Medical Science Publication No. 4, Volume 1
FRIDAY MORNING SESSION
23 April 1954
MODERATOR
LIEUTENANT COLONEL CARLW. HUGHES, MC
SURGICAL CONSIDERATIONS IN THE TREATMENT OFWAR WOUNDS OF THE RECTUM AND RECTOSIGMOID COLON*
LIEUTENANT COLONELH. HASKELL ZIPERMAN, MC
Introduction
Wars tend to increase in lethality through the discovery of new weaponsof destruction and the application of old concepts of warfare in a newerand more deadly fashion. Always parallel with and tending to act as a limitingfactor in this destructiveness is the introduction of new medical and surgicalprinciples which save life and decrease morbidity. That this applies isshown by the decreasing mortality among casualties reaching medical attentionin World War II as compared with the Korean war-4.5 percent in the formeras compared with 2 percent in the latter.
In the Korean war, principles of the management of battle casualtieslearned in preceding wars were applied. Changes were made as experienceand new technics necessitated. Since the war-free interval from the endof World War II to the beginning of the Korean conflict was short, muchof what was learned in the former was applied in the latter with littlechange. This was especially true in the handling of casualties with penetratingwounds of the abdomen and perforations of bowel. That some changes weremade will be evident by comparing this paper with the discussion of rectaland rectosigmoid injuries in TB Med 147.
Diagnosis
Perhaps the first clue found in a casualty who had suffered a penetrationof the rectum or rectosigmoid was the site of the wound of entrance, andin some cases the location of the wound of exit. It was possible by projectionin cases with wounds of exit and entrance to mentally visualize the missiletract and coupled with physical findings to determine the organs damaged.All penetrating perineal, buttocks, and low abdominal and back wounds wereconsidered as potential sources of wounds of the rectum and rectosigmoiduntil proven otherwise.
*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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When first seen, the patient with a penetrating wound of the peritonealcavity with massive fecal contamination of the peritoneum presented a pictureof shock which was difficult to differentiate from that due to severe bloodloss. In fact, in cases with wounds of the peritoneal cavity the attemptto make this clinical differentiation was purely academic since explorationwas essential to determine the true extent of involvement and to instituteproper treatment. It was generally agreed by all surgeons in the KoreanTheater that the most profound and unresponsive shock picture seen amongbattle casualties was that among wounded with severe and continuing hemorrhageand those with massive fecal contamination of the peritoneal cavity.
The shock picture in the patient with an extraperitoneal perforationof the rectum was totally different. Here the casualty was rarely in shockunless there were associated injuries of sufficient severity to cause amarked drop in blood pressure. As can be surmised, it was impossible todetermine bowel perforation on the basis of shock alone.
In the emergency surgical hospitals in the combat zone in Korea as soonas the possibility of peritoneal penetration was entertained, a Levin tubewas introduced into the stomach both to ascertain whether bleeding waspresent and to empty the stomach; a catheter was introduced into the urinarybladder to rule out damage to the genitourinary tract; and inspection,palpation, percussion and auscultation of the abdomen were carried out.Typically the casualty with intraperitoneal perforation of the gastrointestinaltract showed mild to moderate abdominal distention associated with tympany,abdominal rigidity and absent bowel sounds. Clinically it was difficultto determine whether the abdominal distention was due to paralytic ileuswith accumulation of gas, intraperitoneal hemorrhage, or both. Some ofthese casualties were in such a severe state of shock that all musculartonus was decreased and consequently no abdominal splinting was present.
In wounds of the extraperitoneal portion of the rectum there was rarelyany abdominal distention unless there was an associated perforation ofthe bladder or great vessels so that low abdominal distention was producedby extravasation of blood or urine or both into the pelvic tissues andperitoneal cavity. This extravasation was rare and easily differentiatedfrom true abdominal distention.
As frequently as not a digital rectal examination added considerableinformation with regard to lower colon and rectal perforation and associatedinjuries of pelvic structures. The presence of blood in the cul-de-saccould be determined by bulging into the rectum. A low rectal perforationcould actually be palpated in this manner. In any instance where bloodwas found on the palpating finger when withdrawn, it had to be assumedthat either a rectosigmoid or rectal
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perforation existed since rarely did perforations higher in the descendingcolon produce blood in the rectum in the short time elapsed between woundingand admission to the surgical hospital in the Korean experience.
