Rectal damage control: when to do and not to do

Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.

Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma

Unlike intraperitoneal colorectal injuries, the standard of care for extraperitoneal rectal trauma includes a diverting colostomy due to relative inaccessibility of these injuries for primary repair. New technologies to enhance access to the extraperitoneal rectum have gained increasing use in benign and malignant rectal disease. We present two cases of low-velocity penetrating extraperitoneal rectal trauma. In both cases, a transanal minimally invasive surgery (TAMIS) approach was used to access, and primarily repair, full-thickness rectal lacerations. These patients were successfully managed without a colostomy and without complication. TAMIS enables access to distal rectal injuries, facilitating primary repair and bringing the management of extraperitoneal rectal injuries in line with intraperitoneal injuries, with the potential to avoid fecal diversion.

Anorectal Avulsion: Reporting a Rare Case of Rectal Trauma and Review of the Literature

Background: Anorectal avulsion is a rare rectal injury and it is the result of severe blunt pelvic trauma. In this type of injury, the anus and sphincters are detached from the perineum and are displaced cranially and ventrally. Treatment is challenging and only a few reports are available. Case presentation: We report a case of 49-year-old male patient who was referred to our hospital in a septic condition 10 days after a complex crush pelvic trauma with anorectal avulsion. The treatment included external pelvic fixation, control of the pelvic sepsis, sigmoidostomy and negative-pressure therapy of the perineal wound. Salvage of the anus could not be done. The patient was discharged after 90 days suffering from neurologic deficits of both lower extremities and he followed a long-term rehabilitation program. Conclusion: Severe perineal injuries with anorectal avulsion are associated with significant morbidity and mortality. Due to the rarity of this entity treatment is not standardised and requires a multidisciplinary approach involving general surgeons, orthopaedics, intensivists and rehabilitators. Any effort for anal reconstruction should be done, if possible, early in the treatment course.