Penetrating Anorectal Injury

An Unrecognized Hazard for Surgeons

A. R. DENNISON, F . R . C . S . , B. J. B R I T T O N , M . S . , F . R . C . S .

Dennison AR, Britton BJ. Penetrating anorectal injury: an unrecog- From the Nu[Jield Department of Surgery,
nized hazard for surgeons. Dis Colon Rectum 1984;27:624-625. University of OxJord, John RadcliJJe Hospital,
Accidental anorectal injuries are becoming less common. This case,
Headington, Oxford, England
where impalement of the anorectal region by the shaft of a stool
occurred to a junior surgeon at work, illustrates a previously unrecog- right seminal vesicle. The rectal mucosa seemed intact on sigmoido-
nized menace. [Key words: Impalement, anorectum, stool] scopy. A urinary catheter passed easily into the bladder and the 100 ml
of urine obtained did not contain blood.
In view of the large force needed to create the injury and the risk of
IMPALEMENT INJURIES Of t h e a n o r e c t u m m a y b e c a u s e d infection in the hematoma, a colostomy was felt essential. The torn
b y a v a r i e t y of a c c i d e n t a l , i a t r o g e n i c , a n d s e l f - i n d u c e d muscle fibers in the perianal wound were approximated with 2-0
causes.l,2 T h e y a r e a l w a y s l i a b l e t o i n v o l v e o t h e r i n t r a - chromic catgut and the remainder of the wound was packed. The
abdomen was opened through an incision in the left iliac fossa and a
abdominal organs, particularly the bladder, urethra, and limited laparotomy confirmed that there was no rectal perforation, but
v a g i n a a n d , d e p e n d i n g o n t h e d i m e n s i o n s of t h e i m p a l - the perivesical hematoma could be palpated. Nevertheless, a left iliac
ing object and the force involved, the pelvic peritoneum, fossa loop colostomy was constructed and the distal bowel was com-
pletely cleared of feces by a thorough saline washout on the operating
small intestine, sigmoid colon, and pelvic splanchnic table.
n e r v e s m a y a l s o b e a t risk. 3 W e p r e s e n t a n u n u s u a l c a s e The postoperative course was uneventful. The patient was dis-
w h e r e a n a n o r e c t a l i n j u r y o c c u r r e d to a y o u n g s u r g e o n charged on the tenth day and returned two months later to have the
colostomy closed, at which time the perianal wound was fully healed.
assisting at an operation. Six months later bladder and sexual functions are normal, but he has
difficulty controlling flatus, especially when straining, and during one
Report of a Case episode of diarrhea he has suffered from incontinence of feces.
A 26-year-old doctor was assisting at a neurosurgical operation when
it became necessary to use the binocular operating microscope. The Discussion
stools on which all the surgeons were seated then required reposition- Impalement injuries can be caused by a number of
ing. They were of the standard stainless steel swivel type and screwed
up and down to allow height adjustment. In some of these stools it o b j e c t s o t h e r t h a n t h e t o p s o f o p e r a t i n g r o o m stools. F o x ,
appears that the top is able to completely unscrew from its base. When i n 1951, d e s c r i b e d a b o y w h o w a s h i g h j u m p i n g a n d fell
the junior surgeon replaced his weight, the two halves separated, the onto the bar, which broke and entered the perineum. 4
top falling onto the floor, with the shaft uppermost. He then fell
backward, resulting in his impalement upon the unprotected shaft of T h o m a s , i n 1953, r e p o r t e d t w o cases; t h e first w a s a b o y
the top of the stool; he was aware that the shaft had entered the anus and who jumped over a cricket stump, which entered the
immediately experienced great pain and tenesmus. Subsequent exami- a n u s , a n d t h e s e c o n d w a s a m a n w h o fell f r o m a l a d d e r
nation, although limited by discomfort, showed obvious trauma to the
left buttock and anal canal. Fifteen minutes later he began to develop o n t o a s p i k e d w o o d e n l a t t i c e fence. 5 G a b r i e l , i n 1963,
some discomfort in the right iliac fossa, the tenesmus persisted, and he d e s c r i b e d a c a s e s i m i l a r to o u r s i n w h i c h a y o u n g g i r l w a s
was unable to pass urine. He was admitted to a surgical ward and, at
jumping from one wooden chair to another when the
that time, vital signs were normal. Intravenous infusion was started,
antibiotics were given, and he was taken to a theatre area. While chair broke and the leg entered the anus. 6
waiting there, he developed increasing abdominal discomfort, rebound These examples illustrate, however, that although
lower abdominal tenderness, and his bowel sounds disappeared. traumatic mechanisms form only a small percentage of
In the lithotomy-Trendelenburg position it was possible to examine
the perianal region. There were obvious signs of trauma to the left a n o r e c t a l i n j u r i e s , t h e t y p e o f o b j e c t , t h e l a r g e force, a n d
buttock, with a graze that started over the left ischial tuberosity and the often vague history make these injuries dangerous to
extended to the anal margin. There was a 3-cm wound of the perianal m a n a g e . T h e p o t e n t i a l l y l e t h a l n a t u r e o f i n j u r y to o t h e r
skin in the left posterolateral position, with a tear about 1 cm long in
the lowermost fibers of the anal sphincter. The injury then crossed to a b d o m i n a l o r g a n s is a l w a y s p r e s e n t a n d m u s t n o t b e
the right anterior wall of the rectum where there was a palpable u n d e r e s t i m a t e d . T h e C h i n e s e r e c o g n i z e d t h i s 2000 y e a r s
hematoma, about the size of an orange, around the prostate and the ago and, more recently, impalement was used in England
to a v o i d e x t e r n a l e v i d e n c e i n t h e e x e c u t i o n o f c e r t a i n
Received for publication February 1, 1984.
Address reprint requests to Mr. Dennison: Nuffield Department of dignitaries. 7
Surgery, John Radcliffe Hospital, Oxford OX3 9DU, England. Correct management reduces the morbidity and mor-