X-ray examination was considered to be the best adjunctive method fordetermining which organs and viscera had been damaged. For good localization,both AP and lateral examinations were essential. Knowing the site of thewound of entrance, it was possible, on the basis of the position of theretained metallic foreign bodies in relation to the known position of organsand viscera, to determine at least moderately well which structures hadbeen damaged. Where there was both a wound of entrance and exit, the positionof retained metallic foreign bodies allowed for a reasonably accurate estimationof the structures damaged. Where multiple wounds were present, as so frequentlyhappened, it was difficult to determine which retained missile was responsiblefor the particular wound but here its localization in the vicinity of aspecific structure was helpful in determining the particular structureinjured.
In those casualties in whom all other methods of determining whethera vital structure was injured had failed, it was found that débridementof the wound tract proved to be particularly useful. This maneuver consistedin débriding the successive layers of the wound until the missilewas found and removed, or until it was determined that penetration of theperitoneal cavity existed or that a vital structure was injured. This procedurewas an adjunct to definitive laparotomy and was performed prior to thatsurgery and after the casualty had been prepared as if for definitive surgery.This maneuver was reserved only for casualties in whom there was a questionof penetration of the peritoneal cavity or of injury to a vital structurein the pelvis and saved time and morbidity since an unnecessary laparotomywas thus avoided.
Sigmoidoscopic examination as a means of making the diagnosis of rectalinjuries was used as an adjunct to all of the other modalities of diagnosis.All casualties with wounds of the pelvis and buttocks and those in whomblood was found on the examining finger on digital rectal examination weresubjected to sigmoidoscopy. These patients were prepared for laparotomybut sigmoidoscopy was done prior to definitive surgery by placing themin the Sims' position on the operating table. This procedure was foundto be especially useful in those individuals with an extraperitoneal perforationof the rectum since extensive dissection and mobilization of the rectumcould usually be avoided when the exact site of perforation was known inadvance. In the presence of blood on the examining glove after digitalrectal examination, a negative sigmoidoscopic examination was never taken
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as evidence that rectal injury did not exist, since the blood couldeither have been from a point which could not be reached by the scope ora perforation might have been overlooked during the examination.
In the ultimate analysis the only absolute method of determining rectalor rectosigmoid injury in a battle casualty whose symptoms and signs werequestionable was by performing a laparotomy. While it is true that occasionalunnecessary laparotomies were thus performed, these were held to an absoluteminimum by first utilizing all of the other diagnostic modalities in eachcase.
Treatment
It was found expedient in performing a laparotomy on casualties to adopta relatively standard routine for exploration. Knowing the wound of entranceand having received information from x-ray examination as to the positionof fragments within the peritoneal cavity, it was easy to decide wherethe first focus of attention should be placed on opening the peritoneum.In every instance where a large amount of free blood was found in the peritonealcavity, it was felt to be expedient to search first for the bleeding sourceso that it could be controlled by hemostat or pack depending on the amountof blood being lost and the source of the bleeding. Having controlled thebleeding point, attention was then paid to the intra-abdominal organs.A start was made at the point where known injury existed. As soon as theextent of injury at the wounding site had been determined, the entire smallbowel was quickly run from the ligament of Treitz to the ileocecal valve,or vice versa, with each perforation being marked. Where indicated by theknown path of the missile and its tract, both ascending and descendingcolon were then reflected towards the midline so that retroperitoneal aswell as peritoneal surfaces of the bowel could be examined. In all instancesin which injury to the rectum or rectosigmoid was expected but not found,it was deemed advisable to open the pelvic peritoneum and to mobilize andexplore the rectum in the hollow of the sacrum. Where carried out, thisprocedure was performed in such a manner as to allow adequate visualizationof all surfaces of the rectum down to the point of attachment of the levatorani muscles.
In all instances where a perforation of the rectum or rectosigmoid wasfound, all other pelvic viscera, including the urinary bladder, ureters,accessory genital organs and great vessels were visually inspected becauseof the frequent association of injuries of these structures with woundsof the colon in this region. It was axiomatic that where a single perforationof a hollow viscus was found a second perforation likewise would be foundunless the surgeon could prove to his satisfaction either that the injurywas due to concussion, that
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only penetration had occurred and the fragment was retained within thehollow viscus, or that a glancing wound with single penetration had occurred.
