Management of Complex Perineal Injuries

Abstract

A retrospective study of 25 patients with severe soft tissue injuries to the perineum from the last 14 years was performed to determine the most appropriate management strategy for these problematic wounds. There were 20 (80%) men and 5 (20%) women with an average age of 29 years. Six (24%) patients died of exsanguination from their pelvic injuries within the first few hours of presentation. The remaining 19 patients were taken to the operating room for sigmoidoscopy, diverting colostomy, distal rectal washout, and radical debridement and irrigation of any devitalized tissue. Enteral access by jejunostomy was obtained in six patients. Most patients underwent daily debridement and pulsatile irrigation for at least three days, but usually longer, until the treating surgeon deemed the wound to be clean. None of the patients managed in this fashion developed pelvic sepsis. However, pelvic sepsis did occur in all four patients who did not receive early mandatory daily debridement. Total parenteral nutrition was required in eight patients because there were significant delays in the ability of these patients to resume oral intake. In most previously published series in which daily debridement was not performed, a pelvic sepsis rate of 40% to 80% was reported. Therefore, to optimize the clinical course and recovery from these complex wounds, we conclude that mandatory daily debridement with pulsatile irrigation should be instituted in conjunction with sigmoidoscopy, diversion of the fecal stream, distal rectal irrigation, enteral access, and initial radical debridement of devitalized tissue.

The use of vacuum assisted closure (VAC™) in soft tissue injuries after high energy pelvic trauma

“…The wound should be left open, and repeated surgical debridements of the injured tissue are recommended [12]. To prevent septic complications, similar surgical procedures are recommended in the case of complex perineal injuries as well [13][14][15][16][17]. Fecal diversion and rectal washout is recommended in the case of rectal injuries of open pelvic fractures [18][19][20].…”

A Case Report of Traumatic Perineal Degloving Injury

“…Perineal degloving injury involves avulsed perineal skin and subcutaneous tissues which can extend anteriorly into the lower quadrant of the abdomen, posteriorly into the perianal space and laterally into the buttocks and thighs [6]. Perineal trauma can be complicated by lower extremities and pelvic fractures, genitourinary injuries, anorectal lacerations and intra-abdominal injuries [2].…”

Colon and Rectal Injuries

“…A cystourethrogram or CT scan may demonstrate urethral or bladder extravasation, and the latter also may reveal a retroperitoneal hematoma. 176,178,181 Treatment options for penetrating injuries to the rectum include transanal repair of low injuries and celiotomy with repair of upper rectal injuries, with or without fecal diversion, distal rectal washout, and presacral drainage. Most surgeons agree that intraabdominal mobilization of the extraperitoneal rectum, deep in the pelvis, in search of a mid or low rectal injury that may be difficult to visualize and repair is probably not warranted.…”