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Successful Urologic Management of Inadvertent Rectal Injuries
Vol. 106, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
SUCCESSFUL UROLOGJC MANAGEMENT OF INADVERTENT RECTAL IN JURIES A. P. McLAUGHLIN, III*
DAVID L. McCULLOUGH
AND
From the Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
The potential complications resulting f~om rectal injury during urologic operations include recto-urinary tract fistulas, which may be accompanied by lethal pelvic sepsis. These morbid problems commonly require proximal diversion of the fecal stream and pelvic drainage, which are physically and emotionally incapacitating for patients. Besides being life-threatening, these complications frequently commit a patient to a long, unpleasant convalescence, including one or more additional operations. We have developed a technique using sound physiologic and surgical principles for the safe management of occasional and inadvertent rectal injury. Two cases will be presented as illustrations of this technique. SURGICAL TECHNIQUE
The wound is irrigated with 7'2 per cent neomycin solution and the edges of the rectal perforation are sharply debrided (fig. 1). Inverting 3-zero chromic catgut sutures, which include the mucosa and muscularis, are placed every 3 to 4 mm. (fig. 2, A). A second layer of interrupted chromic catgut sutures is placed through the muscularis of the bowel wall to complete a 2-layer closure (fig. 2, B). Lembert's sutures of 4-zero silk are tied over a piece of fat to form a protective patch over the closed rectotomy site (fig. 2, C). This patch graft is similar to the technique used in the plication of perforated duodenal ulcers. Penrose drains are placed adjacent to the suture line. Adequate exposure to perform this closure is easily obtained. The final maneuver is extremely important. After application of a sterile dressing, dilation of the rectal sphincters is carried out with the middle 2 fingers of each hand. The surgeon's fingers are inserted through the anal orifice, which is gently distracted to a diameter of 3 inches (fig. 3).
tuted for 1 week. A suitable broad-spectrum antibiotic is given parenterally. The Penrose drains are advanced 4 days postoperatively and removed the following day, unless drainage is profuse. Constipating regimens are not required. The patient may be discharged from the hospital 7 to 10 days postoperatively. CASE MATERIAL
Case 1. S. A., MGH 86 91 57, a 61-year-old white man, entered the hospital on January 6, 1970 for urinary retention. An inadvertent rectotomy was made while exposing the prostate for a perineal prostatectomy. The rectotomy was repaired as described and the wound was drained. A suprapubic prostatectomy was performed and the patient left the hospital 7 days postoperatively continent of stool and feces. Case 2. S. P., MGH 148 91 59, an SO-year-old white man, entered the hospital with urinary frequency. A large rectotomy was made during a simple perineal prostatectomy. After closure and drainage a retropubic prostatectomy was performed. Convalescence was complicated by an abdominal wound infection. There was no perineal drainage, fecal incontinence or other complications resulting from the inadvertent rectotomy. DISCUSSION
Patients are placed on liquid diets for at least 3 days and oral sulfathaladine therapy is insti-
Inadvertent rectotomy is a potentially serious complication. It may not be an infrequent event, particularly when a resident is learning to do a perineal operation. Discovery of this iatrogenic injury often makes the surgeon apprehensive and confused about choosing the proper therapeutic course which will avert subsequent fistula formation and sepsis. Prompt diversion of the fecal stream through a proximal colostomy is safe but it subjects the patient to further operative procedure along with other unnecessary problems. Rectal irrigation with neomycin and drainage via an indwelling rectal tube has been suggested and presented as an effective regimen. 1 This
Accepted for publication December 1970. * Current address: University Hospital of San Diego, San Diego, California 92103.
1 Allen, T. D.: Management of inadvertent rectal injury: report of a technique used in two cases. J. Urol., 99: 69, 1968.
POSTOPERATIVE CARE
878
SUCCESSFUL UROLOGIC MANAGEMENT OF INADVERTENT RECTAL INJURIES
879
the suture line against disruption or leakage. This technique is commonly used by abdominal surgeons when performing anterior colon resections for this express purpose. Dilatation results in decreased sphincter tone and soft, frequent
Levalor ani m. Sphincter ani
Anus
FIG. 1. Debrided rectal injury site
A
FIG. 3. Manual dilation of sphincter
B
I
I ·....
\l .
•
1'1
·t
/
l~~~
FIG. 2. Method of rectal closure
requires prolonged bed rest with the possibility of pulmonary embolism. Absorption of toxic amounts of neomycin through the rectal mucosa is also a possibility. The presence of a large tube possibly abutting against the rectal closure and continuous bathing of the rectotomy incision with fluid also do not appeal to us. Anal dilatation will suecessfully prevent high intraluminal pressure in the rectum, which effectively decompresses the bowel and protects
bowel movements. For the first few postoperative days mild fecal incontinence is common. As the sphincter regains its tone in 3 to 4 weeks, bowel habits return to normal. However, successful decompression of high intrarectal pressure has been achieved during this brief period when healing of the rectal closure is so important. Rectal injury during a perinea! operation will continue to be a major complication. We routinely use preoperative oral antibiotic prepara-
880
MCLAUGHLIN AND MCCULLOUGH
tion of the bowel together with cleansing enemas prior to an elective perineal operation as prophylactic measures. When obvious rectal injury occurs or is found at the conclusion of an operation during routine inspection of the rectum, our method of management may be used as a safeguard against subsequent complications.
