Large Bowel Injury (simple)
Dec 2010 – by P. DiSaia, MD
Dissection in the pelvis at surgery can be difficult, especially when the patient has had previous pelvic surgery, endometriosis, or a pelvic infection. Dense adhesions are common and injury to the sigmoid colon can occur. As with small bowel injuries, the surgeon needs to make a judgment about the extent of the injury and whether primary closure is possible or whether a resection of the colon is necessary.
If the edges of the injured bowel are free of crushed tissue and the extent of injury is less than half the circumference of the bowel, primary closure should be considered. The line of closure should be so as to produce the widest possible lumen and there should not be tension on the suture line. Atraumatic bowel clamps are helpful both proximal and distal to the injury to prevent stool from oozing from the hole. Delayed absorbable suture (e.g. Vicryl) should be utilized for the mucosal closure, beginning at one end of the injury and placing a water tight running suture to the distal end. Guide sutures placed at both ends is often helpful. A second layer of interrupted 3-0 permanent sutures are then placed so as to invert the first layer.
The avoidance of tension on the repair will help greatly in assuring primary healing. A temporary diverting colostomy is rarely needed unless there is undue tension or the closure is not water tight. Post operatively the patient's low residue diet should be advanced slowly.