手术治疗严重肝外伤36例体会(1)
[摘要] 目的：探讨严重肝外伤的手术方式和治疗效果。方法：回顾性分析1993年5月~2006年5月我院手术治疗的严重肝外伤患者36例，AAST Ⅲ级者17例，Ⅳ级者14例，Ⅴ级者5例。结果：采用肝破裂清创缝合止血15例，清创加带蒂大网膜、明胶海绵填塞缝合9例，清创性肝切除7例，纱布填塞3例，肝后下腔静脉、肝静脉主干缝合修补2例。手术治愈29例，治愈率为80.56%，死亡7例，死亡率为19.44%，死于多器官功能障碍综合征(MODS)3例、败血症1例、失血性休克1例、继发性出血2例。术后出现并发症11例(发生率为30.56%)，其中，并发膈下感染4例，肝脓肿2例，胆瘘1例，再出血2例，MODS 2例。结论：手术是治疗严重肝外伤的有效方法，手术方式应根据具体情况合理选择，加强对合并伤及术后并发症的管理对降低严重肝外伤的死亡率具有重要意义。
[关键词] 肝脏；创伤和损伤；手术
[中图分类号]R657.3 [文献标识码]C [文章编号]1673-7210(2008)05(c)-180-02
, 百拇医药
Experience of operative treatment for 36 cases of patients with severe liver trauma
WANG Yang, LI Hong, DU Bing-li
(Department of Pathology, the First Hospital of Huairou District, Beijing 101400, China )
[Abstract] Objective: To explore the methods of operation and the effects of treatment for severe liver trauma. Methods: 36 cases of patients with severe liver trauma with operative treatmant in our hospital from May 1993 to May 2006 were studied retrospectively.According to the AAST Grading of Liver Injuries,17 cases of grade Ⅲ,14 cases of grade Ⅳ and 5 cases of grade V. Results: Different operations were performed as following：debridement suture of hepatorrhexis in 15 cases, debridement with greater omentum or gelatin sponge packing in 9 cases,resectional debridement in 7 cases,gauzes packing in 3 cases,suture of inferior vena cava in posterior segment of liver and hepatic vein stem in 2 cases.29 cases were cured(cure rate was 80.56%),7 cases died(mortality was 19.44%).The causes of death were multiple organ dysfunction syndrome(MODS) in 3 cases, septemia in 1 case,hemorrhagic shock in 1 case and secondary bleeding after operation in 3 cases. Postoperative complications were 11 cases(incidence rate was 30.56%),including 4 cases of subphrenic infection,2 cases of liver abscess,1 case of biliary fistula,2 cases of reheamorrhagia and 2 cases of MODS. Conclusion: Operation is the effective treatment for severe liver trauma.The methods of operation should be choosed correctly according to the specific conditions.It is significant for reducing the mortality of severe liver trauma to strengthen the management of associated injury and postoperative complications.
, 百拇医药
[Key words] Liver; Wounds and injuries; Operation
肝外伤是外科常见的创伤性急腹症，近年来其治疗虽已取得重大进展，但严重肝外伤仍因伤情复杂、病情危重且易合并多脏器损伤而导致手术处理困难，病死率高。我们于1993年5月~2006年5月共收治严重肝外伤(severe liver trauma，SLT)患者36例，就其术中管理及手术方式的选择进行回顾性分析，以进一步探讨严重肝外伤的有效手术治疗措施。
1资料与方法
1.1一般资料
本组36例，男27例，女9例，年龄12～68(37.51±6.72)岁。闭合性损伤29例，开放性损伤7例。致伤原因：车祸伤21例，坠落伤7例，刀刺伤5例，挤压伤3例。单纯性肝破裂10例，合并其他脏器损伤17例，其中，肋骨骨折8例次，血气胸5例次，肺挫伤4例次，脾破裂5例次，肠管破裂3例次，肾破裂及挫伤1例次，腹膜后血肿3例次，颅脑损伤4例次，四肢骨折5例次，骨盆骨折1例次。合并肝后下腔静脉损伤1例，合并门静脉及肝静脉主干损伤2例。致伤部位：右半肝21例，左半肝8例，左、右肝均累及7例。受伤至手术时间为30 min～9 h，中位时间4.21 h，入院时均伴不同程度的休克[血压为(50～90)/(0～50) mmHg]。
, 百拇医药
1.2诊断及分级标准
本组36例肝外伤患者均根据询问受伤经过、进行全面体检，经诊断性腹腔穿刺、B超或CT检查确诊。根据术中探查所见，肝损伤的程度按照美国创伤外科协会(American Association for the Surgery of Trauma，AAST)制定的肝外伤分级标准[1]确定，AAST分级Ⅲ级以上者为SLT，本组Ⅲ级17例，Ⅳ级14例，Ⅴ级5例。
