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.

The Rocking Pelvis

This chapter reviews the pelvic and genitourinary physical examination in the setting of pelvic trauma, the types of pelvic fractures, and diagnostic tests available, including ultrasound, plain radiography, and computed tomography, to evaluate for pelvic injuries. It discusses the management principles of fluid resuscitation and hemorrhage control with an unstable pelvis, including consideration of consultation with trauma surgery, orthopedic surgery, and interventional radiology. It examines the types of concomitant injuries that may be expected, including splenic, hepatic, urethral, and rectal injuries and emphasizes the need for individualized workup and management for each patient based on a thorough physical examination. The indications for a retrograde urethrogram and treatment options for pelvic fractures are also briefly reviewed.