Background <p>Colonic trauma is a major clinical challenge particularly in resource-constrained conflict settings. The optimal surgical management remains debated. This study evaluated the factors influencing the surgical approach and the associated outcomes of colonic trauma in Yemen.</p> Methods <p>We conducted a prospective observational cohort study from May 2020 to April 2021, enrolling 90 consecutive patients with traumatic colonic injuries at three hospitals in Sana’a City. We collected data on patient demographics, injury characteristics (including AAST Colon Injury Scale grade), and postoperative outcomes. Statistical analyses were performed to compare patients managed with primary repair and colostomy.</p> Results <p>Primary repair was performed in 74 patients (82.2%) and colostomy was performed in 16 patients (17.8%). The decision to perform colostomy was significantly associated with gunshot wounds (<i>P</i> = 0.002), severe fecal contamination (<i>P</i> &lt; 0.001), and high-grade AAST injuries (<i>P</i> &lt; 0.001). Although there was no statistically significant difference in the overall mortality (5.4% for primary repair vs. 12.5% for colostomy; <i>P</i> = 0.279), procedure-specific morbidity was profound. The anastomotic leak rate in the subgroup that underwent resection with primary anastomosis was 55.6%. Furthermore, stoma-related complications affected 50% of patients in the colostomy group.</p> Conclusion <p>Primary repair is the predominant strategy for treating colonic trauma in this conflicting setting, and colostomy is reserved for high-risk patients. However, our findings revealed two critical context-specific dangers: an alarming failure rate for primary anastomosis in severe injuries, and a substantial morbidity burden from stoma formation. These results suggest that when a simple primary suture is not feasible, a damage-control approach with an end colostomy may be the safest option in an austere surgical environment.</p>