SUMMARY
Our management of inadvertent rectal injuries is described. Our primary suture-line closure is buttressed by a free fat graft and protected from high intraluminal rectal pressures by forceful anal sphincter dilation. Adjunctive therapeutic measures are described.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
SUCCESSFUL UROLOGJC MANAGEMENT OF INADVERTENT RECTAL IN JURIES A. P. McLAUGHLIN, III*
DAVID L. McCULLOUGH
AND
From the Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
The potential complications resulting f~om rectal injury during urologic operations include recto-urinary tract fistulas, which may be accompanied by lethal pelvic sepsis. These morbid problems commonly require proximal diversion of the fecal stream and pelvic drainage, which are physically and emotionally incapacitating for patients. Besides being life-threatening, these complications frequently commit a patient to a long, unpleasant convalescence, including one or more additional operations. We have developed a technique using sound physiologic and surgical principles for the safe management of occasional and inadvertent rectal injury. Two cases will be presented as illustrations of this technique. SURGICAL TECHNIQUE
The wound is irrigated with 7'2 per cent neomycin solution and the edges of the rectal perforation are sharply debrided (fig. 1). Inverting 3-zero chromic catgut sutures, which include the mucosa and muscularis, are placed every 3 to 4 mm. (fig. 2, A). A second layer of interrupted chromic catgut sutures is placed through the muscularis of the bowel wall to complete a 2-layer closure (fig. 2, B). Lembert's sutures of 4-zero silk are tied over a piece of fat to form a protective patch over the closed rectotomy site (fig. 2, C). This patch graft is similar to the technique used in the plication of perforated duodenal ulcers. Penrose drains are placed adjacent to the suture line. Adequate exposure to perform this closure is easily obtained. The final maneuver is extremely important. After application of a sterile dressing, dilation of the rectal sphincters is carried out with the middle 2 fingers of each hand. The surgeon's fingers are inserted through the anal orifice, which is gently distracted to a diameter of 3 inches (fig. 3).
tuted for 1 week. A suitable broad-spectrum antibiotic is given parenterally. The Penrose drains are advanced 4 days postoperatively and removed the following day, unless drainage is profuse. Constipating regimens are not required. The patient may be discharged from the hospital 7 to 10 days postoperatively. CASE MATERIAL
Case 1. S. A., MGH 86 91 57, a 61-year-old white man, entered the hospital on January 6, 1970 for urinary retention. An inadvertent rectotomy was made while exposing the prostate for a perineal prostatectomy. The rectotomy was repaired as described and the wound was drained. A suprapubic prostatectomy was performed and the patient left the hospital 7 days postoperatively continent of stool and feces. Case 2. S. P., MGH 148 91 59, an SO-year-old white man, entered the hospital with urinary frequency. A large rectotomy was made during a simple perineal prostatectomy. After closure and drainage a retropubic prostatectomy was performed. Convalescence was complicated by an abdominal wound infection. There was no perineal drainage, fecal incontinence or other complications resulting from the inadvertent rectotomy. DISCUSSION
Patients are placed on liquid diets for at least 3 days and oral sulfathaladine therapy is insti-
Inadvertent rectotomy is a potentially serious complication. It may not be an infrequent event, particularly when a resident is learning to do a perineal operation. Discovery of this iatrogenic injury often makes the surgeon apprehensive and confused about choosing the proper therapeutic course which will avert subsequent fistula formation and sepsis. Prompt diversion of the fecal stream through a proximal colostomy is safe but it subjects the patient to further operative procedure along with other unnecessary problems. Rectal irrigation with neomycin and drainage via an indwelling rectal tube has been suggested and presented as an effective regimen. 1 This
Accepted for publication December 1970. * Current address: University Hospital of San Diego, San Diego, California 92103.
1 Allen, T. D.: Management of inadvertent rectal injury: report of a technique used in two cases. J. Urol., 99: 69, 1968.
POSTOPERATIVE CARE
878
SUCCESSFUL UROLOGIC MANAGEMENT OF INADVERTENT RECTAL INJURIES
879
the suture line against disruption or leakage. This technique is commonly used by abdominal surgeons when performing anterior colon resections for this express purpose. Dilatation results in decreased sphincter tone and soft, frequent
Levalor ani m. Sphincter ani
Anus
FIG. 1. Debrided rectal injury site
A
FIG. 3. Manual dilation of sphincter
B
I
I ·....
\l .
•
1'1
·t
/
l~~~
FIG. 2. Method of rectal closure
requires prolonged bed rest with the possibility of pulmonary embolism. Absorption of toxic amounts of neomycin through the rectal mucosa is also a possibility. The presence of a large tube possibly abutting against the rectal closure and continuous bathing of the rectotomy incision with fluid also do not appeal to us. Anal dilatation will suecessfully prevent high intraluminal pressure in the rectum, which effectively decompresses the bowel and protects
bowel movements. For the first few postoperative days mild fecal incontinence is common. As the sphincter regains its tone in 3 to 4 weeks, bowel habits return to normal. However, successful decompression of high intrarectal pressure has been achieved during this brief period when healing of the rectal closure is so important. Rectal injury during a perinea! operation will continue to be a major complication. We routinely use preoperative oral antibiotic prepara-
880
MCLAUGHLIN AND MCCULLOUGH
tion of the bowel together with cleansing enemas prior to an elective perineal operation as prophylactic measures. When obvious rectal injury occurs or is found at the conclusion of an operation during routine inspection of the rectum, our method of management may be used as a safeguard against subsequent complications.
SUMMARY
Our management of inadvertent rectal injuries is described. Our primary suture-line closure is buttressed by a free fat graft and protected from high intraluminal rectal pressures by forceful anal sphincter dilation. Adjunctive therapeutic measures are described.