What are the repair options for a full-thickness colon injury during laparoscopic (minimally invasive) surgery?

From the Guidelines

Full thickness colon injury during laparoscopic surgery should be immediately repaired, with primary closure being the preferred option for small, clean injuries identified early, as it reduces morbidity and mortality 1. When managing full thickness colon injuries, the following key points should be considered:

• The size and location of the injury, as well as the degree of contamination, play a crucial role in determining the best course of action 1.
• For small defects (less than 1 cm), a single-layer or double-layer closure using 3-0 or 4-0 absorbable sutures like PDS or Vicryl in an interrupted fashion is appropriate 1.
• Larger defects may require a double-layer closure with an inner full-thickness layer and an outer seromuscular layer, while very large injuries or those with significant contamination might necessitate resection with primary anastomosis or temporary diversion with a colostomy 1.
• The decision between continuing laparoscopically or converting to open surgery depends on the surgeon's skill level, injury location, and degree of contamination, with laparoscopic exploration and repair being attempted in all patients with injuries not manageable by medical treatments 1.
• Thorough peritoneal lavage with warm saline should follow repair to reduce infection risk, and postoperatively, patients should receive broad-spectrum antibiotics, be kept NPO initially, and have a nasogastric tube placed to decompress the bowel 1. Some important considerations include:
• Early repair is crucial as delayed recognition increases morbidity due to fecal contamination 1.
• The integrity of the repair should be tested intraoperatively using air insufflation underwater or methylene blue instillation to ensure there is no leak before completing the procedure 1.
• The presence of extensive contamination, poor tissue viability, and poor patient’s general status could eventually lead to the decision of performing a fecal stream diversion 1.

From the Research

Full Thickness Colon Injury Repair Options

• Primary repair is a viable option for full thickness colon injuries, as supported by studies 2, 3, 4
• The decision to perform primary repair or diverting colostomy depends on various factors, including the location and severity of the injury, as well as the patient's overall condition 2, 5
• Laparoscopic primary repair is a safe and effective approach for treating colonic perforations, offering benefits such as shorter incision length, less blood loss, and shorter postoperative hospital stay 6

Factors Influencing Outcome

• Shock on admission, increased blood transfusion requirements, associated organ injury, and severity of the injury are associated with high mortality 2
• Delay before laparotomy, number of associated injuries, and Injury Severity Score (ISS) can also impact outcome 2
• The presence of fecal spillage, hypotension, and high ISS may increase the risk of complications, but do not necessarily preclude primary repair 3

Surgical Management

• Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries 5, 4
• Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia 5
• Liberal primary anastomosis should be considered in almost all patients with destructive colon injuries requiring resection, irrespective of risk factors 3