Bowel injury should be: Primarily repaired

T HardcastleTrauma SurgeonIALCH Durban

Debate?

• Problem– No one rule that fits all situations– You will be wrong some of the time

NEVER A NEVER, NEVER AN ALWAYS IN TRAUMA!

Primary repair – is it safe?• Yes: For most situations• Civilian:

– Surg Ann 1991: 203 – 223– Unfallchirurg 1991: 105– J R Coll Surg Edinb 1996: 20 – 24 – Ann R Coll Surg Engl 1999: 58 – 61– Injury 2002: 611 – 615– J Trauma 2003: 399 - 406– World J Surg 2006: 488 – 94– Cochrane 2003 CD002247

• Military– J Trauma 2009: 1286 – 1291– Dis Colon Rectum 2007: 870 – 877

Primary Repair – how to do it!

• Small bowel– First stop any bleeding– Get rid of the contamination– Either debride the wound edges or do your

resection– Check the numbers

• Patient not for damage control– Single layer sero-submucosal absorbable suture

and close mesentery – Stapled anastomosis higher leak rates*

*J Trauma 2001; 51: 1054

Primary Repair – when to do it!

• Large bowel– Stable patient– Minimal transfusions– Good edge bleeding*– Even after resection^– No residual soiling or devitalized tissue– Single layer sero-submucosal preferably

interrupted suture. Absorbable material– Consider omental wrap (Levuno Wrap)

*Surg Ann 1991: 203 – 223

^ Ann R Coll Surg Eng 1999: 58 - 61

Primary repair not advised?

• Colonic injury– Severely shocked patient– Damage control criteria– Left colonic flexure*

• Massive transfusion and marginal artery

• Other bowel– Complex duodenal injury – maybe!– Most of these can be repaired

• Rectal injury – extraperitoneal^*J Trauma Aug 2005: 59: 359

^World J Surg 2007: 1345

So is it really a debate?

• More about DECISION MAKING• GOOD judgment comes from experience,

experience comes from BAD judgment!• Must know ALL options and choose the

appropriate one at the appropriate time

?