肝脏损伤的术式选择与疗效分析

Operation Selection of Liver Injuries and Relative Effect

目的:探讨肝脏损伤的术式选择与疗效。方法:回顾分析2004年3月—2008年10月收治的32例采用手术治疗的肝脏损伤患者的资料。按照1994年修订版美国创伤外科协会器官损伤分类法分级,Ⅰ级2例,Ⅱ级4例,Ⅲ级19例,Ⅳ级4例,Ⅴ级3例。结果:30例治愈,手术方式主要为行单纯缝合修补6例,带蒂大网膜填塞修补5例,血肿清除、肝创面血管和胆管结扎加对拢缝合11例,不规则性肝切除6例,规则性肝切除2例,左肝静脉修补1例,纱布填塞捆绑止血1例。术后并发症为胆瘘3例,膈下感染2例,肝脓肿4例,均经保守治疗痊愈。2例Ⅴ级肝损伤患者,死于失血性休克。结论:Ⅰ～Ⅱ级患者除血流动力学不稳定或疑有其他空腔、实质脏器损伤外,大部分可采用保守治疗。Ⅲ～Ⅴ级患者以手术治疗为主。Ⅲ级患者主要采用带蒂大网膜填塞修补或血肿清除,肝创面血管、胆管结扎加对拢缝合;Ⅳ级患者则需去除肝毁损组织,行规则或不规则肝切除术,尽量保存正常肝组织;Ⅴ级患者死亡率高,遵循损伤控制性手术原则,尽量缩短术前准备时间,充分暴露手术野、快速有效止血,条件允许行血管修补术,不允许则行创面填塞肝脏捆绑术。

Objective：To evaluate the effects and modes of surgical operation on liver injuries. Methods： This was a retrospective, observational study, on 32 liver injuries patients undergoing surgical operation admitted from March 2004 to October 2008. The severity of liver injuries was classified according to the 1994 revised Organ Injury Scaling Committee of American Association for the Surgery of Trauma （AAST）. Two out of 32 cases were identified as grade Ⅰ , while in grader , Ⅲ , Ⅳ and Ⅴ were 4, 19, 4 and 3 cases respectively. Results： Thirty cases were cured,of which with the complication emerged as 2 biliary fistula, 2 subdiaphragmatic infection, and 4 liver abscess who received conservative managements. The modes of operation of these cases were listed as following： simple suturation, pediculated tamponment of greater omentum, haematoma debridement together with ruptured vessels and biliary ducts suturation, anatomic or nonanatomic liver resection. The other 2 cases classified as grade Ⅴ ,died of irreversible bleeding. Conclusion： Liver injuries patients in grade Ⅰ-Ⅱ can mostly be treated with nono perative managements,but to the patients emerging with other organ injuries, peritonitis, or with unstable hemodynamics. To the patients graded Ⅲ- Ⅴ , we mainly adopt surgical operations. Pediculated tamponment of greater omentum or haematoma debridement together with ruptured vessels and biliary ducts suturation were used in patients in grade Ⅲ. To the patients graded Ⅳ , our treating measures principally aim at destroying the malfunctioned tissue and preserving the normal. The patients in grade Ⅴ have a relatively high death rate. Our focus should be placed upon shortening the preparation time before the surgical operations in order to effectively cease the bleeding in time and do the damage control surgery, such as angiorrhaphy if bleeding was under control, but peri-hepatic packing instead.