4th Surgery Dr.

Mohamed
Stage Upper GIT Lecture: 2

Small & Large Bowel | Part.2

Permanent Colostomy:
1. After abdomino-perineal resection.
2. lrresectable carcinoma of the large bowel with obstruction.
3. Incurable cases of anal incontinence.
4. High anal fistulae that is not amenable to surgery.

Types of colostomies:
1. Loop colostomy is usually temporary and is usually done in the right side
of the transverse colon.

• Loop Colostomy (how to do it?)

- transverse colon brought to the surface, fixed to the
abdominal wall, opened along one of the taenia coli, and
then stitched to the skin. A rod is passed beneath the loop to
prevent retraction, and is removed after one week.

2. End colostomy may be permanent or temporary. It is commonly

constructed in sigmoid colon left colon.

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 3. Caecostomy :for temporary decompression of the colon and done by
insertion of wide bore tube in to the cecum

Colostomy complications:
1) Prolapse.
2) Retraction.
3) Necrosis of distal end.
4) Stenosis of the orifice.
5) Colostomy hernia. through the
anterior abdominal all opening
beside the colon end, or internal
when the surgeon fails to close
the space lateral to the exiting
colon between it and the parietal
peritoneum.

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Intestinal Trauma:’
− The small & large intestines are frequently injured, either alone or in
combination with other intra-abdominal viscera. The prognosis intestinal
injury largely depends on these associated injuries.
− Colon injuries are more dangerous than those of the small intestine because
of the magnitude of intra-abdominal contamination.

The intestine may be injured by:

1. Blunt abdominal trauma as in road traffic accidents (RTA) or blows to the
abdominal wall. Presence of seat belt injuries should direct attention to the
possibility of intestinal injury.

2. Penetrating trauma as stabs and bullets.

− High velocity missiles are more damaging
than low velocity ones and stabs. Indirect
trauma, e.g., blast injuries are known to
affect the colon.

3. Iatrogenic injury is increasing with the rising

popularity of invasive
investigations.

Examples:
− The colon may also be injured
with colonoscopic diathermy.

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Types of Injury:
1. Contusion & haematoma.
2. Rupture which may be complete or incomplete and single or multiple.
3. Tears of mesentery or mesenteric vessels resulting into haematomas, and
gangrene of the affected bowel segments.

Sequelae of Intestinal Trauma:

1. Peritonitis occurs due to the escape of intestinal contents into the
peritoneum.
2. Internal haernorrhage. With intestinal injuries bleeding is less of a problem
than peritonitis.
3. Hypovolaemia and septic shock.
4. Paralytic ileus.
5. Injuries may heal by strictures and massive adhesions by intestinal
obstruction.

Clinical Picture:
1) History of trauma.
2) Abdominal pain at site of trauma which spread to all abdomen.

Signs:
General: tachycardia, fever, & hypotension.

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Local:
1. Signs of injury: bruises, inlet or outlet of a bullet, stab .
2. Tenderness with rebound tenderness.
3. Loss of liver dullness due to free air in peritoneum .
4. Distension due to developing ileus.
5. Shifting dullness because of free intraperitoneal fluid.
6. Frank peritonitis due to perforation early or late.

Investigations:
1. Clinical.

2. Laboratory tests (leukocytosis &

hemodilution).

3. Radiology Plain abdominal:

− X-Ray may show free air under
diaphragm or multiple fluid
levels, due to ileus, bullet &
shell or fracture may be seen.
Ultrasound or CT scan reveals
hematoma or collection.

4. Needle tap, diagnostic peritoneal lavage (DPL) may show free blood, bile,
or intestinal contents.

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Treatment:
Surgery (laparotomy)
Preoperative:
1. Anti-shock measures.
2. Antibiotic coverage Cephalosporin & Metronidazole.
3. Tetanus toxoid booster dose.
4. Insertion of nasogastric tube & urinary catheter.