Whenever a wound of the rectum or rectosigmoid was found, it was feltadvisable to close the perforation in two layers if at all possible. Wherea large segment of rectosigmoid was destroyed it was occasionally necessaryto effect closure by a sleeve type of resection, reestablishing continuityby mobilizing the proximal bowel so that suturing could be done withouttension.
Since most of these wounded had fecal material in the colon at the timeof wounding, it was usual to find fecal contamination of the peritonealcavity in casualties with wounds of the rectum and rectosigmoid. It wasdeemed advisable where contamination of the peritoneum had occurred, towipe the area free of gross material but not to drain the area after sutureof the bowel. Where the wound was extraperitoneal, the peritoneum was closedafter exploration and suture of the bowel, and the pre-sacral space wasdrained, bringing the drain out at a point just anterior to the coccyx.It was necessary at times to remove the coccyx to secure adequate drainage.Where it was felt advisable to do so, a tract for the drain was establishedin the pre-sacral space from above and the drain inserted by incising theskin from below at the conclusion of the laparotomy.
The use of colostomy as an adjunct for treatment of wounds of the colonbecame well established during World War II and was carried over into theKorean war. Wounds of that portion of the colon which could be treatedby exteriorization of the perforated colon over a glass rod were routinelyhandled in this way. Wounds of the rectum or rectosigmoid where exteriorizationcould not be accomplished were treated by a proximal diverting colostomywith the proximal loop being placed caudad to the distal one. It becameroutine during the Korean war to bring out the sigmoid colon as a divertingcolostomy through a left McBurney muscle-splitting incision. The loop wasactually divided, the clamps being left in place to keep the ends of thebowel closed, and the ends were separated by closing at least peritoneumand skin between them. It was felt that this served to prevent any spillof feces from the proximal to the distal bowel. No attempt was made toproduce a spur for later crushing. Although some surgeons brought the twoends of bowel out through individual stab wounds separated by at least2 to 3 inches of intact skin, it was felt that this maneuver served tomake ultimate closure of the colostomy more difficult unless the two stabwounds were carefully placed with respect to the direction of the lineof fibers of the fascial layers. Sutures were never used between the boweland the abdominal wall for fear of placing the sutures too deep and causinga fecal fistula.
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Instead, dry gauze was placed around the exteriorized bowel near itstermination to prevent it from retracting into the peritoneal cavity. Theclamp was left across the proximal bowel end for at least 24 hours to assurean adequate seal between the parietal peritoneum and the bowel serosa.The colostomy wound was separated from the laparotomy wound by means ofwater-tight dressings, and in those instances where an associated bladderinjury was present necessitating a drainage of the space of Retzius, carewas taken to bring this out through a stab wound completely separated fromall other incisions.
The vogue, so popular in World War II, of dusting sulfa powder and/orantibiotics liberally into the peritoneal cavity was completely discontinuedduring the Korean war without deleterious effect. Because of the availabilityof antibiotics at all echelons of medical care in Korea, all casualtiesreceived penicillin at the same time they received their tetanus toxoidat battalion aid stations. Most of these casualties received 600,000 unitsof procaine penicillin as an initial dose but in the closing months ofthe war some question arose as to whether or not an effective blood concentrationcould be produced by this dosage and it was finally decided to increasethis initial dose to 1 million units of crystalline penicillin.
When casualties with penetrating abdominal wounds and intra-peritonealtrauma were received and operated upon at surgical hospitals in Korea,a routine part of their postoperative care consisted in the administrationof antibiotics. Almost without exception the parenteral use of penicillinwas continued, potentiated either by streptomycin or intravenous aureomycinor terramycin, depending on the specific preference of the surgeon. Whileearlier in the war the combination of penicillin and streptomycin was usedalmost to the exclusion of other antibiotics, during the last year of thewar more and more surgeons were shifting to the combination of penicillinand either aureomycin or terramycin. Without the availability of statisticaldata, it is impossible to state whether this produced any significant changein morbidity or mortality figures. Again some question arose as to theefficacy of the antibiotics used in the dosages administered. A researchteam in the area in the closing months of the war recommended larger dosagein order to obtain more effective blood concentrations of the various antibiotics.
