肝周大静脉损伤救治策略的探讨  

Management of juxtahepatic venous injuries

作　　者：吴性江[1] 韩建民[1] 王新波[1] 丁威威[1] 黎介寿[1] 

机构地区：[1]南京军区南京总医院普通外科,210002

出　　处：《腹部外科》2011年第5期271-273,共3页Journal of Abdominal Surgery

摘　　要：目的探讨肝周大静脉损伤救治策略。方法2001年6月至2011年6月，急诊收治肝外伤病人152例，根据术前CT检查和术中探查，18例诊断为肝周大静脉损伤。人院时行创伤严重度评分（ISS）和肝损伤严重度评分。按照损伤控制性外科的原则，分别采用肝脏缝合、损毁肝切除、血管直接修补、纱布填塞等治疗，分析手术并发症和临床疗效。结果18例ISS和APACHE II评分分别为（31．6±4．8）分和（18．9±6．8）分，肝脏损伤分级为V或Ⅵ级。5例左肝、左肝静脉合并肝后下腔静脉（RVC）损伤行肝组织深部缝扎、损毁肝脏切除、血管修补术，无并发症。13例右肝和右肝静脉伴RVC或门静脉损伤者行肝组织深部缝扎、损毁肝脏切除、血管修补术，成功止血4例，术后并发胆漏1例；肝组织深部缝扎、损毁肝脏切除、血管修补和肝周纱布填塞9例，术后成功控制出血3例，进一步药物控制出血3例，肝动脉栓塞止血1例，再出血死亡2例；术后右膈下感染1例，多器官功能衰竭死亡2例。结论纱布填塞和血管修补是控制肝周血管损伤出血的有效方法，肝周纱布填塞符合严重肝外伤救治的损伤控制外科的原则， 特别适用于其它方法不能控制出血的严重肝外伤。Objective To evaluate the experience in the management of juxtahepatic venous injuries. Methods From June 2001 to June 2011, the charts of 18 patients with juxtahepatic venous injury diagnosed with liver injury by abdominal CT scan or operative findings in 152 patients with liver injuries were reviewed in detail. The severity of injury and liver injury was graded according to Injury Severity Score （IS.S）, APACHE II, liver injure score and CT grades of hepatic injury. To follow the principles of damage control surgery, the management for these patients mainly included deep hepatic suture, perihepatic packing, hepatectomy and direct repair of severed vessels. Overall complications and operative procedures were analyzed. Results ISS and APACHE II were 31.6 ± 4. 8 and 18. 9 ± 6. 8 respectively in 18 patients with V and VI score of liver injury. Five patients with injury of LHV, or LHV ＋ RVC were treated with deep hepatic suture, hepatectomy and direct repair of vessels. No complications were observed in the patients. Thirteen patients with injuries of RHV, RHV＋ RVC, RHV ＋ PV were treated with deep hepatic suture, hepatectomy, direct repair of severed vessels, or perihepatie packing. The bleeding was successfully controlled in 4 patients without perihepatic packing. Bile leaks occurred in one patient. The bleeding was treated in 9 patients with perihepatic packing. The bleeding was successfully controlled in 3 patients after operation, in 3 patients with further drug therapy, and in 1 patient with hepatic artery embolizatioru The bleeding was unsuccessfully controlled in 2 patients with coagulopathy. Postoperative subphrenic abscesses occurred in 1 patient. Two patients died of coagulopathy, persistent postoperative hemorrhage and 2 patients died of multiorgan failure. Conclusion Perihepatic packing and venous repair offer the effective method of stopping bleeding of juxtahepatic venous injuries. Perihepatic packing seems to follow the principles of damage control surgery for management of serious liver in

关 键 词：肝 创伤与损伤 血管 出血 外科纱布 止血 

分 类 号：R654.4[医药卫生—外科学]