EP682 - Gluteal Crease Laceration with Anal Sphincter Transection After Motor Vehicle Trauma

Purpose/Background: Anorectal trauma is uncommon in trauma centers and more often results from penetrating rather than blunt mechanisms. Anal sphincter injury may occur with either mechanism, but blunt injuries are typically associated with higher injury severity, increased morbidity, and concomitant pelvic fractures. We present a rare case of blunt anorectal trauma with complete external sphincter transection and partial internal sphincter disruption, grade 3C.

Methods/Interventions: A 55-year-old female presented as a pedestrian struck by a motor vehicle. Initial exam revealed a 20-centimeter (cm) laceration in the gluteal crease with 3 to 4 cm depth. The decision was made by the trauma team to take the patient to the operating room (OR) for wound exploration. Colorectal surgery was consulted intraoperatively due to concerns for external anal sphincter involvement. Intraoperatively, the laceration extended from the superior aspect of sacrum to the anus with complete transection of the external anal sphincter and partial disruption of the internal sphincter (Image 1). Proctoscopy and rigid sigmoidoscopy revealed no mucosal or rectal perforation. Following extensive washout, a complex sphincteroplasty was performed with horizontal mattress sutures to re-approximate the external anal sphincter followed by multilayer closure of the soft tissue, subcutaneous tissue, dermis and skin at the gluteal crease.

Results/Outcomes: Postoperatively the patient did well, with return of bowel function on postoperative day (POD) 2 and was discharged to inpatient rehabilitation on POD 7. At her follow up visit the laceration was noted to have opened on superior aspect, likely secondary to prolonged immobilization (long bone fractures of the right lower extremity) from orthopedic injuries, however the wound was clean with minimal slough and with no signs of infection. The sphincter repair remained intact, and the patient reported normal bowel function with no incontinence. Negative pressure wound therapy was placed to assist with closure and at the most recent visit the incision site was noted to be healed and completely intact. Complete healing after 9 weeks (Image 2).

Conclusion/Discussion: Blunt anorectal trauma is rare and typically occurs in the setting of polytrauma, which carries significant morbidity and often necessitates prolonged immobilization which can impair wound healing. We present a rare case of a pedestrian struck by a motor vehicle leading to a large gluteal crease laceration with complete external anal sphincter transection and partial internal sphincter disruption requiring sphincteroplasty and complex wound closure. Despite wound healing challenges from polytrauma and immobilization, definitive sphincter repair resulted in preserved continence and complete recovery, without the need for diversion.

Image 1
Intraoperative image of gluteal laceration with sphincter involvement
Image 2
Complete healing after 9 weeks