Surgical treatment of liver injury

Liver injury is a common and serious injury in abdominal trauma, which accounts for about 25%1. The mortality rate of simple liver injury wa

Content

Liver injury is a common and serious injury in abdominal trauma, which accounts for about 25%1. The mortality rate of simple liver injury was lower (9%), and the complication rate of complicated liver injury complicated with multiple organ injury was as high as more than 2. For the treatment of liver trauma, in the past has been used in the Second World War in the late establishment of the treatment of liver trauma, that is, once the diagnosis of liver trauma, should be early surgical treatment. The surgical procedures included simple suture, debridement, gauze packing, hepatic artery ligation and hepatectomy and 3~4. But since 70s, due to trauma and surgical treatment center to strengthen the therapeutic room (SICU) generally established, especially the development of imaging diagnosis in recent 10 years, B type ultrasonography and CT, revolutionized the methods of therapy for hepatic trauma and the degree of liver injury, light, hemodynamic stability, has been advocated by non operation the treatment method and successful 4~5. Based on the clinical experience of our hospital, we summarize the surgical treatment of liver injury.

clinical data

1 general data: in our hospital from January 1989 to October 1998, a total of 45 patients with liver injury were treated in our hospital from January to December in. Among them, there were male and female, with a maximum age of 59 years and a minimum of 15 years old, with an average age of 32 years. The causes of injury for extrusion, collision, crash, crash and stab. Open liver injury was found in 6 cases (13.3%) and closed liver injury in 39 cases (86.7%). Simple liver injury occurred in 30 cases (66.7%), complicated liver injury in 15 cases (33.3%). Liver injury severity classification standards 6 see Table 1, the combined injury condition table two.

Table 1 grading criteria of liver injury

Grade # injury

I. hematoma subcapsular, non expandable, < 10% liver surface

Laceration capsule laceration, no bleeding, depth < 1cm

II. hematoma of the liver subcapsular, non expandable, 10%~50% liver surface; or in the liver parenchyma, diameter < 2cm, non scalability

Laceration capsule laceration, active bleeding, depth 1~3cm, long < 10cm

III hematoma subcapsular liver, > 50% liver surface area; extension; rupture of subcapsular hematoma with active hemorrhage; parenchymal blood

Swollen > 2cm or extensibility

Laceration liver parenchyma laceration depth > 3cm

IV liver parenchyma hematoma puncture hematoma and bleeding

Rupture of parenchymal rupture involving hepatic lobe 25%~50%

V laceration parenchyma rupture > 50% hepatic lobe

Injury of hepatic vein (inferior vena cava and main hepatic vein)

Complete rupture of hepatic vessels with VI vascular injury

American Society for surgical trauma standards for grading liver injury

Raise a level # if the liver with multiple injuries

2 treatment: of the 45 patients, 16 (35.6%) underwent nonoperative treatment. Of the 16 patients with systolic blood pressure were "90mmHg, the pulse rate is less than 100 / min, the degree of liver injury were mild (grade I~II, the dynamic CT and B-ultrasound diagnosis). The other 29 cases (64.4%) had different types of surgical treatment. Among them, 18 cases were treated with simple suture repair, and the other one was treated with gauze packing hemostasis, and the other one was treated with irregular resection of right posterior lobe of the liver in 2 cases, and the other one underwent laparotomy in 1 cases, and the other 7 cases were treated with debridement to increase the omentum packing and suture repair.

Table two liver injury complicated with other organs injury (case)

Combined injury cases

Spleen rupture 6

Gastric injury 2

Small intestinal rupture 1

Multiple rib fractures 11

Hemothorax, 4 lung injury

Rupture of diaphragm 2

Gallbladder rupture 2

Retroperitoneal hematoma 5

Rupture of the inferior vena cava 1

Hepatic vein 3

3 treatment results: all the patients were successfully treated by conservative treatment. Among the 29 patients who were treated with surgery, there were mild liver injury in 18 cases (62.1%). All patients were cured after simple suture repair (16). Another 11 patients with severe liver injury (grade III~V). 2 cases (6.9%) for gauze packing method, including 1 cases of right posterior lobe of the liver parenchyma injury (IV) with blood coagulation dysfunction, patients can not continue to tolerate surgery, using iodoform gauze packing hemostasis and the end of surgery, repeated debridement and T tube drainage and cure 4 weeks after biliary infection fistula and intraabdominal; the other 1 patients with hepatic vein and right liver injury, surgery in critical condition and gauze packing, postoperative bleeding and death failed to control. 1 patients underwent laparotomy because of the injury of the right hepatic vein and the inferior vena cava. 1 cases of extensive injury of the right posterior lobe of the liver and the injury of the right hepatic vein were cured by resection of the right posterior lobe of the liver. The other 7 patients with severe liver injury (grade III~V) were treated with debridement and omental packing and suture repair. All of the 6 cases were cured and discharged, and the other 1 cases died of MSOF after operation. The operative mortality rate was 10.3%, and the total mortality was 6.7%

Discussion

Preparation before operation

1 any suspected patients with liver injury should be rapid establishment of infusion channels, such as shock, to quickly in the superior vena cava distribution area to establish more than 2 infusion channels. Pressure infusion or arterial transfusion if necessary.

