations. The wound is then initially [first stage] closed with a double-layer suture and repositioned, followed by a colostomy in the proximal mobilized colon. For example, a sigmoid colostomy is performed after suturing a rectal injury, and a transverse colostomy is performed after suturing a descending colon injury. This achieves fecal diversion and promotes wound healing.
⑶ Suture with Exteriorization: For injuries to mobile colon loops such as the transverse colon or sigmoid colon, the injured loop is debrided, sutured, and then exteriorized onto the abdominal wall. Postoperatively, wound healing can be observed externally. If healing is satisfactory, the loop is returned to the abdominal cavity after about 10 days. If healing is inadequate, the sutures are removed, converting it into a loop colostomy, which is later reduced during the intermediate stage [second stage].
⑷ Rectal Injury Suture with Sigmoid Colostomy: Most rectal injuries occur outside the peritoneal reflection. The rectal injury should be debrided and sutured, with a proximal sigmoid colostomy to divert fecal flow. The distal end of the sigmoid colostomy is thoroughly irrigated with saline and filled with metronidazole solution. A Penrose drain is placed anterior to the sacrum and posterior to the rectum (Figure 22-3). The drain is removed 3–4 days postoperatively. After 4 weeks of wound healing, an intermediate stage [second stage] procedure is performed to resect and anastomose the exteriorized sigmoid colon.
3. Complications After Colostomy or Exteriorization
⑴ Proximal Stoma Torsion: Due to improper positioning of the colon at the stoma site, torsion occurs, leading to postoperative fecal obstruction. Prevention: ① The taenia coli must be positioned toward the abdominal wall during surgery; ② The colonic loop for the stoma must be fully mobilized and exteriorized without tension. Management: For grade I torsion, digital dilation can be performed, followed by placing a thick, soft rubber tube in the proximal stoma to support fecal discharge. Severe torsion causing circulatory impairment, colonic necrosis, or peritonitis requires immediate reoperation for stoma revision.
⑵ Stoma Retraction: Causes: ① Inadequate mobilization of the proximal or distal colon for the stoma; ② The stoma protrudes less than 3 cm from the skin; ③ Although the stoma protrudes sufficiently, poor blood circulation leads to postoperative necrosis and retraction; ④ Insecure suturing of the stoma to the abdominal wall layers, resulting in suture loosening; ⑤ In loop colostomy, premature removal of the supporting glass rod before adhesion formation causes retraction. Treatment: For grade I retraction with established adhesions, fecal contamination may occur—observation is initially advised. If retraction into the abdominal cavity causes peritonitis, emergency surgery is required to resect the necrotic loop and create a new stoma in the proximal mobile colon segment.
⑶ Small Intestine Prolapse Near Stoma: If excessive muscle separation occurs around the stoma and the colon is not securely sutured layer-by-layer to the peritoneum and external oblique aponeurosis, postoperative irregular peristalsis of the small intestine may cause prolapse near the stoma, commonly seen in sigmoid colon exteriorization or colostomy. Immediate reduction of the small intestine into the abdomen and re-suturing of the colon are necessary.
⑷ Sigmoid Colon Internal Hernia: If the sigmoid colon is not sutured and fixed to the adjacent parietal peritoneum during exteriorization or colostomy, a gap remains. Postoperatively, small intestine peristalsis may cause the small intestine to herniate into the pelvic cavity through the lateral sigmoid space, leading to internal hernia, intestinal obstruction, or even strangulated intestinal necrosis. Prompt surgery is required to reduce the small intestine. If incarceration or necrosis occurs, intestinal resection and anastomosis are performed, and the paracolic space should be sutured to prevent recurrence.
⑸ Stoma Mucosal Prolapse: Causes: ① Excessive protrusion of the colonic mucosa from the abdominal wall; ② Stomal stenosis causing partial obstruction or postoperative constipation, leading to prolonged straining during defecation, which eventually results in mucosal relaxation and prolapse. In rare cases, prolapse may exceed 10 cm. This complication develops gradually, and patients may adapt over time, manually reducing the prolapse after defecation.
(6) Stoma stenosis: Causes: ① The opening of the stoma skin or tendon membrane is too small; ② Scar contraction and stenosis after infection and healing of the incision around the stoma; ③ Neglecting regular finger anal dilation after stoma surgery. If it is grade I stenosis and feces can still pass, perform an intermediate stage [second stage] surgery to close the stoma as soon as possible. If stenosis causes obstruction, surgical incision of the colon at the stoma and surrounding scar tissue is required to enlarge the stoma.
(7) Incision infection and dehiscence: Colon injuries often involve abdominal contamination, resulting in a high postoperative incision infection rate. If the surgery is performed long after the injury, or if the colostomy or exteriorization method is improper—especially when the stoma or exteriorization is placed on the exploratory laparotomy incision—feces may flow into the incision postoperatively, increasing the risk of infection. Once infection occurs, full-thickness dehiscence is likely, exposing the small intestine and complicating late-stage (third-stage) management, even threatening life. Prevention: When performing colostomy or exteriorization, avoid the original incision and create a separate one. Before closing the abdomen, irrigate the abdominal cavity extensively with isotonic saline and place an antibiotic solution. If full-thickness abdominal wall dehiscence occurs with fecal contamination of the abdominal cavity, immediate surgery is necessary to create a new stoma proximal to the original one, diverting fecal flow to prevent further contamination of the incision and abdominal cavity.
4. Colostomy Closure
(1) Conditions for closure: The timing of colostomy closure depends on: ① Whether the patient’s overall condition has recovered; ② Whether local inflammation is under control—if infection is present, delay until it resolves; ③ Confirmed healing of the distal colon suture (anastomosis); ④ If multiple abdominal organs are injured, ensure other injuries have healed; ⑤ Barium enema confirming distal patency; ⑥ Adequate preoperative bowel preparation for disinfection.
(2) Timing of closure: Generally 4–6 weeks after colostomy, but may be delayed if the patient’s overall condition is unstable or if abdominal wound infection persists.
(3) Closure method: Depends on the location and technique of the colostomy or exteriorization. The primary goal is to restore normal intestinal continuity and function. Excise the original stoma site and surrounding tissue, mobilize the proximal and distal colon, and perform a tension-free end-to-end anastomosis. Place a double-lumen drain near the anastomosis for postoperative continuous suction. Then suture the abdominal wall layers meticulously and monitor closely, performing daily anal dilation to prevent anastomotic leakage. Note that this surgery carries a mortality rate of 0.5–1%, so it should not be considered risk-free.
(4) Complications of closure: Common issues include anastomotic dehiscence or fistula, caused by inadequate mobilization of the ends during closure, high anastomotic tension, or poor blood supply to the anastomosis, exacerbated by postoperative colonic distension. This can lead to anastomotic leakage and peritonitis. Immediate diagnosis, surgical drainage, and re-establishment of a stoma are required.
Another complication is incision infection, often due to inadequate preoperative systemic, local, or bowel preparation, bacterial contamination, or poor overall condition, leading to infection and dehiscence. Aggressive symptomatic treatment usually results in recovery.
