肝癌切除术并发大出血的防治

Prevention and Treatment of Massive Bleeding in Liver Cancer Resection

目的：总结肝癌切除术中防治大出血的经验，提高手术安全性和彻底性。方法：对本院近１０年３６例手术中和术后并发大出血病例进行总结，对其发生的原因、出血部位和应急处理及如何预防等进行分析和讨论。结果：大出血的常见原因：①术野显露差；②过度牵拉肝脏撕破大血管；③肝内解剖不熟判断失误；④术野粘连严重和操作粗疏；⑤创面处理不当等。损伤血管多发部位依次为：肝短静脉（１９．０％）、肝右静脉（１６．７％）、肝中静脉（１４．３％）、瘤体破裂（１１．９％）、下腔静脉和右肾上腺静脉（各９．５％）、肝创面（７．１％）、肝动脉或门静脉支（４．８％）、左肝静脉（２．４％）、其他（４．８％）；术中出血２６例，平均出血量１８９６．５ｍｌ； １３例术后继发出血（其中３例术中止血，术后再继发出血），９例再手术的平均出血量为１１２０ｍｌ，４例继发出血保守疗法治愈。本组无术中死亡，术后１个月内死亡４例。结论：应重视难治性肝癌手术切除的适应证选择、手术操作技术、应急处理措施和围手术期监护处理等，其是保证手术安全性的重要因素。

Objective: To learn lessons by summarizing the experience gained in the management of massive bleeding during liver resections. Methods: Thirty-six cases of massive intraoperative and postoperative bleeding occurred during the past 10 years; their common causes and sites, emergent management and preventive measures were studied. Results: The common causes of massive bleeding were: ①inadequate surgical exposure; ②tearing of major blood vessels due to excessive traction on the liver; ③familiarity with the liver anatomy; ④inadvertent surgical technique; ⑤improper management of resection surface. The common sites of bleeding were: short hepatic veins(19.0%), right hepatic vein(16.7%), middle hepatic vein(14.3%), rupture of tumor(11.9%), inferior vena cava(9.5%), right suprarenal vein (9.5%), raw surface of hepatic resection(71%), hepatic hilus(4.8%), left hepatic vein(2.4%) and other .sites(4.8%). The mean amount of intraoperative bleeding volume was 1896.5ml in 26 cases; the mean amount of bleeding volume in 9 cases of emergent re-exploratory surgery after hepatic resection was 1120ml; 4 cases of secondary hemorrhage were stopped by conservative means. There was no death during operation, while 4 cases died within one month after operation with a mortality rate of 0.062%. Conclusions: In order to ensure security during difficult hepatic resections, attention should be paid to the choice of appropriate surgical indications, adoption of meticulous surgical technique and perioperative care.