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  • The presence of blood on digital examination of the anorectum is highly suggestive of injury, but its absence does not rule out injury to the colon or rectum.

  • Primary repair of colonic injuries is safe and is the preferred option for nondestructive wounds.

  • The management of patients with destructive colon wounds is controversial, but a prudent approach would be resection and anastomosis for stable patients without shock or other major comorbidities and diversion for unstable or high-risk patients.

  • Degree of fecal contamination influences the probability of developing septic complications, including intra-abdominal abscess, but is not associated with an increased risk of suture line failure (anastomotic leaks).

  • Patients with intraperitoneal penetrating rectal injuries should be managed the same as those with colon injuries. In patients with blunt injuries, proximal colostomy is usually the procedure of choice, as these injuries are frequently associated with pelvic fractures or complex perineal injuries.

  • Extraperitoneal rectal injuries should be managed according to the anatomy of the injury. If the injury is accessible, it may safely be repaired primarily without diversion. If it cannot be repaired, then diversion is indicated.

  • The anatomy of the rectal injury should dictate whether presacral drains be placed (selective use), but the practice of rectal washout cannot be supported by contemporary data.


The management of injuries to the colon and rectum has changed dramatically through the years. Colon-related morbidity has decreased to approximately 15% to 20%, and mortality has decreased from approximately 90% during the Civil War to around 1% in the current literature.

Much of the early description of management for patients with colon and rectal injuries was from wartime experiences. These principles were then used for civilian patients initially. Over time, surgeons realized that civilian wounds were different from military ones, and new clinical approaches were devised. These evidence-based approaches have improved morbidity and mortality for civilian patients, as noted earlier.

Controversy still exists with respect to destructive wounds, location of colonic injury, blunt injury, abbreviated laparotomy, primary rectal repair, and presacral drainage. In this chapter, we will address these controversial issues and present a workable management scheme.


Military and Civilian Experience

In order to understand the controversies that exist with management of colon wounds, it is important to review military and civilian experiences. The first report of a colon injury is recorded in the book of Judges when Ehud killed King Eglan. “And Ehud reached with his left hand, took the sword from his right side, and thrusted into his belly. And the hilt also went in after the blade, and the fat closed over the blade, for he did not pull the sword out of his belly; and the dung came out.”1

Little was written about the management of colon ...

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