Ⅴ级肝外伤合并肝门部胆管横断伤的诊断与治疗

Diagnosis and treatment of grade Ⅴ liver trauma combined with hilar bile duct transection injury

美国创伤外科学会（AAST）分级为Ⅴ级的肝外伤是合并有肝后下腔静脉损伤的极为严重的肝外伤,伴有胆管损伤较少见,治疗困难.及时快速做出判断,急诊剖腹探查,对损伤胆管进行有效地修复是治疗胆管损伤的关键.2013年8月30日南京军区福州总医院收治1例Ⅴ级肝外伤合并肝门部胆管横断伤患者,术前经多学科会诊,入院4h行急诊剖腹探查,发现左右半肝交界处完全断裂,第一肝门见左右肝管分叉处断裂,切除失活的肝组织,采用Poly线缝合破损左、中肝静脉,并逐个缝扎肝创面出血点及胆管,6-0PDS线缝合左右肝管破口,间断对垄缝合肝断面.打开胃壁,清除大量胃内容物,采用闭合器修补.术后经对症支持治疗,各项指标逐渐恢复,住院26 d后出院.出院31 d后因腹腔引流管引流出脓性液体,再次入院,根据药物敏感试验结果使用头孢曲松钠他唑巴坦钠抗感染,并持续腹腔冲洗.术后83 d拔除腹腔引流管及左右肝管内引流管,第2次住院28d出院.术后随访至2014年12月,恢复良好,未出现并发症.

According to the Organ Injury Scale Grading System of the American Association for the Surgery of Trauma （AAST-OIS）,grade Ⅴ liver trauma is always complicated with retrohepatic inferior vena cava injury and less bile duct injury,and it is extremely severe and difficult to be treated.Timely and fast judgment,emergent exploration and effective repair of the injured bile duct are the key points for the treatment of bile duct injury.One patient with grade Ⅴ liver trauma combined with hilar bile duct transection injury was admitted to the Fuzhou General Hospital of Nanjing Military Command on August 30,2013.The rupture of left and right liver junction was detected by preoperative multidisciplinary consultation and emergency open surgery at admission hour 4.There was left and right hepatic duct bifurcation rupture at the first hepatic hilum.Non-functional liver tissues were excised.Breakage left and middle hepatic vein were sutured by polymer suture line.Liver traumatic bleeding and bile duct were sutured and ligatured individually.Left and right hepatic duct laceration was sutured by 6-0 PDS suture line.A hole in the stomach wall was opened fist,and then most part of the gastric contents was removed and the gastric wall was reparied by stapler.Patient received the postoperative symptomatic treatment with gradual recovery,and was discharged from hospital at admission day 26.The patient was readmitted to the hospital at 31 days of discharge due to outflow of purulent fluid from abdominal cavity drainage tube,and was treated by ceftriaxone sodium and tazobactam sodium according to the results of drug sensitive test and continuous peritoneal lavage.The abdominal cavity drainage tube and left and right hepatic duct drainage tube were removed at postoperative day 83.The patient was discharged from hospital at readmission day 28,and was followed up till December 2014 with good recovery and without complication.