1.3手术方式
本组术前均存在血流动力学不稳定现象，手术指征明确。根据肝损伤实际情况决定术式：肝破裂清创缝合止血15例，清创加带蒂大网膜、明胶海绵填塞缝合9例，清创性肝切除7例，纱布填塞3例，肝后下腔静脉、肝静脉主干缝合修补2例，同时行胆总管探查“T”管引流术7例。, 百拇医药(王 杨 李 宏 杜秉利)
[关键词] 肝脏；创伤和损伤；手术
[中图分类号]R657.3 [文献标识码]C [文章编号]1673-7210(2008)05(c)-180-02
, 百拇医药
Experience of operative treatment for 36 cases of patients with severe liver trauma
WANG Yang, LI Hong, DU Bing-li
(Department of Pathology, the First Hospital of Huairou District, Beijing 101400, China )
[Abstract] Objective: To explore the methods of operation and the effects of treatment for severe liver trauma. Methods: 36 cases of patients with severe liver trauma with operative treatmant in our hospital from May 1993 to May 2006 were studied retrospectively.According to the AAST Grading of Liver Injuries,17 cases of grade Ⅲ,14 cases of grade Ⅳ and 5 cases of grade V. Results: Different operations were performed as following：debridement suture of hepatorrhexis in 15 cases, debridement with greater omentum or gelatin sponge packing in 9 cases,resectional debridement in 7 cases,gauzes packing in 3 cases,suture of inferior vena cava in posterior segment of liver and hepatic vein stem in 2 cases.29 cases were cured(cure rate was 80.56%),7 cases died(mortality was 19.44%).The causes of death were multiple organ dysfunction syndrome(MODS) in 3 cases, septemia in 1 case,hemorrhagic shock in 1 case and secondary bleeding after operation in 3 cases. Postoperative complications were 11 cases(incidence rate was 30.56%),including 4 cases of subphrenic infection,2 cases of liver abscess,1 case of biliary fistula,2 cases of reheamorrhagia and 2 cases of MODS. Conclusion: Operation is the effective treatment for severe liver trauma.The methods of operation should be choosed correctly according to the specific conditions.It is significant for reducing the mortality of severe liver trauma to strengthen the management of associated injury and postoperative complications.
, 百拇医药
[Key words] Liver; Wounds and injuries; Operation
肝外伤是外科常见的创伤性急腹症，近年来其治疗虽已取得重大进展，但严重肝外伤仍因伤情复杂、病情危重且易合并多脏器损伤而导致手术处理困难，病死率高。我们于1993年5月~2006年5月共收治严重肝外伤(severe liver trauma，SLT)患者36例，就其术中管理及手术方式的选择进行回顾性分析，以进一步探讨严重肝外伤的有效手术治疗措施。
1资料与方法
1.1一般资料
本组36例，男27例，女9例，年龄12～68(37.51±6.72)岁。闭合性损伤29例，开放性损伤7例。致伤原因：车祸伤21例，坠落伤7例，刀刺伤5例，挤压伤3例。单纯性肝破裂10例，合并其他脏器损伤17例，其中，肋骨骨折8例次，血气胸5例次，肺挫伤4例次，脾破裂5例次，肠管破裂3例次，肾破裂及挫伤1例次，腹膜后血肿3例次，颅脑损伤4例次，四肢骨折5例次，骨盆骨折1例次。合并肝后下腔静脉损伤1例，合并门静脉及肝静脉主干损伤2例。致伤部位：右半肝21例，左半肝8例，左、右肝均累及7例。受伤至手术时间为30 min～9 h，中位时间4.21 h，入院时均伴不同程度的休克[血压为(50～90)/(0～50) mmHg]。
, 百拇医药
1.2诊断及分级标准
本组36例肝外伤患者均根据询问受伤经过、进行全面体检，经诊断性腹腔穿刺、B超或CT检查确诊。根据术中探查所见，肝损伤的程度按照美国创伤外科协会(American Association for the Surgery of Trauma，AAST)制定的肝外伤分级标准[1]确定，AAST分级Ⅲ级以上者为SLT，本组Ⅲ级17例，Ⅳ级14例，Ⅴ级5例。
1.3手术方式
本组术前均存在血流动力学不稳定现象，手术指征明确。根据肝损伤实际情况决定术式：肝破裂清创缝合止血15例，清创加带蒂大网膜、明胶海绵填塞缝合9例，清创性肝切除7例，纱布填塞3例，肝后下腔静脉、肝静脉主干缝合修补2例，同时行胆总管探查“T”管引流术7例。, 百拇医药(王 杨 李 宏 杜秉利)