Management of complex perineal injuries

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.