Stomach, Small Bowel, and Colon Injuries: Techniques

Gastrointestinal (GI) injuries involving the stomach, small bowel, and colon are common. They occur more often as a result of penetrating than blunt abdominal trauma. Proper diagnosis requires a high index of suspicion as missed injuries lead to increased morbidity and mortality. Physical examination findings along with selective radiographic imaging can help guide decision-making. Should exploration be required in the hemodynamically unstable patient, early initiation of damage control should be considered, and significant focus should be placed on prevention of the “lethal triad” of acidosis, coagulopathy, and hypothermia. The surgeon needs to be mindful of this lethal triad while quickly working to obtain optimal exposure in order to stop hemorrhage, control contamination, and identify injuries—with patient physiology being the key driver of decision-making when considering definitive repair. In general, gastric injuries can usually be repaired in either single- or two-layered fashion. Larger areas of injury may require a stapled, nonanatomic resection. When considering repair options of the small bowel and colon, one can choose from primary repair, resection with hand-sewn or stapled anastomoses, or resection and temporarily leaving the two ends in discontinuity. Alternatively, ostomies of the small bowel or colon can be created at the either primary or subsequent second-look laparotomy. Should a second-look laparotomy be desired, temporary abdominal closure devices allow for restoration of normal physiology through continued resuscitation and rewarming of the patient prior to definitive repair.