Colonic trauma pptColonic trauma pptppppp

Colonic trauma ppt

1. Colonic trauma
SR Brown
Colorectal Surgeon
Sheffield Teaching Hospitals

2. 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

3. Blunt trauma
•Mechanisms for damage
–Crushing
–Shearing
–Bursting
–Penetrating

4. Evaluation of abdominal
penetrating trauma
•Haemodynamically unstable
–Laparotomy
•Haemodynamically stable
–Serial clinical exam
–Local wound exploration
–DPL
–FAST
–CT
–Laparoscopy
–Laparotomy

5. DPL
•Positive if
–>10ml frank blood
–RCC>100,000/mm
3
–WCC>500/mm
3
–Amylase>20 IU/L
–Presence bacteria/bowel contents

6. Adjuncts to evaluation
•CXR
•NG tube
•Catheter
•PR

7. Pros/cons
•Awake/cooperative patient
•Invasive
•Admission
•Retroperitoneum
•High clinical workload
•Complications

8. 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

9. Evaluation of blunt abdominal
trauma
•Haemodynamically unstable
–DPL/FAST/CT
•Haemodynamically stable
–Serial examination
–FAST
–CT

11. Surgery for abdominal trauma

12. Advantages of primary repair
•Reduced morbidity of colostomy closure
•Reduced disability of colostomy
•Reduced hospital stay

13. Colonic surgery; primary repair
Primary repairColostomyLeak
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

14. Colonic injury; primary repair in
destructive injury
Primary repairColostomyLeak
Chappuis, 199111 28 0
Falcone, 199212 12 0
Sasaki, 199512 28 0
Gonzalez, 19965 53 1
Total 40 121 1

15. Risk factors for primary repair
•Haemodynamicaly unstable
•Significant underlying disease
•Associated injuries
•Peritonitis

16. Damage control surgery
•‘Multiple trauma patients are more
likely to die from intra-operative
metabolic failure than a failure to
complete operative repairs’

17. Pathophysiology
•Hypothermia
•Acidosis
•Coagulopathy

18. Principles of surgery
•Control haemorrhage
•Prevent contamination
•Avoid further injury

19. Principles of colonic surgery
•Repair small enterotomies
•Extensive damage resect and close off ends
•No stomas
–Time consuming
–Spillage difficult to control

20. Abdominal compartment
syndrome
•Pressure >25cm water
•Oedema
–Reperfusion injury
–Crystalloid infusion
–Capillary leakage
–Packing

21. 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

22. Diagnosis
•Oliguria + increasing CVP
•Foley catheter in bladder
–Normal 0 cm water
–>25cm water suggestive
–>30cm water diagnostic

23. Treatment
•Anticipate
–Difficulty closing
–Horizontal view, guts above level of wall
•Laparostomy
–Bogota bag
–VAC dressing