肝损伤累及肝静脉主干或下腔静脉的救治体会

Treatment of liver injury involving major hepatic vein or inferior vena cava

目的探讨肝损伤累及肝静脉主干或肝后段下腔静脉的救治。方法回顾分析我院2010年4月～2011年11月收治的10例手术治疗外伤性肝破裂(Ⅴ级)临床资料,其中,男性8例,女性2例;年龄19～46岁,平均32岁。致伤原因:道路交通伤6例,重物砸伤1例,马踏伤1例,刀刺伤2例。均属Ⅴ级的严重肝破裂。血管损伤:下腔静脉破裂9例,肝右静脉主干破裂4例,肝左静脉破裂1例,门静脉主干破裂1例;10例均合并有右侧或(和)双侧肋骨骨折;9例有肺挫伤;入院时均呈休克表现。10例均在积极抗休克的同时急诊行手术治疗。结果治愈8例,死亡2例。全肝血流阻断下行下腔静脉破裂+肝破裂修补术2例,肝上下腔静脉局部血流阻断(用血管阻断钳)下腔静脉修补术1例,肝右静脉破裂修补术3例,肝后下腔静脉破裂修补术5例,不规则右肝切除术6例(其中Ⅵ、Ⅶ、Ⅷ段肝切除1例)。结论在严重的外伤性肝破裂(Ⅴ级)救治过程中,需要多科积极配合,缩短术前准备时间,充分游离肝脏,合理阻断肝脏血流,正确的处理肝断面和大血管的损伤,可提高严重肝破裂的救治成功率。

Objective To discuss the treatment of liver injury involving major hepatic vein or inferior vena cava. Methods Retrospective analysis was conducted in 10 cases of traumatic liver rupture （ V level） ,who were admitted into our hospital from Apr. 2010 and Nov. 2011. There were 8 males and 2 females;age ranged from 19-46 years （ mean 32 years ）. The injury mechanisms included road traffic injury in 6 cases, heavy weight falling injury in 1 case, horse treading injury in 1 case, stab injury in 2 cases. All these cases had severe hepatic rupture of V grade. Patients who had vascular injury included 9 cases of rupture of the inferior vena cava,4 cases of right hepatic vein rupture, 1 case of left hepatic vein, 1 case of main portal vein ; ten cases were found right or bilateral rib fractures ; nine cases were found pulmonary contusion; shock symptoms were observed in all these patients on admission. Antishock treatment and emergency operation were simultaneously performed in 10 cases. Results Eight cases were cured and 2 cases died. There were 2 cases of total hepatic vascular oxclusion of the inferior vena cava rupture combined with repair of liver rupture, 1 case of inferior vena repair combined with partial occlusion of suprahepatic vena cava,3 cases of repair of right hepatic vein rupture,5 cases of repair rupture of post-hepatic inferior vena cava,6 cases of irregular right hepatic resection. Conclusion During the severe traumatic liver rupture （ V grade ） treatment process, doctors should have active multidisciplinary cooperation, shorten preoperative preparation time, fully liberate the liver, reasonably block hepatic blood flow, well deal with the injury in crosssection of liver and large vessels so as to improve the treatment success rate of severe liver rupture.