Operation:
− Midline incision full exploration Bleeding managed 1st then bowel injury.
Priorities of multiple trauma management should be followed:

1. Small bowel and Right side of colon: if tinny small injury suturing is
enough. bigger need trimming & suturing , big wounds , big segment need
resection & anastomosis.

2. Transverse colon and left colon: localized injury exteriorized as colostomy

or injury sutured and protective proximal colostomy closed after 1 month
or resection of injured segment with proximal colostomy & distal mucous
fistula or Hartman's procedure, closure after month, good peritoneal
irrigation with N.S.

Intestinal Fistula:
− Pathology: Fistula is abnormal communication between two epithelial
surfaces. It is lined by granulation tissue but sometimes it is lined by
epithelium.

Causes:
1. 80% of external fistulae develop after an abdominal operation.
− The cause is either:
o Unrecognized intestinal injury.
o Failure of an intestinal anastomosis. Failure of an intestinal
anastomosis include:

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 1. Poor vascularity.
2. Anastomosis under tension.
3. Anastomosis in the presence of sepsis.
4. Distal obstruction.
5. Lack of proper surgical technique.
6. Presence of a specific pathology as Crohn's disease.
7. Generalized diseases that impair healing, e.g.,
hypoproteinaemia.

2. Other Causes of intestinal fistula:

− Congenital as patent vitello intestinal duct through the umbilicus.
− Abdominal trauma.
− Inflammatory bowel disease (Crohn's) , colonic diverticulitis, radiation
enteritis which produce internal and external fistula .
− Malignant tumour.

Classification:
− Internal: connect the intestine to hollow viscera (bladder, vagina, etc.).
− External: when it is connected to the skin. External fistulae are low-output
fistulae that discharge less than 500 ml/day, and high-output more than 500
ml/day. amount of fistula output has an important metabolic effect .

According to origin
According to origin in intestine. & by the nature of discharge:
− Bile stained → duodenum, jejunum.
− Greenish fluid → fecal fluid → ileum, cecum.
− Fecal material → distal colon.

Complications:
1. Metabolic effect: high output fistulae lead to loss of intestinal contents with
malabsorption & catabolic state, the metabolic effect include:
a. Dehydration.

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 b. Malnutrition, e.g., hypoalbuminemia.
c. Electrolyte disturbances as hyponatremia, hypokalemia.
d. Acid-base disturbance causes acidosis.
2. Sepsis If fistula track is not effectively walled off, and enteric contents escape
producing an intraperitoneal abscess.
3. Skin irritation & maceration due to continuous flow of intestinal contents.

Management:’
− The great majority of intestinal fistulae heal spontaneously if sepsis is treated, the
nutritional status is maintained and distal obstruction is relieved.
1. Resuscitation & skin protection : I.V.fluid ,blood,correct electrolyte &
skin protection.
2. Nutritional support.: TPN for high output, entral feeding for low
output fistula.
3. Investigate & treat sepsis: to know level of fistula , bowel disease, distal
obstruction & sepsis by:
A. Clinical assessment,
B. Fistulography & Ba follow through,
C. U/S or CT scan for abscess to be treated /aspirated.
4. Suppression of intestinal secretion by Somatostatin.

Definitive Treatment:
External Fistula:
− Conservative treatment succeeds mostly.

Surgery:
I. If no improvement after 6-8 weeks ,
II. Distal obstruction ,
III. Active disease Malignancy or Crohn's ,
IV. Total discontinuity of bowel ends ,
V. Mucocutaneous continuity ,
VI. Excision of the fistula correct pathology .

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Internal Fistula: spontaneous closure rare.
− Many internal fistulae need no correction.

Surgery indicated:
I. Internal fistula to urinary bladder.
II. Fistula Bypassing long segment of bowel causing malabsorption.

Causes of non-healing fistula:

Mnemonic is: Friends
- F for foreign body in the fistula as suture.
- R for radiation to fistula site.
- I for inflammation at fistula site as in Crohn’s.
- E for epithelialization of fistula tract.
- N for neoplasm at fistula site.
- D for distal obstruction.
- S for steroids.