EP336 - Management of Blunt Rectal Hydrotrauma: A Case Report of Perineal Injury from a Jet Ski Accident

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Purpose/Background: Blunt colorectal traumas are infrequent clinical events that present significant challenges in diagnosis and surgical management. This unique case highlights the difficulties in the optimal treatment of complex rectal injuries. Despite their rarity, addressing rectal trauma complexities is essential for improving patient outcomes and advancing trauma care practices.

Methods/Interventions: A 24-year-old female with no past medical history was brought to the emergency room after falling off a jet ski and sustaining a perineal/perirectal injury from the jet ski thruster. Upon arrival, the patient was initially hemodynamically unstable, with evidence of peritonitis on abdominal exam and a large perineal injury with soft tissue protruding from the anus. After resuscitation in the trauma bay, she was stabilized and underwent imaging to evaluate for other traumatic injuries. CT scan showed large amount of pneumoperitoneum and ascites as well as extraperitoneal perianal and presacral emphysema, consistent with perforation. She underwent an exploratory laparotomy and perineal wound exploration, revealing a large amount of seawater in the abdomen. A burst injury of the sigmoid colon with a 12 cm linear laceration extending anteriorly to the peritoneal reflection was identified, and the mucosa within this segment had dissected away from the muscular wall. A healthy proximal sigmoid colon was divided with a stapler and brought up as an end colostomy. The segment of colon with mucosal avulsion appeared viable, therefore an attempted primary repair of the injured colon was performed, closing the laceration after excising the detached mucosa. Anorectal exam including rigid proctoscopy was performed. The perineal laceration involved the pelvic floor muscles and perineal skin extending back to the coccyx. The pelvic floor including the sphincter complex was repaired primarily and a penrose drain was placed lateral to this repair. She returned to the operating room 5 days later due to failure of her primary colonic repair. A low anterior resection was performed to the peritoneal reflection and the posterior rectal defect was drained transanally with a large mushroom catheter. Her fascia was closed, but the skin left open where a VAC dressing was applied subsequently. She recovered from her acute injury and 29 months later subsequently underwent a robotic colostomy closure with diverting ileostomy, followed by eventual ileostomy closure. At long-term follow-up, the patient recovered well with normal bowel function and good control, having 1-2 bowel movements per day without incontinence or leakage of stool or gas.

Results/Outcomes: Non applicable

Conclusion/Discussion: Blunt rectal trauma can result in significant morbidity, but with timely and appropriate management, favorable functional outcomes are achievable. Based on our experience, optimal management includes exploratory laparotomy, resection of the injured bowel, sphincter and pelvic floor repair, and creation of a colostomy with delayed reconstruction. These interventions can contribute to improved long-term outcomes for patients with complex anorectal trauma.