NARUS 2019: Rectal injury
However, at times, the rectal injury goes unrecognized during the procedure, or the injury is delayed and appears only after the operation. This can be due to a thermal injury, ischemia, local invasion, and it is also possible that there is a zero-muscular injury to the rectum which is not recognized intraoperatively and is incorporated into the anastomosis.
The most important therapeutic principle in these cases is prevention. Surgeons need to be aware of this operative risk, and patient selection is also important for the prevention of this complication. Patients after many previous surgeries, radiotherapy, chemotherapy, and other medical treatments, are at increased risk for rectal injuries, and this needs to be taken into account during the procedure. The dissection technique should be modified according to the intraoperative findings, and surgeons need to pay attention to the technical tools that are used intraoperatively, which can inadvertently cause injury. Both the surgeon and the assistant can easily cause this injury, and careful placement of the instruments should be upheld at all times. Another important tip is to use a rectal probe when dissection near the rectum. This helps to identify and protect the rectum. Lastly, in robotic prostatectomy, it is essential to stay as close as possible to the prostate, to avoid damaging the rectum.
Dr. Hemal concluded his talk summarizing some of the key elements of the required treatment of rectal injuries. When performing primary closure of the rectal injury, it is essential to do two separate suture layers, as it has been shown to result in fewer leaks. After completion of the closure, reinforcement with omental, or peritoneal or gracilis flap or perirectal flap should be performed. Testing of the repair with air insufflation in the rectum with fluid-filled pelvis is a mandatory step. It is advisable to leave the urinary Foley catheter for a longer time (approximately 14 days) and to perform a cystogram before removal of the catheter. Lastly, if the injury is recognized intraoperatively, calling a general surgery consultant to come and give his opinion on the required treatment, is always advisable.
Presented by: Ashok K Hemal, MD, Wake Forrest Baptist Health Urology, Winston-Salem, North Carolina
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at 2019 3rd Annual North American Robotic Urology Symposium (NARUS), February 8-9, 2018 - Las Vegas, Nevada, United States