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Number 9 PENETRATING ANORECTAL INJURY 625

tality from these injuries. D u r i n g the first W o r l d War, u p o n each i n d i v i d u a l p a t i e n t as well as the skill a n d
w h e n the m e t h o d of treatment was p r i m a r y closure of experience of the s u r g e o n involved, xx,12
rectal w o u n d s , the m o r t a l i t y was 60 per cent. I n the
second W o r l d War, the preferred t r e a t m e n t was p r o x i m a l References
colostomy a n d the m o r t a l i t y was reduced by 50 per cent.
I n the Korean War, further i m p r o v e m e n t was achieved 1. Nelson RL, Abcarian H, Prasad ML. Iatrogenic perforation of the
colon and rectum. Dis Colon Rectum 1982;25:305-8.
a n d the m o r t a l i t y was o n l y 15 per cent. T h i s was due 2. Barone JE, Sohn N, Nealon TF Jr. Perforations and foreign bodies
largely to r a p i d t r a n s p o r t of the i n j u r e d to hospitals, as of the rectum: report of 28 cases. Ann Surg 1976;184:601-4.
well as i m p r o v e m e n t s i n i n resuscitative procedures. As a 3. Johnson PA. Rectal impalement with perforation of the bladder.
Br Med J 1971;2:748-9.
consequence, p r o x i m a l colostomy became p o p u l a r i n 4. Fox PF. Impalement perforations of the perineum. Am J Surg 1951;
civilian practice.S, 9 82:511-6.
N o t everyone agrees that p r o x i m a l colostomy is always 5. Thomas LP. Impalement of the rectum. Lancet 1953;2:704-5.
6. Gabriel WB. Injuriesof the rectum. In: The principles and practice
necessary i n c i v i l i a n practice and, i n retrospect, i n o u r of rectal surgery.5th ed. London: HK Lewis, 1963,chapt 15:407-9.
case the necessity for a colostomy was n o t obvious. O n the 7. Furste W, Knoernschild H. Perforation of the distal large intestine
other h a n d , if the pelvic h e m a t o m a h a d become infected, produced by intraluminal traumas. Am J Surg 1980;99:665.
8. Samhouri F, Grodsinsky C, Fox T Jr. The managementof colonic
p e r h a p s because a small p e r f o r a t i o n was n o t recognized and rectal injuries. Dis Colon Rectum 1978;21:426-9.
d u r i n g the first operation, t h e n the presence of the colos- 9. Grablowsky OM, Gage JO, Ray JE, Hanley PH. Traumatic
tomy w o u l d have m i n i m i z e d the c o m p l i c a t i o n s a n d made colonic and rectal injuries. Dis Colon Rectum 1973;16:296-9.
10. Haas PA, Fox TA Jr. Civilian injuries of the rectum and anus. Dis
m a n a g e m e n t easier.I~
Colon Rectum 1979;22:17-23.
M a n a g e m e n t of the p e r i a n a l w o u n d is also controver- 11. Bartizal JR, Boyd DR, Folk FA, Smith D, Lescher TC, Freeark RJ.
sial. All will agree that complete removal of all dead a n d A critical reviewof management of 392 colonic and rectal injur-
ies. Dis Colon Rectum 1974; 17:313-8.
d y i n g tissue is the first essential. H o w often the a n a l 12. Abcarian H, Lowe R. Colon and rectal trauma. Surg Clin North
s p h i n c t e r s h o u l d be p r i m a r i l y repaired m u s t d e p e n d Am 1978;58:519-36.