Operations for rectal injuries

Basic principles of surgical treatment

Treatment of traumatic injuries of the rectum (rectum) is one of the most critical tasks in emergency surgery. The success of surgical intervention is based on two fundamental principles, the failure of which inevitably leads to severe purulent-septic complications.

The first and most important principle is creating conditions for healing of the intestinal wall wound defect. The anatomical and physiological specifics of the organ are such that the constant passage of infected intestinal contents prevents the wound from closing on its own. To completely exclude the damaged segment from the digestive tract, surgeons resort to creating an artificial anus (colostomy). Bringing out a stoma guarantees that feces will no longer enter the area of injury.

The second mandatory principle is wide drainage of the fascial spaces of the lesser pelvis. The rectum is surrounded by thick layers of adipose tissue. When the rectum is injured, its contents infect these spaces, requiring the immediate creation of pathways for exudate drainage.

Surgical approaches for adequate drainage

The choice of surgical approach for draining the pelvic adipose tissue strictly depends on the topography of the wound. In operative surgery, there are three main approaches allowing access to the infection focus:

• Paraanal approach. The incision is made in the tissues directly adjacent to the anus. This path is optimal for draining the lowest sections of the perirectal adipose tissue.
• Parasacral approach. The incision is made lateral to the sacrum. It allows surgeons to penetrate into deeper layers of the pelvic adipose tissue.
• Coccygeal incision. This is the most radical and traumatic approach, used in severe injuries. Its key feature is that to create a sufficiently wide window, the surgeon is forced to perform coccygeal resection and remove the two lower sacral vertebrae. Only this volume of bone structure resection provides a full view and the possibility of adequate drainage of deep pelvic spaces.

Surgical tactics in perineal segment injuries

The perineal segment of the rectum has its own topographical and anatomical features that dictate a strict algorithm of action when it is damaged. If the injury is localized in this zone, the operation is performed in three consecutive stages:

1. First of all, primary surgical debridement (PSD) of the perineal wound is performed. The surgeon cleans the wound tract and excises non-viable tissues.
2. The second stage is wide drainage of the adipose tissue. Given the high risk of infection development in the perineum, drains must ensure the most efficient outflow.
3. The final stage is creation of an artificial anus. Even if the wound is at the very outlet of the pelvis, diverting the bowel remains an immutable rule.

Choice of anesthesia method

Adequate anesthesia is the key to the successful execution of all stages of the surgery. Depending on the severity of the injury and the scope of the planned intervention, the following types of anesthesia are used:

• Local anesthesia. Can be used for limited interventions, for example, primary surgical debridement of small superficial wounds.
• General anesthesia (narcosis). Is the method of choice for extensive injuries and the need for colostomy formation.
• Presacral block. This is a specialized method of regional anesthesia in which the anesthetic is injected into the presacral fascial space. The solution bathes the pelvic nerve plexuses, providing reliable anesthesia of the rectum. It is important to remember that other types of regional anesthesia (for example, paranephric or spermatic cord block) are not used for rectal operations, as they are intended for completely different anatomical areas.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of artificial anus (colostomy) formation
• Topographical anatomy of the lesser pelvis fascial spaces
• Stages of primary surgical debridement (PSD) of perineal wounds
• Technique of performing a presacral block
• Features of paraanal and parasacral approaches

Other topics in the section «Pelvic and Perineal Surgery»

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.