Bowel injury should be: Primarily repaired

1. Bowel injury should be: Primarily repaired T Hardcastle Trauma Surgeon IALCH Durban

2. Debate? • Problem • No one rule that fits all situations • You will be wrong some of the time NEVER A NEVER, NEVER AN ALWAYS IN TRAUMA!

3. Primary repair – is it safe? • Yes: For most situations • Civilian: • Surg Ann 1991: 203 – 223 • Unfallchirurg 1991: 105 • J R Coll Surg Edinb 1996: 20 – 24 • Ann R Coll Surg Engl 1999: 58 – 61 • Injury 2002: 611 – 615 • J Trauma 2003: 399 - 406 • World J Surg 2006: 488 – 94 • Cochrane 2003 CD002247 • Military • J Trauma 2009: 1286 – 1291 • Dis Colon Rectum 2007: 870 – 877

5. Primary Repair – how to do it! • Small bowel • First stop any bleeding • Get rid of the contamination • Either debride the wound edges or do your resection • Check the numbers • Patient not for damage control • Single layer sero-submucosal absorbable suture and close mesentery • Stapled anastomosis higher leak rates* *J Trauma 2001; 51: 1054

7. Primary Repair – when to do it! • Large bowel • Stable patient • Minimal transfusions • Good edge bleeding* • Even after resection^ • No residual soiling or devitalized tissue • Single layer sero-submucosal preferably interrupted suture. Absorbable material • Consider omental wrap (Levuno Wrap) *Surg Ann 1991: 203 – 223 ^ Ann R Coll Surg Eng 1999: 58 - 61

9. Primary repair not advised? • Colonic injury • Severely shocked patient • Damage control criteria • Left colonic flexure* • Massive transfusion and marginal artery • Other bowel • Complex duodenal injury – maybe! • Most of these can be repaired • Rectal injury – extraperitoneal^ *J Trauma Aug 2005: 59: 359 ^World J Surg 2007: 1345

10. So is it really a debate? • More about DECISION MAKING • GOOD judgment comes from experience, experience comes from BAD judgment! • Must know ALL options and choose the appropriate one at the appropriate time

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