Mistakes and Complications
Perhaps the commonest mistake seen in the handling of casualties withwounds of the rectum and rectosigmoid colon in the Korean Theater was lackof recognition that this type of wound was present. This oversight wasencountered most frequently in those casualties who had suffered retroperitonealtrauma so that the site of injury
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could not be seen unless the bowel was mobilized. Commonly this resultedin a pelvic or pararectal abscess, as frequently as not associated witha fecal fistula along the missile tract. In at least one instance knownto the author this resulted in a peritonitis with adhesions and repeatedobstructions of the small intestine.
Less frequent were those instances in which the pre-sacral drain wasnot placed deep enough in the pelvis or where by some oversight the pre-sacralspace was not drained at all. These errors commonly led to deep retroperitonealor pararectal suppuration so that adequate drainage had to be instituted.In a few instances, after débridement of the missile tract, drainshad been placed down to the rectum or rectosigmoid along these tracts.This type of drainage especially in those casualties in whom the woundof the colon was not sutured led to a particularly intractable sinus tractinfection with prolonged morbidity and convalescence.
Occasionally an inexperienced surgeon would bring at least the distalcolostomy loop out through some part of the laparotomy wound. Almost inevitablythis led to wound infection and breakdown. It was therefore felt to beabsolutely mandatory to insist not only that the colostomy be brought outthrough a separate incision but that it also be separated from the laparotomywound by some type of waterproof dressing.
The problem of adequate diversion of the fecal flow in wounds of therectum and rectosigmoid was not solved until midway through the Koreanwar. It was found that the term "diverting colostomy" meant differentthings to different surgeons. After several casualties with rectal woundswere found to have simple loop colostomies with no diversion of the fecalstream from the suture line in the bowel, it was felt necessary to insistthat diverting colostomies be so constructed that the two bowel ends wereseparated by 2 or more inches. General acceptance of this procedure decreasedmarkedly the incidence of fecal fistula resulting from spillage of fecalmaterial from the proximal into the distal bowel.
In the last three wars in which the United States has engaged, therehas been a progressive decline in the mortality rate among battle casualtiesreaching medical attention. The exact reason for this decline is hard topinpoint but most observers are in agreement that two of the more importantfactors are availability and utilization of various antibiotics, and speedy,nontraumatic evacuation of seriously wounded casualties to surgical hospitals.(The time lag between wounding and surgery of 58 casualties in World WarII was 15.2 hours as compared with 9.95 hours for 62 casualties in theKorean war.) Although statistics for this latest war have not yet beenanalyzed, it is probably logical to assume that along with the overall
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decrease in mortality there was probably also a decrease in the mortalityassociated with wounds of the rectum and rectosigmoid colon. Due creditfor the methods of handling this type of casualty must be given to thesurgeons of World War II who evolved so much of this routine of managementby trial and error based on experience.
References
Bradford, B., Jr., Battle, L. H., Jr., and Pasachoff,S. S.: Abdominal Surgery in an Evacuation Hospital. Ann. Surg. 123:32, 1946.
DeBakey, M. E., and Simeone, F. A.: Battle Injuries ofthe Arteries in World War II, Ann. Surg. 123: 534, 1946.
Department of the Army Technical Bulletin, TB Med. 147:12, 1951.
Haffner, H., and Lynn, R. B.: The Closure of Colostomies.Ann Surg. 127: 243, 1948.
Holder, H. G., and Lewison, E. F.: Management of ColostomiesPerformed for War Injuries. Ann. Surg. 126: 253, 1947.
Pearson, R. W., Tuhy, J. E., and Welch, C. S.: AbdominalSurgery in the Evacuation Hospital. Surgery 21: 1, 1947.
Poer, D. H.: The Management of Penetrating Abdominal Injuries.Ann. Surg. 127: 1092, 1948.
Sperling, L., Bosher, L. H., and Zimmerman, H.: Surgeryof War Wounds of the Abdomen. Surgery 21: 258, 1947.
Ziperman, H. H.: Acute Arterial Injuries in the KoreanWar. Ann. Surg. 139: 1, 1954.