2 patients underwent surgery to be an ample supply of blood for intraoperative control of hemorrhagic shock in preparation.

3 if the preoperative hemodynamic stability, in the active treatment at the same time, B ultrasound or CT examination in order to understand the degree of liver injury, provide the basis for surgical treatment or conservative treatment.

4 general use of broad-spectrum antibiotics.

5 preparation of intra-abdominal blood collection and transfusion device.

Two. Surgical methods

1: general selection of incision incision or right upper abdominal midline abdominal rectus incision 2, so fast

The abdominal incision should be large enough to facilitate the exposure of the surgical field. If necessary, the right side of the chest and abdomen

In this case, a patient with a right posterior lobe of the liver was injured with a right hepatic vein injury

Full exposure to the incision.

2 simple suture repair method: this method is suitable for superficial liver contusion, knife and stabbed.

Fruit satisfaction. This group of 18 cases of mild liver injury patients with this method can cure. Attention should be paid to suture

The wound, wound through the needle should be at the bottom, do not stay dead in the deep cavity, so as to avoid secondary infection hematoma,

Secondary hemorrhage.

3 debridement and omental packing and suture repair: complete debridement is an effective procedure for the treatment of severe liver injury

One of the key steps, because the wound is likely to have a loss of living liver tissue debris or foreign tamponade, injury

There may be active bleeding or biliary fistula in the mouth. If you do not completely debridement may lead to bad

Guo 4. Before the debridement, we routinely blocked the hepatic hilum at normal temperature to facilitate exposure. Debridement do not do the edge

Resection, expansion, so as not to increase bleeding. In case of rupture of blood vessels and bile ducts during debridement, the

Ligation. The main hepatic duct rupture should be repaired by suture, and the internal support tube drainage. Hepatic portal obstruction

After 3~5 minutes of observation, confirmed complete debridement no active bleeding after using pedicled net

In the film a wound, the liver margin to mattress suture. We understand that the method is simple

Patients with small, less complications and good results. In this group, 7 cases were treated with this method

Only 1 cases died (III~V).

4 gauze packing hemostasis: this group of patients with 1 cases, although the success of this method, but we

It is suggested that this method is easy to cause liver tissue compression necrosis, infection, biliary fistula, secondary hemorrhage and so on

Severe liver injury does not require routine use of this method. Unless the patient has coagulopathy or surgery

Lack of technology and conditions on the preparation, can use this method to control bleeding, to transfer to the higher hospital to win

Time.

5 irregular liver lobectomy: surgical mortality as reported in the literature is as high as more than 2 by 50%,

Many scholars are unable to accept this method. But for those with a larger range of inactive liver tissue or liver fragmentation

In the case of crush injury, stellate rupture, multiple fragmentation and so on, we performed irregular liver resection.

This method can reduce the incidence of secondary bleeding and biliary fistula, and the hemostatic effect is reliable 3. And regularity

Liver resection should be abandoned, because the rule of liver resection too much removal of normal liver tissue, increase the liver

Injury, but also increase the difficulty of surgery and mortality.

Two. Nonoperative management

Due to the strengthening of the establishment of surgical ward, strengthening the treatment of increasingly rich, as well as B ultrasound CT

The wide application of such methods makes it possible to preserve some liver injury. We think patients

The following requirements can be considered conservative treatment: 1 stable blood circulation or slightly after rehydration

The situation was stable; 2 without peritoneal irritation sign; 3.CT examination of liver injury was minor injury (I~II); no 4

Abdominal organ injury; 5 for liver injury of blood transfusion itself does not exceed 400~800ml; 6

CT scan showed stable or progressive liver injury. In this group, 16 cases were treated conservatively

Were cured.

Reference

1, Lin Zhijin. Abdominal surgery. First edition, Tianjin science and Technology Press, 1995

2, Wu Jieping, Qiu, Huang Jiasi surgery. Fifth edition, Beijing: People's Medical Publishing House

3. Balasegaram DM. resection trauma. Adv Surg, in, 1984,17:129, Hepatic

4. Chen Xiaoping, Wu Zaide, Yan Qun, et al. Surgical treatment of liver injury. Chinese Journal of surgery, 1994,32 (6): 354

5, Tang Baoshan. Clinical analysis of non operative treatment of simple liver injury in 77 cases,

1994; 32 (8): 477

6, Pachter HL, Spencer FC, Hofstetter SR. trends the of trauma: experience with injuries. Ann Surg, 1992215:492, Significant, in, hepatic, treatment

 

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